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Should you take antidepressants for hot flashes?

Last updated: October 2010

Your face and chest feel intensely hot, your skin reddens, and you're soaked in sweat. A cold chill follows. At night you wake up drenched and shivering.

Hot flashes—whether debilitating, embarrassing, or merely annoying—are inevitable for most menopausal women, with about 70 percent experiencing some symptoms. How much they interfere with a woman's quality of life varies greatly, and most of them will have only mild to moderate ones. But they will be more severe for about 20 percent of women.

Until recently, menopausal hot flashes were routinely and successfully treated with medicines containing various forms of the female hormones estrogen and progestin. But in 2002 a large clinical trial found that those hormones increased the risk of heart disease, stroke, blood clots, breast cancer, urinary incontinence, and dementia. The increased risks were small but noteworthy on all accounts. (Although more recent research has found that women ages 50 to 59 who have a low risk of heart disease or breast cancer and who started menopause within the past five years might be candidates for low-dose hormone therapy if their symptoms are severe. They might not have a greater risk of heart disease but still face a risk of breast cancer, blood clots, and strokes.)

Fear of such risks has sent many women and their physicians in search of nonhormonal remedies. Fortunately, a growing body of evidence suggests that some newer antidepressants might be an effective alternative, according to new analysis of the published evidence by the American Society of Health-System Pharmacists.

Known as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) these drugs are approved by the Food and Drug Administration for the treatment of major depression and in some cases anxiety or other psychiatric disorders. But they're also used off-label for the treatment of hot flashes, which occur when changing hormone levels throw off the part of the brain that controls body temperature. SSRIs and SNRIs are thought to work by modifying the amounts of certain brain chemicals-serotonin and norepinephrine-that are involved in temperature regulation.

"Newer antidepressants decrease hot flashes more than placebo, and are reasonable options," says Charles Loprinzi, M.D., Regis Professor of Breast Cancer Research at the Mayo Clinic in Minnesota. "They have side effects, and some people don't like the way the drugs change their mood, while others like that component."

What is the evidence for the use of antidepressants for hot flashes?

During the past decade there have been multiple randomized, controlled, double-blind trials on the use of newer antidepressants to relieve hot flashes. Virtually all hot-flash studies have found some placebo effect—more so than with other studied conditions—and a few studies failed to include data about patients' hot flashes before the trial, so there was no baseline measure against which to compare the effects of the study drugs.

In a 2009 meta-analysis, Loprinzi and other researchers evaluated seven trials, all with baseline data. Of the four antidepressants studied, paroxetine (Paxil, generic) and venlafaxine (Effexor, generic) appeared to be the most effective (at studied doses), reducing the frequency and severity of hot flashes by 65 percent and 57 percent, respectively. In addition, another 2009 review of past research, published in Pharmacotherapy, found those two drugs more consistently effective than other antidepressants—although they have also been studied more extensively than any of the other antidepressants. Now another antidepressant, citalopram (Celexa, generic), appears to offer comparable benefits, relieving hot flashes by 55 percent in a 2010 trial published in the Journal of Clinical Oncology. Hormones work in the range of 75 to 85 percent.

While most of the research has focused on women, as many as 80 percent of men receiving androgen suppression therapy for advanced prostate cancer also experience hot flashes. Venlafaxine significantly reduced the number and intensity of hot flashes in such patients in a 2009 trial published in Lancet Oncology.

Hot flashes and antidepressants: What are the risks?

Sexual disorders. Loss of libido and inability to reach orgasm can occur with SSRI or SNRI treatment, although women also report those problems during menopause. Speak with your physician if you experience a change in sexual desire or performance after you start taking the drug.

