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Abstract & Commentary
Synopsis: Since the results of the Women’s Health Initiative randomized trials, many fewer postmenopausal women are using estrogen to control hot flashes. Alternatives include progesterones, antidepressants in low doses, caffeine avoidance, exercise, phytoestrogens, and black cohosh. More studies are needed to clarify the benefits of these therapies.
Source: Pradhan A, Bachmann G. Women’s Health in Primary Care. 2003;6(11):527-534.
Many fewer women wish to take estrogen after the results of the Women’s Health Initiative randomized trials showing increased risk of heart disease and cancer. This leaves the control of troublesome hot flashes after menopause to other methods, most of which are not as effective. This review by 2 leaders in women’s health at the Robert Wood Johnson medical school clarifies the data supporting other methods.
A hot flash is the sudden onset of an increase in body temperature that induces feelings of warmth, reddening of the skin in the upper body and perspiration. In most menopausal women, these symptoms last for 1-2 years, but 25% of women experience vasomotor symptoms for more than 5 years. These symptoms are clearly related to a decline in estrogen production, and hence estrogen replacement is the most effective treatment.
Several placebo-controlled studies have shown that progesterones alone may alleviate the symptoms. Oral doses of medroxyprogesterone acetate of 10-20 mg/d can be 50% to 80% effective. At these doses, side effects of irregular bleeding, fatigue, mood changes, bloating and weight gain do occur. This makes nonhormonal alternatives more attractive.
Two of the newer antidepressants—paroxetine and venlafaxine— have been shown in low doses to reduce vasomotor symptoms by about 60%. They offer the best pharmacologic option for treatment. Older drugs such as bellergal, clonidine patch, and methyldopa are either not effective or have side effects exceeding the benefit to warrant their use.
Lifestyle methods worth trying include avoidance of spicy foods, caffeine, and alcohol. Dressing in layers and lightweight clothing help prepare the women to minimize the discomfort. Exercise is beneficial in reducing vasomotor instability. Of all of the "natural" methods suggested for hot flashes, phytoestrogens, such as from soy and other legumes, and black cohosh have some evidence to support their use. Phytoestrogens are best consumed by diet rather than in pills. A nice review of black cohosh was recently published in the American Family Physician (July 1, 2003 www.aafp.org/afp/20030701/114.html).
Comment by Joseph E. Scherger, MD, MPH
The variation among menopausal and postmenopausal women with respect to hot flashes is great, and treatment must be individualized. The temporary nature of this problem needs to be kept in mind, since many women consider that this problem will follow them into their sixties. Pradham and Bachmann point out that the WHI cohort consisted mostly of older women (mean age, 62) while those who typically seek help for hot flashes are younger (mean age, 51). When the vasomotor symptoms are very troublesome, estrogen replacement for 2 years may be the most direct and effective therapy. A high phytoestrogen diet is a health diet of soy and high quality vegetables. Coupled with regular exercise, these lifestyle recommendations may also have other benefits to the women. As for the herbs, they may fit the classic description of Voltaire, that the purpose of medicine is to amuse the patient while nature seeks a cure.
Dr. Scherger is Clinical Professor, University of California, San Diego.
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