Research moves forward to relieve hot flashes
If your clinical practice includes treatment of perimenopausal women, the subject of hot flashes is familiar territory for you. In a 2002 national survey of menopausal women, hot flashes (70%) led the top four reasons for seeking medical attention, followed by night sweats (68%), mood disturbances (50%), and sleep disturbances (49%).1
Hormone replacement therapy was once considered the gold standard of treatment for hot flashes. However, results from the Women's Health Initiative (WHI) reduced interest in use of such treatment.2,3 WHI indicated increased risks for breast cancer, coronary heart disease, thromboembolism, stroke, and dementia for combined hormone (estrogen plus progesterone) treatment, and an increased risk of stroke with no reduction of coronary heart disease risk for estrogen alone.2,3
Science now is eyeing various alternative therapies for managing vasomotor symptoms associated with peri/postmenopause.4 Just-published research indicates that desvenlafaxine, a serotonin and norepinephrine reuptake inhibitor, might serve as possible treatment for moderate to severe hot flashes.5 The drug, developed by Wyeth Pharmaceuticals of Collegeville, PA, is under review by the Food and Drug Administration.
A hot flash or flush can be described as a warm sensation that begins at the top of the head and progresses toward the feet, frequently followed by chills. A hot flash may last for a few seconds or for several minutes and might occur as frequently as every hour to several times per week.4
To conduct the current study, researchers enrolled 707 healthy, postmenopausal women in a randomized, double-blind, placebo-controlled trial. Women who were experiencing 50 or more moderate-to-severe hot flushes per week were included in the trial. Participants randomly received desvenlafaxine 50 mg, 100 mg, 150 mg, or 200 mg or a placebo daily. The trial duration was 52 weeks. Primary outcomes were change from baseline in average daily number of moderate-to-severe hot flushes and in daily hot flush severity score at weeks 4 and 12.
Findings from the study indicate desvenlafaxine is an effective nonhormonal treatment for vasomotor symptoms in postmenopausal women, with a tolerability profile consistent with that of other serotonin-norepinephrine reuptake inhibitors.5
Options are needed
Why is it important to have a number of treatment options when it comes to menopausal vasomotor symptoms? The answer is not complicated, says Leon Speroff, MD, professor of obstetrics and gynecology at Oregon Health & Science University in Portland.
"There are many women who cannot or do not want to take estrogen, the most effective treatment for hot flushing," says Speroff, who served as lead author of the current research. "A good example is breast cancer survivors; thus, there is a need for effective treatment as a nonestrogen option."
Research has looked at paced respiration, defined as slow, deep, abdominal breathing, for treatment of hot flashes. Findings indicate such practice can reduce hot flash frequency.6-9 Because isoflavones or phytoestrogens possess estrogenic properties, researchers have looked at soy products and red clover, as well as black cohosh, as possible treatment options. A 2002 review of 22 controlled studies — 12 on soy and 10 on other botanical compounds — found no consistent improvement of hot flashes relative to placebo.10
Antidepressants also have been considered as treatment options. Results from studies of paroxetine and fluoxetine, both selective serotonin-reuptake inhibitors, indicate effectiveness in treatment of hot flashes.11,12 Clonidine, an antihypertensive agent, also has been shown to be somewhat effective for treating hot flashes in postmenopausal women; however, these trials have been performed in very few patients.13,14 A 2006 meta-analysis that weighed studies of the efficacy and adverse effects of nonhormonal therapies for menopausal hot flashes concluded that use of such therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.15
References
- Utian WH. Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: A comprehensive review. Health Qual Life Outcomes 2005; 3:47.
- Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestins in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321-333.
- The Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women's Health Initiative randomized controlled trial. JAMA 2004; 291:1,701-1,712.
- AACE Menopause Guidelines Revision Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause. Accessed at www.aace.com.
- Speroff L, Gass M, Constantine G, et al. Efficacy and tolerability of desvenlafaxine succinate treatment for menopausal vasomotor symptoms: A randomized controlled trial. Obstet Gynecol 2008; 111:77-87.
- Freedman RR, Woodward S. Behavioral treatment of menopausal hot flushes: Evaluation by ambulatory monitoring. Am J Obstet Gynecol 1992; 167:436-439.
- Freedman RR, Woodward S, Brown B, et al. Biochemical and thermoregulatory effects of behavioral treatment for menopausal hot flashes. Menopause 1995; 2:211-218.
- Irvin JH, Domar AD, Clark C, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynecol 1996; 17:202-207.
- Wijima K, Melin A, Nedstrand E, et al. Treatment of menopausal symptoms with applied relaxation: A pilot study. J Behav Ther Exp Psychiatry 1997; 28:251-261.
- Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: A review of randomized, controlled trials. Ann Intern Med 2002; 137:805-813.
- Stearns V, Beebe KL, Iyengar M, et al. Paroxetine controlled release in the treatment of menopausal hot flashes: A randomized controlled trial. JAMA 2003; 289:2,827-2,834.
- Loprinzi CL, Sloan JA, Perez EA, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol 2002; 20:1,578-1,583.
- Nagamani M, Kelver ME, Smith ER. Treatment of menopausal hot flashes with transdermal clonidine. Am J Obstet Gynecol 1987; 156:561-565.
- Laufer LR, Erlik Y, Meldrum DR, et al. Effect of clonidine on hot flashes in postmenopausal women. Obstet Gynecol 1982; 60:583-586.
- Nelson HD, Vesco KK, Haney E, et al. Nonhormonal therapies for menopausal hot flashes: Systematic review and meta-analysis. JAMA 2006; 295:2,057-2,071.
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