Use of Antidepressants for Management of Hot Flashes

Dana G. Carroll, Pharm.D.; Kristi W. Kelley, Pharm.D.

Disclosures

Pharmacotherapy. 2009;29(11):1357-1374. 

In This Article

Recommendations

The North American Menopause Society recommends the following antidepressants and dosages for relief of hot flashes: venlafaxine 37.5-75 mg/day, paroxetine 12.5-25 mg/day, and fluoxetine 20 mg/day.[3] The American College of Obstetricians and Gynecologists recognizes that venlafaxine, paroxetine, and fluoxetine may be helpful in treating hot flashes in women with a history of breast cancer or who do not want to take hormonal therapy.[2] Recommendations by both of these organizations regarding use of SNRIs and SSRIs were last updated in 2004. Since that time, a significant amount of data has been published regarding these antidepressant therapies and others in the treatment of hot flashes. Venlafaxine and paroxetine have been studied more extensively than any of the other SNRIs and SSRIs for relief of hot flashes (Table 3). At this time, venlafaxine and paroxetine appear to be effective in reducing the frequency and severity of hot flashes and should be considered first-line options when selecting an antidepressant for hot flash relief. Desvenlafaxine, sertraline, fluoxetine, and citalopram should be considered second- or third-line options if patients fail therapy with or cannot tolerate venlafaxine or paroxetine. Duloxetine, escitalopram, fluvoxamine, and mirtazapine should be reserved as last-line therapy until more rigorous studies are conducted to assess their use in the management of hot flashes. Ideally, these studies should be randomized controlled trials with more diverse menopausal patient populations. In addition, they should be at least 12 weeks in duration but preferably longer to determine long-term effects.

Regardless of which antidepressant is chosen to help relieve hot flashes, the following general principles apply:[3]

  • Start at a low dose; low doses will usually minimize adverse effects but still provide relief of hot flashes

  • Use recommended doses; there is no evidence to support higher doses

  • Recommend a trial for 1-2 weeks before increasing the dose or stopping therapy

  • Do not abruptly stop therapy; taper off the drug if used for more than 1 week

  • Monitor all patients for nausea and sexual dysfunction

  • Take with food if drug causes nausea

  • Take at bedtime if drug causes drowsiness

Patients should not abruptly stop any of these drugs. Also, for patients who have been taking these drugs more than 1 week, the usual recommendation is to taper off the drug to prevent the headaches and anxiety often associated with withdrawal.[3] All patients should be monitored for relief of hot flashes as well as for adverse effects that may occur with therapy.

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