What non-hormonal alternatives to antidepressants are available for the management of menopausal hot flushes?

· Southampton Medicines Advice Service, UKMi

This is one of two Medicines Q&As addressing the management of menopausal hot flushes with non-hormonal drug therapy.

Summary

  • Hot flushes (or flashes), along with night sweats, palpitations and headaches, are one of a group of symptoms known as vasomotor symptoms (VMS) commonly experienced by women in the menopause.
  • To help reduce hot flushes, women should be encouraged to take regular exercise, reduce obesity and stress and wear lighter clothing. Any trigger factors should be avoided
  • Hormone replacement therapy (HRT) is established as the most effective treatment for menopausal VMS and is thus recommended as the first-line choice for women requiring pharmacological management. However, alternatives may need to be considered for women with contraindications or who do not wish to take HRT.
  • Aside from antidepressants, the non-hormonal therapies most frequently considered as an alternative to HRT for the management of menopausal hot flushes are clonidine and gabapentin.
  • Studies have also been conducted using methyldopa, octreotide, and pregabalin which have produced variable results.
  • Clonidine is the only non-oestrogen based preparation that is licensed for menopausal flushing in the UK, but its usefulness is limited by moderate efficacy and relatively high rate of adverse effects. It is not recommended as a routine first-line treatment in the NICE Menopause Guidelines, and international Endocrine Society guidelines suggest it should be reserved for women not responding to, or unable to tolerate SSRI/SNRI antidepressants, gabapentin or pregabalin.
  • Although not licensed for menopausal flushing and not recommended in the NICE guidelines, gabapentin is suggested as one of the preferred options for women requiring non-hormonal therapy in a variety of other guidelines. Its efficacy appears to be similar to SSRI/SNRI antidepressants, although side effects may be greater.
  • Most studies have been short-term, and the long-term efficacy and safety of non-hormonal treatments for menopausal hot flushes is not known.
  • Clinicians should review efficacy and tolerability of treatment after 3 months and annually thereafter.
ClonidineGabapentinMethyldopaObstetrics and gynaecologyOctreotidePregabalinQ&A

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