In spite of the reassurances of menopause experts like me, many women choose not to take estrogen or have been advised by their doctors to steer clear. In fact, fewer than 10 percent of women with hot flashes ultimately accept a prescription for estrogen, and many never fill it. For the 90 percent who prefer not to take estrogen, or have been told they should not, most quickly find that doing yoga, wearing layers, and avoiding red wine are not real solutions.
For years, my go-to alternative to estrogen therapy has been to prescribe a selective serotonin reuptake inhibitor (SSRI) such as Paxil (paroxetine) or a serotonin and norepinephrine reuptake inhibitor (SNRI) such as venlafaxine. It has been known for some time that these non-hormonal drugs developed to treat depression also significantly reduce hot flashes in menopausal women.
The problem, other than that women really don’t want to be prescribed an antidepressant for hot flashes when their problem is not depression, is that many women experience the known side effects of SSRIs – namely, loss of libido and weight gain. The last thing a menopausal woman needs is a drug that might sabotage her diet or an already waning sex drive!
Now there is an additional concern. A new study published in the BMJ journal Injury Prevention suggests that hot-flashing women who take an SSRI at the standard doses used to treat depression may accelerate bone loss and increase their fracture risk. This is actually not new information: Prior epidemiological studies on bone fracture risk following exposure to SSRIs have reported an association (as opposed to a cause-and-effect relationship) between SSRI treatment and fractures.
The real question: Is the same issue seen in low-dose paroxetine? Specifically, does Brisdelle (the only FDA-approved nonhormonal option for hot flash relief), with 7.5 milligrams of paroxetine, have the same side effects seen in doses of 10, 20, 30, and 40 mg of paroxetine?
In clinical trials, Brisdelle, unlike the higher doses of paroxetine used to treat depression, was not associated with a decrease in libido or an increase in weight.
At this point, it is impossible to say with certainty that 7.5 mg of paroxetine does not accelerate bone loss since this dose was not studied in the BMJ/Injury Prevention group. However, it stands to reason that 7.5 mg of paroxetine used to treat hot flashes is less likely to cause bone loss than higher doses intended to treat depression.
So, the bottom line: SSRIs are an excellent option to alleviate hot flashes if estrogen is not an option. But make sure you are bone savvy. Take your calcium, get in that weight-bearing exercise, check your vitamin D levels, and have your bone density checked according to National Osteoporosis Foundation guidelines. Know that if you are losing bone, your SSRI might be part of the problem. As with every drug with potential side effects, it makes good sense to take the lowest dose needed to treat the problem. While it’s tempting to take a less expensive higher-dose generic to alleviate your hot flashes, know it might kill your libido, put on the pounds, and possibly deplete your bones.