Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
14 March 2007

THOSE PESKY HOT FLASHES

            A lady recently wrote in asking for help with hot flashes that had occurred as she was proceeding through menopause.  This is an age-old problem but hot flashes are only one part of the complex of symptoms that occur in menopause.  In order of incidence, the most common symptoms include unaccustomed headaches, sleep disturbance, hot flashes and vaginal dryness.  There are some women that note that their husbands become unusually difficult to get along with but we men have never figured out quite how menopause makes us irritable. 

            Forty years ago, we thought we had a solution to menopausal symptoms with the use of something called estrogen replacement therapy.  The Wyeth Pharmaceutical Company produced Premarin for the express purpose of stopping menopausal symptoms.  There are enough studies to show that the drug is very effective in most women.  In addition, there is no argument today that it is a potent protector of bone health preventing broken hips and broken backs.

            In 2002, a very large study of women called the Women’s Health Initiative published results of the effects of estrogen replacement therapy with Premarin and other estrogen replacement products.  To that time, estrogen had been touted as being heart protective.  The Women’s Health Initiative clearly showed that estrogen replacement therapy did not prevent heart attacks and some misinformed individuals contended that estrogen actually caused heart attacks.  In the Women’s Health Initiative, there were more heart attacks in the group of women who took estrogen than the group that did not, but the statistics do not support the concept that estrogen caused the heart attacks.  It merely showed that it did not prevent them. 

            In regard to cancer risk, there does seem to be a very small increased risk of carcinoma of the breast in women who use estrogen.  I have always contended that estrogen did not cause the breast cancer but rather allowed those cancers that did occur to grow faster.  As a fringe benefit, those cancers that are estrogen sensitive are easier to treat and thus there does not appear to be an increased mortality from breast cancer in women who used estrogen. 

            To this time, estrogen replacement therapy remains very controversial.  It is my personal belief that if a lady does not have major risk factors for heart disease, the use of low dose estrogen replacement therapy to prevent menopausal symptoms is safe.  Annual surveillance with mammography and pap smears for women who have not had a hysterectomy are important healthcare maintenance steps for women who would choose estrogen replacement therapy. 

            But what about that large group of women who the media have convinced that estrogen is “poisonous” causing cancer, stroke and heart disease.  In 2001, there were 91 million prescriptions for estrogen.  By 2003, after the Women’s Health Initiative was published, that had dropped to 57 million prescriptions.  In other words, not every woman believes that estrogen is poisonous or at least they believe that the relief that they get from their menopausal symptoms is worth the risk. 

            So what are the alternative medicines that have been studied for this purpose?  In a study published in the Annuals of Internal Medicine in December of 2006, five different treatments were evaluated for the ability to stop menopausal symptoms.  One group of women had no medication but took a “blank pill”.  They had lots of symptoms.  Another group took estrogen and their symptoms were reduced by 80%.  A third, fourth, and a fifth group took black cohosh or botanical products containing black cohosh or botanical products containing black cohosh and using soy as an additional ingredient.  None of the three black cohosh groups had any reduction in their menopausal symptoms.  Soy had no effect to stop postmenopausal symptoms.  So here goes another bubble burst with an alternative medicine that makes money for the people who sell it but doesn’t do anything for the people who use it.

            There are other medications that have small studies supporting their use to treat post menopausal symptoms.  One of these that seems to help some women is Prozac.  This medication was originally prescribed as an antidepressant.  Incidentally, it was noted that some menopausal depressed women who used Prozac had fewer hot flashes.  Several small studies have been done and it does appear that Prozac reduces hot flashes in some woman.  Now that the drug is generic, it is a relatively cheap and safe medication to reduce hot flashes.  

            There are web sites on the internet for the National Institute of Health.  This is your governmental agency analyzing things that work and things that don’t.  The National Institute of Health does seem to get things right.  While I am loath to mention it, their web site indicates that “diet and exercise” is one of the mainstays to prevent menopausal symptoms.  It has been noted for many years that women who tend to be more overweight have more menopausal symptoms than those who are at “ideal body weight”. 

            Lastly, there is one more drug that may be some help for some women.  Specifically, the blood pressure medication called clonidine in low dose may be helpful in preventing hot flashes and headaches.  This is another one of those accidental observations whereby women taking the medication for blood pressure control suddenly found that their menopausal symptoms got better. 

            In summary, menopausal symptoms vary quite substantially from one individual to the next.  What helps is also highly variable from one individual to the next.  Our genetics are very different and what works for some people may not work at all for others.  If black cohosh works for a given woman, go for it; at least it has not been shown to be dangerous.  The healthcare providers at your local clinics are aware of these various considerations and can work with individual programs for individual people to alleviate their symptoms.