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Antidepressant officially labeled for menopause relief: the FDA's approval of the antidepressant paroxetine brisdelle brings forward a nonhormonal option to offer relief, but there are limitations.

Hot flashes are the most common symptom of menopause and often the most bothersome. While some women may never experience the vasomotor symptoms hot flashes cause, for those who do their impact can be life altering. In a pursuit for relief, many turn to hormone replacement therapy. Yet, for those who can't take estrogen or choose not to due to the feu of an increased risk of heart disease and breast cancer, there may be another answer.

With the approval of the antidepressant paroxetine (Brisdelle) by the Food and Drug Administration (FDA) to treat moderate to severe hot flashes, women may find the selective serotonin reuptake inhibitor (SSRI) drug as the non-hormonal answer to end their suffering. But antidepressants aren't for everyone, according to Holly I. Thacker, MD, FACP, Professor and Director of the Cleveland Clinic Center for Specialized Women's Health. 'Although many patients have no contraindications to menopausal hormone therapy, often the first thing they're prescribed is an off-label psychiatric medication to treat their hot flashes," says Dr. Thacker. "The lower dose of Bris-delle approved by the FDA does help avoid the issues of sexual dysfunction and weight gain that the higher doses of paroxetine (Paxil) are related to, but antidepressants do not offer the same possible health benefits that hormone replacement therapy offers:"

Why antidepressants may help

Women have long been prescribed off-label psychiatric drugs to treat hot flashes, especially if they can't tolerate hormone therapy--or have a history of heart disease, blood clots, deep vein thrombosis, and stroke. Theoretically, SSRIs like paroxetine help manage hot flashes because serotonin is believed to play a role in regulating body temperature. "Many women who are already on psychiatric medicines for other reasons don't have hot flashes--or avoid them and don't even realize it--due to this class of medication literally 'resetting' the thermostat in the brain," says Dr. Thacker.

Studies have shown that certain antidepressants may be beneficial in relieving hot flashes. A randomized, controlled trial of escitalopram (Lexapros[R]) published in JAMA (January 2011) found that menopausal women had at least a 50 percent reduction in the severity and number of hot flashes a day after eight weeks of treatment. Separate research shows that venlafax-Me (Effexors[R]) lowers the number and severity of hot flashes for most women.

When HRT may be a better option

While the newly approved version of paroxetine helps avoid weight gain and sexual dysfunction typically caused by higher doses of antidepressants, there are certain groups of patients who are not candidates for this alternative hot flash treatment, explains Dr. Thacker.

We would recommend cautioning using paroxetine in women being treated for breast cancer with tamoxifen due to the combination causing a possible reduction in effectiveness." she says.

Dr. Thacker explains that the liver relies on a certain enzyme known as CYP2D6 to convert tamoxifen into endoxifen, a form that is active in the body. Studies suggest that paroxetine inhibits CYP2D6 and interferes with tamoxifen treatment.

"Paroxetine also does not treat vulvovaginal atrophy caused by the lack of estrogen," says Dr. Thacker. And, it's important that a woman be evaluated for her risk of osteoporosis before using paroxetine. Antidepressants do not treat or prevent osteoporosis like hormone replacement therapy does. "Hot flashes are not a minor nuisance or a joke--they are serious and should be treated," she says. "But, a woman's overall health should be taken into consideration before deciding which treatment route to prescribe,"
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Publication:Heart Advisor
Date:Jul 1, 2014
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