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Vasomotor Symptoms of Menopause
Aka: Vasomotor Symptoms of Menopause, Hot Flashes, Hot Flushes, Flushing, Menopausal Diaphoresis
- See Also
- Night Sweats
- Hyperhidrosis
- Epidemiology
- Vasomotor symptoms occur in 85% of perimenopausal women
- Starts 1-2 years before Menopause
- Continues for up to 5 years
- Differential Diagnosis
- Medications
- Isoniazid
- Disulfiram reaction
- Griseofulvin
- Flagyl
- Chlorpropamide
- Chloral Hydrate
- Niacin
- Hydralazine
- Calcitonin
- Aspirin sensitive
- Procardia
- Capsaicin
- MAO inhibitor when taken with Tyramine (beer, cheese)
- Medication Withdrawal
- Clonidine Withdrawal
- Alpha-Methyldopa withdrawal
- Alcohol Withdrawal
- Pheochromocytoma
- Carcinoid
- Mastocytosis in Leukemia
- Histamine and Prostaglandin D Release
- Hypotensive episodes
- Dermatographia
- VIP-oma or WDHA: Diarrhea, Hypokalemia, achlorhydria
- Menopausal Flushing
- Emotional blushing
- Food and Environmental Stimuli
- Monosodium glutamate
- Thermal stimuli
- Ethanol (worse with Rosacea, Carcinoid, Mastocytosis)
- Scombroid Fish Poisoning: Tuna, Mahi-mahi, Mackerel
- Syndrome obscure in women
- Characteristics
- Telangiectasia
- Urticaria
- Flushing
- Peptic Ulcer Disease
- Diarrhea
- Increased blood and urine histamine
- Not associated with Mastocytosis or Carcinoid
- Management: Lifestyle
- Precautions
- No single lifestyle modification has been found consistently effective in Hot Flashes
- However, many lifestyle measures listed have broader health benefits (e.g. weight loss, Tobacco Cessation)
- (2015) Menopause 22(11): 1155-72 [PubMed]
- Kaunitz (2015) Obstet Gynecol 126(4): 859-76 [PubMed]
- General measures (no strong evidence of benefit)
- Wear cool clothing (e.g. breathable)
- Use a fan
- Drink cool liquids and eat cold foods
- Regular Exercise has mixed results (no strong evidence of benefit)
- Original study supported Exercise as effective
- Ivarsson (1998) Maturitas 29:139-46 [PubMed]
- Recent study does not show benefit in Hot Flushes
- Aiello (2004) Menopause 11:382-8 [PubMed]
- Avoid Exacerbating food products (no strong evidence of benefit)
- Caffeine
- Alcohol in excess
- Spicy food
- Dietary Fat intake
- Associated with Hot Flushes in Postmenopause
- Riley (2004) J Gen Intern Med 19:740-6 [PubMed]
- Vitamin Supplementation (no strong evidence of benefit)
- Vitamin B6 may be helpful
- Vitamin E is no more effective than Placebo
- Other measures associated with decreased symptoms (no strong evidence of benefit)
- Tobacco Cessation
- Yoga
- Massage
- Meditation
- Leisurely bath
- Weight loss
- Associated with less Hot Flushes in Perimenopause
- Riley (2004) J Gen Intern Med 19:740-6 [PubMed]
- Management: Medications
- Hormonal agents (most effective, but review risks and contraindications)
- Estrogen Replacement Therapy
- Relieves symptoms in 80-90% of patients
- Progestin
- Progesterone transdermal cream (20 grams/day)
- Leonetti (1999) Obstet Gynecol 94:225-8 [PubMed]
- Megestrol acetate (Megace) 20 mg PO bid
- Relieves symptoms ~50% of cases
- Medroxyprogesterone acetate (Provera) 20 mg orally daily
