A Risky Side Effect of Hot-Flash Treatment: Bone Loss

EverydayHealth.com June 30, 2015

EverydayHealth.com June 30, 2015

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.

Non-hormonal Help for Hot Flash Hell

By Lauren Streicher, MD

Published Nov 11, 2013, EveryDay Health

The millions of menopausal women who are sweating, disrobing and desperately trying to manage their hot flashes by layering clothes, taking herbs and carrying a portable fan now have another alternative. Brisdelle™, the first and only FDA approved non-hormonal option for hot flash relief is now available.

Up until now the only FDA approved products proven to reduce hot flashes have been estrogen-based prescriptions. I am in the camp that most women can safely take estrogen and that the risks are dramatically smaller than many women think. But, having said that, I am also well aware that in spite of the reassurances of menopause experts like myself, the majority of women choose not to take estrogen, or have been advised by their doctors to steer clear. In fact only 7% of women with hot flashes ultimately accept a prescription for estrogen. The rest just tough it out.While that works out for some women, (like the one’s who live in Alaska), other’s who have severe hot flashes though out the day and nights are totally blind sided by just how debilitating hot flashes can be. Many women also are not prepared for how long they last. While the average woman can expect to experience moderate to severe hot flashes for 3- 5 years, in some women they continue forever.

Brisdelle™ is a low dose (7.5 mg) of paroxetine, one of the selective serotonin reuptake inhibitor (SSRI) antidepressants that years ago was serendipitously found to significantly reduce hot flashes in menopausal women. I, like many physicians, have in the past prescribed paroxetine “off label”. There are two reasons why I am glad I can now prescribe a low dose FDA approved version as opposed to generic paroxetine:

  • Paroxetine at higher doses is intended for, studied and FDA approved only for the treatment of depression, not hot flashes. Many of my patients have received a prescription and then also had the experience of their insurance company giving them a diagnosis of depression even though they are not depressed. Just hot. I had one patient for whom I prescribed Paxil for hot flash relief (clearly documented on her electronic medical record) who was contacted by her insurance company to see if her “depression” was improving and to offer psychotherapy! Brisdelle 7.5 mg is FDA approved only for treatment of moderate to severe hot flashes as a result of menopause. It cannot, and should not, be prescribed for treatment of depression and therefore is not interpreted as a treatment for depression on your medical record.
  • The doses of generic paroxetine available for treatment of depression are higher than needed to relieve hot flashes. With higher dosage, comes a greater risk of side affects. As an example, Paxil and other SSRI’s are associated with an increase in sexual problems and an increase in pounds. The last thing a menopause women needs is a drug that might sabotage her diet or an already waning sex drive. In clinical trials, Brisdelle, with only 7.5 mg of paroxetine, did not demonstrate a decrease in libido or an increase in weight.

Every once in awhile someone will say, my grandmother didn’t take anything for hot flashes, why should I? Well grandma was more likely to be home baking cookies than doing a job that required a good nights sleep and the ability to think clearly. Grandma was unlikely to be starting a second marriage or a new relationship in her 50’s. Grandma likely did not live nearly as long as you will. The average age of menopause is 51, which means most woman will live more than one third of her life post menopause.

So, you now have options, and whether you personally decide to take estrogen, Brisdelle or do yoga to manage your flashes; you owe it to yourself to know what those choices are.

Cold Facts About Hot Flashes

By Lauren Streicher, MD

Published May 27, 2014, Everyday Health

The number one reason most women start systemic estrogen is to treat hot flashes once they realize that yoga, carrying a portable fan, and dressing in layers are not real solutions. Hot flashes occur in 75 percent of menopausal women and typically begin as a sudden sensation of heat on the face and upper chest that becomes generalized. A severe flash can be pretty intense (I call it the furnace inside you) lasting between two and four minutes with profuse sweating, followed by chills and shivering. Physiologically, a hot flash happens for the same reason that you sweat in a sauna… the body is trying to cool down. The difference is, you don’t really need to cool down, but your menopausal brain thinks you do. While most last 2-4 years, some women will experience flashes for up to 10 years. About 10 percent…forever.

Toughing it out works out for some women, but other’s who have severe hot flashes though out the day and nights are totally blind sided by just how debilitating hot flashes can be. Estrogen therapy will eliminate or dramatically reduce flashes, but many women choose not to take estrogen, or have been advised by their doctors to steer clear. In fact only 7 percent of women with hot flashes ultimately accept a prescription for estrogen. As an estrogen alternative, menopause experts, including myself, often prescribe one of the antidepressants which years ago were serendipitiously found to reduce hot flashes in menopausal women. This of course is the rationale for Brisdelle; the FDA approved option of low dose paroxetine, one of the selective serotonin reuptake inhibitor (SSRI) antidepressants.

While numerous scientific studies have shown that many antidepressants are effective at reducing hot flashes, no studies have compared antidepressants, estrogen and placebo in the same study.

In the May 27 issue of JAMA, a new research study is published looking specifically at this issue. 339 peri and postmenopausal women in the study took estrogen, venlafaxine (an antidepressant), or a placebo for 8 weeks. Women that took the venlafaxine had a reduction in hot flashes that was essentially as good as women that took low dose estrogen.

In addition to flash frequency, this study also looked at “treatment satisfaction” and interference of symptoms with daily life and found that treatment satisfaction was highest for estradiol, intermediate for venlafaxine, and lowest for placebo.

The study is somewhat limited in that it was short (only 2 months) and did not evaluate libido or weight gain, both of which have been shown to be affected by antidepressants used in typical doses used to treat depression. That evaluation would require a longer study and more women. But, be that as it may, this is still important information and confirms that venlafaxine, like other SSRI’s and SNRI’s, at least in the short term, not only reduces hot flashes, but does it almost as well as estrogen.

Every once in awhile someone will say, my grandmother didn’t take anything for hot flashes, why should I? Well grandma was more likely to be home baking cookies than doing a job that required a good night’s sleep and the ability to think clearly. Grandma may have been having occasional sex with Grampa, (there’s a visual I didn’t need to give you!) but was unlikely to be starting a second marriage or a new relationship in her 50’s. Grandma likely did not live nearly as long as you will. So whether you chose to take hormone therapy or an alternative, if your flashes are getting in the way of your sleep, your sexual health or your quality of life, know that you have options.