ASK THE DOCTOR: Cooling the hot flashes
By DR. JIM MITTERANDO
The Patriot Ledger

Q I am going through menopause and need treatment for my annoying hot flashes. I am reluctant to take hormones with all the concerning things I have read. What do you recommend?

A When you have a hot flash, one of the most common symptoms of menopause, you may feel warm from your chest to your head, often in wave-like sensations. Your skin may turn red and you may sweat. You may feel sick to your stomach and dizzy. You also may have a headache and feel like your heart is beating very fast and hard. Hot flashes can increase with fatigue and stress. They are often worse at night and may adversely affect sleep. Fifty percent of women may experience symptoms for five years or more.

Before trying any medication, try to make lifestyle changes that may improve your symptoms and help you to get through menopause. These include exercise, weight loss, stress reduction and relaxation techniques such as meditation or yoga. They may not quell severe hot flashes, but they can improve sleep and mood problems that become more common during menopause.

Today, there are many medications available for treating hot flashes. It can be confusing wading through the many products and trying to choose which one is best. As always, buyer beware - especially with over-the-counter products that may not be regulated and whose advertised claims and web sites may not be truthful. Be patient with any treatment which may take 4 to 8 weeks to fully work. No single treatment helps everyone and women often have to experiment with several products before they find what is right for them. It also may be useful to keep a symptom diary to be better assess your progress with a medication. The treatments may not eliminate the hot flashes but, hopefully, make the symptoms more manageable.

Estrogen

If the hot flashes are quite disabling, the best treatment is estrogen; this helps symptoms about 90 percent of the time. With increased media coverage of estrogen's side effects, women tend to overestimate its risks. The Women's Health Initiative Study in 2002 reported that the estrogen/progesterone hormone combination (Prempro) is no longer recommended for long-term preventative use for osteoporosis or heart disease. Hormone therapy slightly increased the risk of heart attack, stroke, blood clots and breast cancer by 1 in 1,000 each year. This study advised against use for more than five years. Short-term use for treating menopause symptoms is still recommended - mindful of these small risks. About 10 percent of women cannot take estrogen treatment because they have had a history of heart attack, angina, blood clot or breast cancer.

The bad press regarding estrogen has sent many women looking for alternatives. Fortunately there are many prescription and over-the-counter options. Unfortunately, most treatments have not had large studies to truly evaluate their risks and benefits.

Over-the-counter medicines

—Soy - The most publicized over-the-counter treatment is soy. Menopausal women living in Asian countries experience fewer hot flashes that may be related to a diet high in soy. Studies have shown only a modest benefit in treating hot flashes. One in seven women who take 50 mg of soy isoflavones daily may notice improvement in their symptoms. If you do not notice any improvement in three months, you can try one of the other options mentioned below.

Including tofu, soy milk and other soy products in your diet will, at the very least, promote healthy cholesterol levels, and may help protect from certain types of cancer. Soy has a weak estrogen effect and its long-term effects on breast cancer are not known. Soy may decrease the absorption of thyroid medication and should not be taken at the same time.

—Black Cohosh - Herbal medications have gained in popularity in recent years in an attempt to get more ‘‘natural'' treatments. But herbs are drugs with possible risks and may not be any more ‘‘natural'' because they often require processing in a laboratory. Since they are not regulated you may want to choose a more reputable brand for quality assurance.

Black Cohosh is an herbal medicine that may be effective in treating hot flashes. Side effects are uncommon causing occasional stomach pains, nausea or headaches. It should not be taken for more than six months due to lack of safety data. It also should be used cautiously in women with a history of breast cancer.

— Other Herbals - The following herbs or supplements have not been shown to help treat hot flashes: evening primrose oil, dong quai, flaxseed oil, fish oil, omega3 fatty acids, red clover, ginseng, rice bran oil, wild yam, calcium, gotu kola, licorice root, sage, sarsaparilla, passion flower, chaste berry, ginkgo biloba, valerian root and homeopathic medicines

Progesterone

In search for hormone alternatives to estrogen, progesterone creams have become popular and are effective in treating hot flashes. However, many of the concerns raised about estrogen therapy also can be raised about all progesterone treatments. Long-term effects of progesterone are not known. Progesterone should not be used in women with a history of breast cancer.

There are many over-the-counter progesterone creams sold with varying concentrations and absorption. Use a reputable brand that has been tested such as Pro-Gest. Often you will see claims of ‘‘natural progesterone'' but realize side effects may occur including breast tenderness, fluid retention, fatigue and dizziness. If it causes fatigue, try using it at night. Avoid wild yam creams because they do not have any active progesterone and are not helpful. Prescription progesterone pills also are effective in treating hot flashes.

Prescription medications

Antidepressants such as Effexor (venlaflaxine) and the SSRI (serotonin reuptake inhibitor) drugs Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline) are effective in treating hot flashes and have become popular because they are a safe, non-hormone alternative. Side effects include stomach pain, diarrhea, fatigue and possible withdrawal if stopped abruptly.

Other prescriptions

Clonidine, a pill or patch typically used to treat high blood pressure, is occasionally used for hot flashes. Doctors don't prescribe it as often as other remedies for hot flashes because it only helps some women and it has frequent side effects including dizziness, low blood pressure, drowsiness, dry mouth and constipation.

Megace (Megestrol) and Neurontin (Gabapentin) are other prescription drugs that may help with hot flashes if other options have failed.

Dr. Jim Mitterando is a family doctor at Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.

Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.

Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.

Copyright 2004 The Patriot Ledger
Transmitted Tuesday, February 17, 2004