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NON-HORMONAL PRESCRIBED TREATMENTS FOR MENOPAUSAL SWEATS AND FLUSHES

Hot flushes and night sweats are experienced by most menopausal women for an average of seven years, and for some, these can last a lifetime. HRT is the first choice of treatment but some women with certain medical conditions shouldn’t be prescribed hormone-based treatments. By caring for breast cancer survivors, doctors have extended their experience in prescribing alternative medicines for the menopause.

This article was included in issue 80 (spring 2019) of The Menopause Exchange newsletter.

The prescribable alternatives are limited to their effects on vasomotor symptoms (hot flushes and night sweats), and in some cases on mood and sleep. The National Institute for Clinical Excellence (NICE), which evaluates the effectiveness of treatments, has included some of these prescribed drugs in its assessment of the response to hot flushes and night sweats. This involves assessing the effectiveness of the medicines in reducing the severity and frequency of flushes rather than clearing them up completely.

These medicines have been developed for other medical conditions, such as epilepsy, pain or high blood pressure, but have also been found to have a beneficial effect on hot flushes and night sweats. They include clonidine, antidepressants, gabapentin and pregabalin.

Clonidine
Clonidine is the only medicine with an indication or ‘licence for use’ in managing flushes and sweats. It’s an old-fashioned blood pressure-lowering medication that’s hardly ever used in blood pressure control, as there are now much better medicines available. Clonidine may not work at lower doses so the dose is increased slowly over two-week intervals.

The higher the dose, the more likely clonidine is to work, but it’s then also more likely to cause side effects, such as sleep disturbances and a dry mouth (worse with higher doses of clonidine). Since clonidine has been prescribed in the past to lower high blood pressure (hypertension), it also reduces blood pressure and has been found to reduce blood pressure steeply in women who start off with normal blood pressure. If clonidine doesn’t work, women have to then come off the medicine very gradually to avoid what’s called ‘rebound hypertension’. Fifty percent of users also have significant sleep disturbance when they take clonidine.

Anti-depressants
Anti-depressants are often offered to menopausal women, sometimes because their doctors aren’t confident about prescribing HRT. You must always ask your doctor why they’re suggesting an antidepressant for menopausal symptoms rather than hormonal treatment. If, however, you know you should avoid taking hormonal medicines, then instead you may be able to take an antidepressant from the family of Selective Serotonin Reuptake Inhibitors (SSRIs).

Paroxetine is the SSRI that works best for flushes and sweats. This works at 10mg, half the dose usually used to treat depression. An increase to 20mg will have no extra benefit on flushes and sweats. The side effects increase as the dose of paroxetine is increased.

Fluoxetine, citalopram and escitalopram may also be used for flushes and sweats. Sertraline is the least effective of the SSRIs for flushes and sweats, but is probably the best for patients with anxiety. Venlafaxine is a mix of SSRI and Noradrenaline Reuptake Inhibitor (SNRI).

All of the antidepressants work as mood enhancers. Their side effects include nausea, tummy upset, dizziness, short-term aggravation of baseline anxiety and a significant effect on libido. No single SSRI is any better than any other, in terms of whether they’re less likely to cause side effects and everyone varies in how they respond to treatment, but paroxetine is probably the best tolerated. Fluoxetine and paroxetine must be avoided in patients who are taking tamoxifen, as these SSRIs interact with an enzyme that then makes tamoxifen ineffective. For this reason, doctors tend to choose venlafaxine for breast cancer survivors taking tamoxifen; the side effects may be more prominent at the beginning of treatment, but if the patient can persevere, then venlafaxine may also bring an improved quality of life and have an antidepressant effect.

Gabapentin and pregabalin
Other medicines sometimes used for the menopause are gabapentin and pregabalin. Both of these are usually used to treat epilepsy, neuropathic pain and migraine.

Gabapentin reduces hot flushes at a dose of 900mg per day in about 50% of patients and pregabalin would be used at a dose of between 50mg and 300mg with the same benefit. In addition to suppressing flushes and sweats, gabapentin causes drowsiness and, if taken at night, can have a positive impact on sleep and may also help to reduce any pain. Pregabalin doesn’t have this effect on sleep, but it works as a useful antidepressant.

The possible side effects of these drugs are dry mouth, weight gain, dizziness and of course drowsiness, which is worse with the higher doses. The major problem now recognised is that gabapentin and pregabalin are addictive, and, in the United States, these medicines are linked to an epidemic of dependence. In the UK, since 1st April 2019, these medicines have become subject to special rules requiring a ‘words and figures’ prescription in a set format, in which only one month of medicine can be prescribed at a time. Most GPs are wary of using controlled drugs and will probably wish to avoid prescribing them.

Future treatments
New non-hormonal medicines on the horizon are neurokinin-3 receptor agonists, which seem to have an excellent effect on flushes and sweats in small trials and there are ongoing larger studies underway. So ‘watch this space’.

Summary
There are a number of medicines that can be prescribed by a menopause specialist for women who can’t take HRT. These may help with flushes and sweats, but most can cause significant side effects.

About the author
Dr Jane Woyka is a nationally accredited Menopause Specialist, is an Associate Specialist at the Northwick Park Menopause and Clinical Research Unit in Harrow and has a private menopause practice based at the Clementine Churchill Hospital within the Harrow Health Care Centre.

Created Spring 2019

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