TREATMENT FOR HOT FLASHES AND NIGHT SWEATS

Some women have hot flashes and night sweats in perimenopause and in menopause. They can last for a few months or many years. They can come and go over time. They can be mild or quite severe. Generally, they reduce in frequency and severity after menopause.

There are three groups of treatment options for hot flashes and night sweats: behavioral management, non-hormonal medications and hormone therapy (HT). Many women use the severity and frequency of their symptoms to decide whether or not to treat them. The decision to treat hot flashes with hormonal or non-hormonal medication should be made in conjunction with your provider.

Behavioral management includes wearing loose cotton clothing, lowering the temperature in your living environment, practicing yoga or meditation, paced breathing and avoiding triggers such as alcohol, caffeine and stress. It can also be helpful to work toward a healthy body weight and exercise regularly with a goal of 150 minutes/week of moderate physical activity.

There are non-hormonal medications which may help with hot flashes including an antidepressant medication paroxetine (Paxil) and fezolinetant (Veozah), a neurokinin-3 antagonist. Herbal remedies that have been studied have not been found to be effective.

Hormone therapy is also effective in treating hot flashes and night sweats. Hot flashes generally occur with lower levels of estrogen in menopause so by increasing estrogen, the symptoms resolve. Unless you have already had a hysterectomy, for some other reason, you would also need to take medication to protect your uterus from the estrogen. You don't need to check an estrogen level as the level (blood or salivary test) doesn't correlate with symptoms. Some women with lower levels of estrogen have no symptoms while women with higher levels of estrogen can have severe symptoms. In general, we start by using the lowest dose of estrogen and assess symptoms improvement after about 6 weeks.

Estrogen is available in oral (pills) and transdermal (gel, patch) formulations. Transdermal estrogen has a lower risk of causing blood clots, less impact on your cholesterol and libido and is preferred over oral medications.

If you take estrogen and have a uterus, you must also take a medication to prevent uterine cancer. This can be a progesterone or a SERM (selective estrogen receptor modulator) called bazedoxifene. Progesterones are also available in various formulations (oral, patch, intra-uterine device).

Some forms of hormone therapy are available as combinations of estrogen and a progesterone (patches) or combinations of estrogen and bazedoxifene (pill).

Other benefits of HT include improvement in quality of sleep and mood, reduction in vaginal dryness, urinary urgency and frequency as well as preserving bone density. Some studies show HT might be good for your heart health if you start before age 60 or within 10 years of your last period. If you don't have hot flashes or night sweats and your only symptoms are vaginal and bladder symptoms, you might consider a vaginal estrogen/DHEA medication rather than HT.

HT also has potential risks. HT might increase your risk of strokes or blood clots. Starting HT in women over age 65 may increase the risk of dementia. There may be an increase risk of breast cancer for women who use combination HT (estrogen and progesterone) over age 60 for more than 5 years. For women using estrogen-only HT, studies have shown no increased risk of breast cancer at 7 years but there may be risk with longer use.

Your provider might use guidelines by The Menopause Society to determine if HT is a good option for you. One algorithm for this decision making can be found at

http://www.menopause.org/docs/default-source/2014/menopro-app-algorithm-2014.pdf

There are many doses and formulations of HT and you should discuss all your options with your provider.