Hot Flashes: What Are the Alternatives?

Breast cancer survivors look for alternatives to HRT to quell their hot flashes, including antidepressants, antiseizure medications, and integrative therapies. 


Sue Holmes, RN, a breast health coordinator at the deNicola Breast Health Center in Nashua, New Hampshire, was diagnosed at 54 with estrogen receptor-positive noninvasive breast cancer seven years after starting hormone replacement therapy, or HRT, for her symptoms of menopause. “Everybody was taking HRT, then the pendulum swung the other way, and nobody was taking HRT.”

After her diagnosis, Holmes was immediately taken off HRT and her menopausal symptoms returned with a vengeance. “It seemed even worse than I remembered it,” Holmes says. “I was miserable, absolutely miserable. I had terrible hot flashes. I couldn’t think, I couldn’t sleep at night. It was not a good way to live.”

After the Women’s Health Initiative, a large study that examined the effects of combined estrogen and progestin, showed HRT increased the risk of breast cancer, survivors were told to abandon their pills to prevent recurrence. But with few alternatives to combat hot flashes, many survivors feel they must decide between risk of recurrence and quality of life.

Charles Loprinzi, MD, a medical oncologist at Mayo Clinic Cancer Center in Rochester, Minnesota, and a member of the North American Menopause Society, says it doesn’t have to be an either-or decision. While other treatments may not be as effective as HRT, researchers are actively looking at other possibilities to find what works and what doesn’t. Here’s what they’ve found. 

Studies have shown two types of antidepressants—selective serotonin reuptake inhibitors, or SSRIs, and serotonin-norepinephrine reuptake inhibitors, or SNRIs— can reduce the severity and frequency of hot flashes. Effexor (venlafaxine), an SNRI, has the least interference with tamoxifen and has shown effectiveness for hot flashes, decreasing the symptom by 60 percent in more than half of women with hot flashes compared with placebo.

Paxil (paroxetine), an SSRI, decreases hot flashes by up to 70 percent, but new studies show Paxil may interfere with the activity of tamoxifen in some women. Zoloft (sertraline) and Prozac (fluoxetine), also SSRIs, have shown benefit, but not as much as the other antidepressants. 

While Neurontin (gabapentin) is marketed as an antiseizure medication, there are several published placebo-controlled trials that have found it can reduce hot flashes by half. Additional data demonstrate a high dose of the drug might reduce hot flashes a bit more. Dr. Loprinzi recently completed a study of Neurontin to combat hot flashes in prostate cancer patients, and found hot flashes were reduced by almost half compared with about 25 percent reduction with placebo. 

A clinical trial looking at vitamin E and the frequency of hot flashes showed a slight positive effect, says Dr. Loprinzi. Soy and black cohosh have anecdotal evidence as a treatment for hot flashes, but more definitive trials demonstrate that these agents do not appear to be any better than placebo. Because some natural remedies also have potential phytoestrogenic properties (estrogen-like properties seen in natural plant compounds), some physicians advise caution to survivors considering taking large doses for hot flashes.

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