There are a number of non hormonal options shown to be effective by the British Menopause Society for the very small minority of women for whom systemic HRT is not recommended first line.
SSRI's like Paroxetine, Fluoxetine and Citalopram and SNRI's like Venlafaxine are recognised for their positive effects on depression and anxiety, but studies have shown that in a lower dose they improve hot flushes and night sweats by 50-70%.
Side effects: Headaches, sleep problems, nausea, dry mouth, constipation, low sex drive
Paroxetine 10mg seems to be the most effective and is now licensed in the USA for menopausal hot flushes (if not on Tamoxifen). Others that might be helpful are citalopram 20mg and fluoxetine 20mg.
In breast cancer survivors taking Tamoxifen, Venlafaxine 75mg can reduce hot flushes and shows some improvement in fatigue, mental health and sleep disturbance.
SSRI's should not be offered for vasomotor symptoms unless HRT cannot be given. Women on Tamoxifen should not take fluoxetine or paroxetine as it will make tamoxifen ineffective.
Fezolinetant is a NK3 Receptor antagonist and works on inhibiting NK3 receptors in the thermoregulatory zone in the brain. It is highly effective in reducing hot flushes and night sweats and is generally well tolerated. It is particularly helpful for women with estrogen-sensitive cancer. Dosage: 45mg once a day.
Side effects: Abdominal pain, difficulty sleeping, diarrhoea.
Oxybutynin is used to treat an overreactive bladder, but it has shown to reduce hot flushes and night sweats by up to 75%.
Side effects: Dry mouth, dry eyes, constipation, dizziness, drowsiness, headache, palpitations.
Clonidine is the only non hormonal drug licensed for hot flushes in the UK. ) It is used for high blood pressure, but clonidine can help reduces hot flushes and night sweats in up to 40% of women. It must be stopped gradually as sudden withdrawal can cause rebound hypertension and as it is an anti-hypertensive medication it may not be suitable for patients with low blood pressure.
Side effects: Dry mouth, tiredness, sleep problems.
Gabapentin (and Pregabalin) is used for nerve pain, migraines and to control seizures but studies have shown it can improve flushes and sweats by 50-60% but needs high doses. The dose of Gabapentin needs to be changed gradually according to response and side effects. Some women benefit from this medication as it improves sleep, others find it very sedating, especially during the day. Pregabalin is often slightly better tolerated.
Side effects include sleepiness, dizziness, palpitations, weight gain and dry mouth.