- Relieves symptoms ~50% of cases
- Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
- Efficacy
- Venlafaxine appears to be most effective among SNRI and SSRI agents
- However, SNRIs also have more side effects than SSRIs (e.g. Nausea, Dry Mouth, Constipation)
- Desvenlafaxine (Khedezla)
- Venlafaxine (Effexor)
- Dose: 12.5 mg orally twice daily or 75 mg orally at bedtime
- (1998) J Clin Oncol 16:2377 [PubMed]
- Loprinzi (2000) Lancet 356:2059-63 [PubMed]
- Selective Serotonin Reuptake Inhibitors (SSRI)
- Efficacy
- More effective and better tolerated than Clonidine or Gabapentin
- Precaution: Avoid Prozac and Paxil in Breast Cancer patients on Tamoxifen
- CYP2D6 Inhibitors (e.g. Paroxetine, Fluoxetine, Bupropion) may decrease Tamoxifen efficacy
- SSRIs shown to be effective
- Paroxetine (Paxil CR)
- Paroxetine 12.5 to 25 mg orally daily
- Stearns (2003) JAMA 289:2827-34 [PubMed]
- Released as Brisdelle (7.5 mg Paroxetine) in 2013 specifically targeting Hot Flushes
- Paroxetine 10 mg generic tablet daily is nearly equivalent (at 6% of the Brisdelle cost)
- Fluoxetine (Prozac)
- Loprinzi (2002) J Clin Oncol 20:1578-83 [PubMed]
- SSRIs not found to be effective
- Citalopram (Celexa)
- Sertraline (Zoloft)
- Suvanto-Luukkonen (2005) Menopause 12:18-26 [PubMed]
- Miscellaneous agents with some efficacy against Hot Flushes
- Clonidine 0.1 - 0.2 mg PO qhs (or transdermal patch)
- Modest benefit, but adverse effects (Hypotension, Dizziness) may limit use
- (1994) JCO 12:155
- Gabapentin (Neurontin) 300 mg orally three times daily
- Guttuso (2003) Obstet Gynecol 101:337-45 [PubMed]
- Bellergal-S 100
- Small risk of addiction
- Aldomet 250 mg PO bid
- Management: Herbals and Dietary Supplements
- Possible benefit
- Omega-3 Fatty Acids
- Black Cohosh
- Hernandez (2003) Maturitas 44:S59-65 [PubMed]
- Soy Isoflavones or Phytoestrogens
- See Soy Protein
- Original studies with mixed results (prior to consideration of pharmacogenomic factors )
- Faure (2002) Menopause 9:329-34 [PubMed]
- Han (2002) Obstet Gynecol 99:389-94 [PubMed]
- Nikander (2003) Obstet Gynecol 101:1213-20 [PubMed]
- Effectiveness appears dependent on pharmacogenomic factors
- Equol is a soy metabolite with Estrogenic Activity
- Only 40% of North American women convert Soy Isoflavone (daidzein) to equol
- Conversion is most common in Asian and Hispanic women
- The majority who lack this conversion are unlikely to see benefit from soy
- References
- Clarkson (2011) Menopause 18(7):732-53 [PubMed]
- Unlikely benefit
- Dong Quai (No better than Placebo)
- Evening Primrose Oil
- Red Clover
- Tice (2003) JAMA 290:207-14 [PubMed]
- Vitamin E slightly better than Placebo
- Barton (1998) J Clin Oncol 16:495-500 [PubMed]
- References
- Carroll (2006) Am Fam Physician 73:457-67 [PubMed]
- Diem (2020) Menopause 27(10): 1126-36 [PubMed]
- Handley (2015) J Am Assoc Nurse Pract 27(1): 54-61 [PubMed]
- Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
- Israel (1997) Pharmacotherapy 17:970-84 [PubMed]
- Morelli (2002) Am Fam Physician 66(1):129-34 [PubMed]
- Shanafelt (2002) Mayo Clin Proc 77:1159-63 [PubMed]