Serotonin syndrome. This rare but life-threatening reaction happens most often when two drugs that raise serotonin in the brain are used at the same time, causing confusion, hallucinations, loss of coordination, fever, rapid heart rate, and vomiting. Avoid the use of older antidepressants such as monoamine oxidase inhibitors, migraine headache medicines called triptans (Amerge, Imitrex), tryptophan supplements, herbal products like St. John's wort, over-the-counter cough medicines containing dextromethorphan, and prescription painkillers like meperidine (Demerol).

Suicidal behavior. Antidepressants can increase the risk of suicide in people younger than 25. But no matter what your age, if you are thinking about hurting yourself, talk with your doctor.

Common side effects. They include headaches, nausea, anxiety, dry mouth, fatigue, insomnia, drowsiness, and dizziness, but they might be temporary.

What precautions can you take?

Start with a low dose for one to two weeks to minimize side effects and evaluate the drug's effectiveness. Keep a diary of the frequency and severity of your hot flashes and any other symptoms that occur during treatment, and share it with your physician.

Don't abruptly stop taking an antidepressant. That can cause agitation, irritability, anxiety, confusion, nightmares, nausea, insomnia, and electric-shock sensations. If you use the drug for more than a week, it should be tapered off under a doctor's supervision.

If you experience nausea, take the dose with food.

If drowsiness occurs, take the medication at bedtime. Don't drive a car or operate machinery until you know the drug's effects. Limit or eliminate your use of alcohol, which can have a stronger effect when you're taking an antidepressant.

Don't use paroxetine if you are taking the breast-cancer drug tamoxifen. Paroxetine might block the effect of that treatment, putting women at higher risk of dying from the cancer. In general, according to our latest Consumer Reports Best Buy Drugs report on Antidepressants, you should also be aware that there's conflicting evidence from two recent studies about the potential for some antidepressants to negatively interact with the breast cancer drug tamoxifen (Nolvadex and generic). Many women may be taking both drugs because antidepressants are also sometimes used to treat hot flashes. A U.S. study found that women taking tamoxifen and SSRI antidepressants had an increased rate of recurrence of their cancer over two years. But another study done in The Netherlands found no increased rate of cancer recurrence in women taking both tamoxifen and antidepressants for four years.

Until these conflicting results are resolved, we would recommend that if you are taking tamoxifen, then you should avoid SSRI antidepressants for treating hot flashes and talk to your doctor about using other therapies.

Paroxetine should not be taken with the psychiatric drugs thioridazine (generic) or pimozide (Orap).

SSRIs and SNRIs might increase the risk of abnormal bleeding. Tell your physician if you are taking or plan to take a blood thinner such as warfarin (Coumadin, generic) or a nonsteroidal anti-inflammatory such as aspirin or ibuprofen (Advil, generic).

Hot flashes and antidepressants: Lifestyle changes you can try

Avoid potential hot-flash triggers such as alcohol, caffeine, hot or spicy foods, hot drinks, and cigarette smoking. Also avoid using hair dryers and taking hot showers.

Wear loose-fitting cotton clothing in layers that can be removed.

Keep ice water at hand. Lower room temperatures or use a fan.

To help alleviate night sweats, take a cool shower before bed. Wear light cotton pajamas—they're easier to change than sheets. Use cotton sheets only and layered bedding that can be peeled off during the night. Keep a frozen ice pack under the pillow, and turn the pillow often so your head rests on a cool surface.

Try paced respiration—slow, deep abdominal breaths in through your nose and released through your mouth—once or twice a day or at the beginning of a hot flash.

Bottom line. Newer antidepressants might be an effective treatment for moderate to severe hot flashes. Currently published studies support the use of paroxetine and venlafaxine as first-line choices among those drugs. Our advice: Talk with your doctor about your symptoms and all available treatments. If you're concerned about using hormones, consider newer antidepressants only after their risks and benefits have been thoroughly explained to you.

This off-label drug use report is made possible through a collaboration between Consumer Reports Best Buy Drugs and the American Society of Health-System Pharmacists. This is the 16th in a series based on professional reports prepared by ASHP.

These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).
   

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