Pearls of Wisdom: Choices for Menopausal Hot Flashes

A 52-year-old woman has been having hot flashes 12 to 15 times a day for almost 6 months, causing a strong negative impact on her work and sleep. She has a history of stage 1 breast cancer (estrogen receptor-negative) 10 years prior.

Which therapeutic option might be best for her to try?

A. Conjugated estrogen, 0.625 mg/d
B. Conjugated estrogen, 0.31 mg/d
C. Gabapentin
D. Duloxetine

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.

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Answer: Gabapentin

Hot Flashes

When women reach midlife maturity and beyond, they are often bothered by hot flashes. Because men don’t experience hot flashes except in extraordinary circumstances of hormone deprivation, it may be difficult for male clinicians to understand the burden associated with them.

In typical trials of women who are experiencing adverse menopausal symptoms, hot flashes are described as experiences that last as long as 4 to 6 minutes; are associated with intense flushing, a sensation of heat, and sweating; and occur as often as 12 to 15 times a day. Hot flashes don’t respect the clock, either, so women may experience disturbed sleep because they are awakened once or twice a night by hot flashes. Hot flashes can be a major issue for many women that sometimes lasts for years.
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Our patient has a history of breast cancer, so one would be most reluctant to prescribe typical hormone replacement therapy. Whether or not hormone therapy is absolutely contraindicated in this situation has been debated, but it is probably best to avoid that course of treatment if possible.

So what about gabapentin or duloxetine?

The Research

Researchers conducted a randomized, double-blind, placebo-controlled trial of 60 postmenopausal women aged 35 to 60, directly comparing a nonestrogen treatment against estrogen.¹ All participants had reported at least 50 hot flashes per week for at least the previous 2 months, and they were randomly assigned to recieve either gabapentin titrated to 2400 mg/d (n=20), traditional therapy with 0.625 mg/d of conjugated estrogens (n=20), or placebo (n=20) for 12 weeks.

The Results

Overall, despite a small decline in hot flashes observed in participants assigned to placebo, estrogen and gabapentin markedly outperformed placebo.

Hot Flashes: Estrogen Alternative¹

After 1 week of treatment, gabapentin was associated with moderate improvement in the average number of hot flashes the women experienced. By 2 to 4 weeks, both gabapentin and estrogen were associated with significant improvement. By 12 weeks, the results with gabapentin and estrogen were nearly indistinguishable.

What’s the “Take-Home”?

The authors conclude that, despite the small size of the study, the results appear to indicate that gabapentin is as effective as estrogen in the treatment of hot flashes. Luckily, we already have a good deal of comfort with the safety and efficacy profile of gabapentin. In women with hot flashes who cannot take estrogen, are other choices are available.

Reference:
1. Reddy SY, Warner H, Guttuso T Jr, et al. Gabapentin, estrogen, and placebo for treating hot flushes: a randomized controlled trial. Obstet Gynecol. 2006;108(1):41-48.