COMMENTARY

Nonhormonal Treatments for Hot Flashes Offer Women More Choices

JoAnn E. Manson, MD, DrPH

Disclosures

July 18, 2014

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Hello. This is Dr. JoAnn Manson, Professor of Medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts.

Today I want to talk about a study published in JAMAInternal Medicine several weeks ago that looked at the effects of a hormonal and a nonhormonal treatment for reducing hot flashes. This was a randomized clinical trial,[1] part of the Ms-FLASH clinical trial network that compared low-dose oral estradiol, low-dose venlafaxine, a serotonin-norepinephrine reuptake inhibitor, and placebo in reducing vasomotor symptoms in perimenopausal and postmenopausal women. The study was led by Dr. Hadine Joffe, and I was one of the coauthors of the study.

We all know that it is important for women to have choices for managing menopausal symptoms. Many women are not candidates for hormonal treatment or would strongly prefer a nonhormonal option for managing the vasomotor symptoms of menopause. This trial included 339 perimenopausal and postmenopausal women who had an average of 8.1 hot flashes per day at baseline. They were randomly assigned to receive a low-dose oral estradiol, 17-beta estradiol, 0.5 mg per day; low-dose extended release venlafaxine, 75 mg per day; or placebo.

Overall, both the estradiol and the venlafaxine led to substantial reductions in hot flashes, but the estradiol was slightly more effective. Women in the estradiol arm experienced a 53% reduction overall in hot flashes during the 8 weeks of treatment; women in the venlafaxine arm had a 48% reduction; and women in the placebo arm had a 29% reduction in hot flashes.

In terms of severity and bother, both of the interventions led to substantial improvements, but again, the estradiol was slightly better. And in terms of satisfaction with treatment, with the estradiol, 70% of the women reported satisfaction with treatment; with venlafaxine, 51%; and with placebo, 38%.

Adverse Effects May Help Identify Appropriate Candidates for Nonhormonal Option

This was an 8-week trial, so few risks or adverse events were identified. We know that hormone therapy is associated with some risks. As expected, the frequency of vaginal bleeding was higher with the estradiol than with venlafaxine or placebo. But with venlafaxine, there was an increase in blood pressure in some women, particularly the women who had higher body mass index or higher baseline blood pressure. This is important information for clinicians when identifying women who are appropriate candidates for venlafaxine treatment.

Overall, this study is good news for women because it suggests that there are both hormonal and nonhormonal treatments for hot flashes. We know that low-dose paroxetine has been approved by the US Food and Drug Administration for management of vasomotor symptoms. Venlafaxine is not yet FDA approved for this indication, but this study suggests that venlafaxine also has substantial benefits in terms of reducing frequency of hot flashes related to menopause.

Thank you very much for your attention. This is JoAnn Manson.

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