HRT Alternatives

I am a 55 year old woman and recently decided to discontinue hormone replacement therapy, but have been troubled by hot flashes. Are there any alternatives?

Most other problems associated with estrogen withdrawal (vaginal dryness, osteoporosis, high cholesterol) can be managed just as well with lifestyle changes or medications. Unfortunately, hot flashes lack a perfect therapeutic alternative.

First, wean gradually off HRT over several weeks, as this may lessen the severity and duration of initial hot flashes. Avoiding caffeine, alcohol, and spicy foods, and keeping temperatures low in your home and work environments may decrease the number of hot flashes. Cardiovascular exercise helps as well. Vitamin E has not proven much better than placebo in small studies, but I sometimes recommend it to women wanting to avoid other medications (1000 IU/day for at least six weeks initially).

Alternative medications that have proved better than placebo in preventing hot flashes include Effexor and Prozac (antidepressants), Neurontin (traditionally used as a pain medication--promising, but expensive), and Clonidine (a blood pressure med). Topical progesterone cream and another progestin (Megace) are also effective; these are not good choices for women who have discontinued estrogen because of a breast cancer diagnosis.

I have had patients who have anecdotally reported improvement with black cohosh, wild yam cream, and a variety of herbal and nutritional supplements. To date, none of these has been evaluated in large randomized trials against placebo. Also, these supplements are not closely regulated by the FDA; they may vary considerably in their composition and concentration.

Finally, if your hot flashes prove refractory to alternative therapies, you may want to reexamine the risks of estrogen with your health care provider. Quality of life is important, and this may outweigh other concerns, especially in the short term.

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