–History and Physical done, as above.
-Counseling: “Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives.”
-Will start low dose paroxetine (i.e. Paroxetine 7.5mg QD, trade name, Brisdelle), which the only nonhormonal medication approved by the FDA to treat hot flashes. Will consider other dosages if necessary.
-May consider black cohosh. No good evidence per AFP. Some gynecologists recommend it.
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“There is no evidence that using low-dose vaginal estrogen increases the risk of breast cancer recurrence.” AAFP 2016.
“Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years. Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.
Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene.” AAFP 2016
Tx:
Oral SSRIs and SNRIs, including venlafaxine, are effective for menopausal vasomotor symptoms, and paroxetine is FDA-approved for this purpose without the associated risk for developing a DVT that you see with estrogen.
The vasomotor symptoms associated with menopause are best controlled with oral or topical estrogens. However, one of the known risks of systemic estrogen treatment is an increased rate of developing DVTs. This risk is not lessened by adding progestin.
Vaginal estrogen treatment results in very little circulating estrogen. Its use has NOT been associated with DVTs.
Systemic estrogen and progesterone
“For women who are perimenopausal or newly menopausal, start with a cyclic administration of oral micronized progesterone (200 mg/day for 12 days of each calendar month). Continuous administration in this population is associated with irregular, unscheduled bleeding due to the exogenous hormones and the continued endogenous ovarian function.
For women who are ≥2 to 3 years postmenopause, use a continuous regimen (micronized progesterone 100 mg/day); irregular and breakthrough bleeding is less of a problem once ovarian function has ceased.” UTD
I recently refilled a prescription of Progesterone micronized 100 mg capsule daily + Estradiol 0.0375 mg/24 hr semiweekly transdermal patch for a 61year old patient. She was having great results and hasn’t had hot flashes in almost 7 years on them.
References
Am Fam Physician. 2016 Dec 1;94(11):884-889. http://www.aafp.org/afp/2016/1201/p884.html