Antidepressants: A possible cure for peri/menopausal hot flashes
My exclusive interview with Dr. Robert P. Kauffman, MD, MSCP, Professor of Obstetrics and Gynecology and Assistant Dean for Research Education at Texas Tech University Health Sciences Center School of Medicine
Two years into menopause, my hot flashes kicked into high gear. Night sweats were a minor inconvenience compared to my workday: Sweating profusely and fanning myself — while attempting to teach a class of 30 sixteen-year-olds — was one of the most embarrassing professional predicaments I’ve ever found myself in.
I finally discussed the situation with my primary care doctor at my annual checkup. While she wasn’t comfortable prescribing hormone replacement therapy (HRT) due to the possible link between HRT and cancer, she happily prescribed an antidepressant to treat my hot flashes.
I started out on a very low dose of the antidepressant venlafaxine (brand name Effexor) and was pleased to find relief from the heat waves almost immediately. Fortunately, I didn’t endure any of the common side effects associated with antidepressants, such as nausea, difficulty sleeping or drowsiness, weight gain, dry mouth, or sexual dysfunction. Unfortunately, the drug’s effectiveness began to wane after a couple of months, and my dosage had to be increased.
Again, while I experienced some relief at first, the benefits lagged very quickly. After several months on the medication and two dosage increases, it became clear venlafaxine wasn’t going to be the savior I’d been hoping for.
Antidepressants vs. hormone replacement therapy
When antidepressants proved ineffective against my hot flashes, my doctor prescribed Duavee, a drug that combines estrogen with an estrogen agonist/antagonist, making it less likely than estrogen alone to possibly lead to breast cancer. Duavee worked extremely well against my hot flashes, with no side effects; however, just a few months into treatment, a Duavee shortage left me unable to fill my prescription. (This problem was later resolved.) My internist, still reluctant to delve into the realm of traditional hormone replacement therapy (HRT), referred me to an OB-GYN, who immediately started me on HRT in the form of estradiol (estrogen) combined with norethindrone acetate (progesterone).
According to Dr. Robert P. Kauffman, MD, MSCP, Professor of Obstetrics and Gynecology and Assistant Dean for Research Education at Texas Tech University Health Sciences Center School of Medicine, hormone replacement therapy “has a high degree of safety and efficacy in those who are within 10 years of menopause [or later in some] and who do not have a contraindication.” I am fortunate to fall into this group, and HRT turned out to be a great option for me; no more night sweats, and no more embarrassing sweat stains on my teacher outfits.
However, HRT is not for everyone, including “breast cancer patients, women with cardiovascular disease, history of thromboembolism [blood clots], known clotting disorders, untreated endometrial hyperplasia/cancer, and advanced cirrhosis.” While this list leaves a not-insignificant number of patients unable to take advantage of HRT – which Dr. Kauffman terms the “gold standard” in hot flash treatment – it is important for this population to explore the many non-hormonal therapies for hot flashes in menopause.
How SSRIs work for hot flashes
There are two types of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). According to Dr. Kauffman, the way antidepressants work in the brain to combat hot flashes remains largely unknown; however, “it is theorized that hot flashes could be linked to excessive serotonin receptors in the hypothalamus. Accordingly, SSRIs and SNRIs could increase serotonin, the chemical in the brain that promotes feelings of well-being, to bind with those receptors.” Hence, the drugs curb the brain’s menopausal tendency to respond to non-existent heat.
Not all women find hot flash relief with antidepressants. According to Dr. Kauffman, this variance in effectiveness “may have to do with dosing or individual responses in brain neurochemistry.” A 2015 study found that antidepressants reduced hot flash symptoms by as much as 65% compared to placebo. For some women, this relief might be just what the doctor ordered; for those experiencing more intense symptoms, the medications may not result in a sufficiently cooling effect.
Patients have options when seeking treatment for hot flashes
Lifestyle changes are a logical first step in the treatment of hot flashes. According to the National Institute on Aging, some changes, which may help curtail hot flashes include:
- Dressing in layers that can be removed when the heat sets in
- Avoiding alcohol, spicy foods, and caffeine
- Quitting smoking
- Maintaining a healthy weight
- Exploring mind-body practices, such as hypnotherapy and mindfulness meditation
When lifestyle changes don’t go far enough, non-hormonal treatments for hot flashes include a variety of antidepressants, both SSRIs and SNRIs. It should be noted that women with a history of breast cancer who are taking tamoxifen should avoid SSRIs due to their interference with the clinical mechanism of the anti-cancer drug; however, SNRIs (such as venlafaxine) remain an option for these patients.
Other medications, such as gabapentin and clonidine, have also proven effective against hot flashes, although these drugs have additional side effects that should be weighed against their potential benefits. A new medication, Veozah (fezolinetant), dubbed by Dr. Kaufmann as “a welcomed new addition to hot flash management with good effectiveness,” received FDA approval in May.
As mentioned previously, Duavee, which contains estrogen and an estrogen agonist/antagonist, is a great option for patients who are candidates for hormone replacement therapy, but for whom progesterone causes unwanted side effects such as weight gain and mood swings.
Finally, traditional hormone replacement therapy might be the best option for those patients who are good candidates for HRT. As always, patients should discuss their medical history and options with their doctors to determine which treatment is right for them.
Antidepressants for other symptoms of menopause
Patients who get hot-flash relief from antidepressants may find the medication also helps with other peri/menopausal symptoms. It is an unfortunate fact that the experience of perimenopause through post-menopause can cause not only hot flashes, but insomnia, mood fluctuations, and even depression. According to Johns Hopkins Medicine, estrogen and progesterone, which are the hormones that control the menstrual cycle, also impact serotonin, the “feel-good” brain chemical. The dramatic reduction in these hormone levels during menopause leads to a drop in serotonin, causing increased irritability, anxiety, and sadness. In addition, night sweats lead to insomnia in many patients, and poor sleep can make you up to ten times more likely to become depressed.
Since antidepressants are commonly prescribed for mood disorders, patients experiencing hot flashes in conjunction with menopause-induced depression and mood swings can be doubly helped when prescribed an SSRI or SNRI for their symptoms.
Explore treatment options to find one that’s right for you
Although antidepressants weren’t a long-term fix for me, I found a solution, which is an important point: Everyone is different, and what works for one won’t necessarily work for another. As the medical establishment works toward investing in the necessary research into women’s health issues, it is crucial for patients to speak up and work closely with their healthcare providers to explore the various treatment options available.
