Alternatives to HRT: Prescription Options

Prescription options for treating hot flashes include antidepressants, gabapentin, and clonidine

Not all women want to take hormone replacement therapy (HRT), and women who have had breast cancer or are at high risk for breast cancer are not advised to do so, due to fears it will increase the risk of cancer or a recurrence. What options are available to these women? Prescription options for treating hot flashes include antidepressants, gabapentin, and clonidine.


Studies have found that the antidepressant venlafaxine (brand name Effexor) decreased hot flashes by 50%. Studies of two SSRIs (selective serotonin reuptake inhibitors), fluoxetine (brand name Prozac) and paroxetine (brand name Paxil), found that these also reduced hot flashes by 50% when compared to placebo. That means if you have six hot flashes a day, taking an SSRI may reduce this to three. If your hot flashes are bad, these drugs may be worth a try. Because each drug works slightly differently, if one doesn’t work, you may want to try another before giving up on all of them. Antidepressants might be especially helpful to women whose symptoms include both hot flashes and depression. SSRIs are believed to work because of the role serotonin plays in regulating the body’s temperature. When used to treat hot flashes, these drugs are prescribed at half of the daily dose that would be used to treat depression. This is done to try to decrease SSRI-associated side effects, such as dry mouth, nausea, appetite change, and decreased libido.


Gabapentin (brand name Neurontin) is another drug that may have found a home as a treatment for hot flashes. It’s typically used to treat migraines, but when women using it for that purpose found it also stopped their hot flashes, researchers began to study the drug more closely. In September 2005, results from a study conducted at the University of Rochester of 420 women with breast cancer who were having two or more hot flashes a day were published in Lancet. The study, which randomized women to two different doses of gabapentin or to a placebo, found that 900mg of gabapentin reduced hot flashes by about half. (A dose of 300mg/day was not effective.) That means if you had four hot flashes a day, you would now have two. Although the study was conducted in women with breast cancer, there is no reason to believe these findings are limited to that group, making the drug an option for all women in need of symptom relief.


Clonidine (brand name Catapres) is normally used to control blood pressure, but it is now sometimes recommended for women who experience hot flashes while on tamoxifen, a hormone used to treat breast cancer. In an eight-week placebo-controlled trial in postmenopausal women with tamoxifen-induced hot flashes, 38% of the women on clonidine reported a reduction in hot flash frequency compared with 24% of the women on placebo. However, there were a lot of side effects: fatigue, nausea, irritability, headache, and dizziness. So, while this drug may be an option for some women, the side effects may be a huge drawback for others. Note: In May 2006, the Journal of the American Medical Association published “Nonhormonal Therapies for Menopausal Hot Flashes”. This paper is a review and assessment of the previously published studies on the use of antidepressants, gabapentin, and clonidine for treating hot flashes. The authors concluded that these drugs are less effective than estrogen in reducing hot flashes and that “these therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.”

In an accompanying editorial, Jeffrey A. Tice, MD, and Deborah Grady, MD, of the University of California, San Francisco, discuss the research findings. They note, “Women with hot flashes should understand that most symptoms resolve over several months to several years … For women with more bothersome symptoms, clinicians should understand the advantages and disadvantages of both hormone therapy and nonhormonal alternatives. Hormone therapy is more effective than nonhormonal alternatives but should probably be avoided by women at high risk for venous thromboembolic events [blood clots], cardiovascular disease, and breast cancer.”

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