The Use of Antidepressant Drugs in Climacteric Syndrome

Maria Célia Mendes Marcos Felipe Silva de Sá About the authors

Vasomotor symptoms (VMS) or hot flashes interfere with women's quality of life and are the probable cause of sleep disorders, lack of energy, depression and tiredness in the peri- and postmenopausal period. These symptoms normally last between 2 and 10 years, with an average of 7.4 years or more.11 Pinkerton JV, Sánchez Aguirre F, Blake J, Cosman F, Hodis HN, Hoffstetter S et al. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause.2017;24(7):728-753. doi: 10.1097/GME.0000000000000921
https://doi.org/10.1097/GME.000000000000...
22 Avis NE, Crawford SL, Greendale G, Bromberger JT, Everson-Rose SA, Gold EB et al. Study of Women's Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539. doi: 10.1001/jamainternmed.2014.8063
https://doi.org/10.1001/jamainternmed.20...
Estrogen therapy is the treatment of choice for VMS and reduces both the weekly frequency and the severity of these symptoms.33 Santen RJ, Allred DC, Ardoin SP, Archer DF, Boyd N, Braunstein GD et al; Endocrine Society. Postmenopausal hormone therapy: an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2010;95(7, Suppl 1):s1-s66. doi: 10.1210/jc.2009-2509
https://doi.org/10.1210/jc.2009-2509...
44 Maclennan AH, Broadbent JL, Lester S, Moore V. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev. 2004;(4):CD002978. doi: 10.1002/14651858.CD002978.pub2
https://doi.org/10.1002/14651858.CD00297...
For hot flashes relief, hormone treatment lasts 3 to 5 years and discontinuity may lead to recurrence in up to 50% of symptoms. On the other hand, by considering the benefits of hormone therapy for osteoporosis prevention, quality of life improvement and treatment of persistent VMS,11 Pinkerton JV, Sánchez Aguirre F, Blake J, Cosman F, Hodis HN, Hoffstetter S et al. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause.2017;24(7):728-753. doi: 10.1097/GME.0000000000000921
https://doi.org/10.1097/GME.000000000000...
there is a current trend to extend treatment until the age of 60 or 65 years old.

Other drug therapies are suggested for women who do not wish to undergo estrogen therapy, usually for fear of cancer, and those with contraindications to hormone treatment, although the results of these therapies are far lower than conventional estrogen therapy. These include selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs). Despite the inferior therapeutic results, after estrogen, these are the most used drugs for the treatment of VMS,55 Santen RJ, Loprinzi CL, Casper RF. Menopausal hot flashes [Internet]. UpToDate; 2016 [2019 May 12]. Available from: https:// www.uptodate.com/contents/menopausal-hot-flashes
https:// www.uptodate.com/contents/menop...
and they have a very fast action (in days) in reducing hot flashes, while their antidepressant action will occur later (in weeks).66 Freeman EW, Guthrie KA, Caan B, Sternfeld B, Cohen LS, Joffe H et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA. 2011;305(3): 267-274. doi: 10.1001/jama.2010.2016
https://doi.org/10.1001/jama.2010.2016...

The efficacy of this treatment is hard to evaluate, because the symptom reduction may be caused by the placebo effect of these drugs.55 Santen RJ, Loprinzi CL, Casper RF. Menopausal hot flashes [Internet]. UpToDate; 2016 [2019 May 12]. Available from: https:// www.uptodate.com/contents/menopausal-hot-flashes
https:// www.uptodate.com/contents/menop...
Furthermore, clinical trials have no long-term follow up of patients, and most studies evaluate treatment efficacy by comparing with placebo at 4 to 12 weeks and the effect at 12 to 24 weeks after drug discontinuation.77 [No authors listed]. Nonhormonal management of menopauseassociated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11): 1155-1172, quiz 1173-1174. doi: 10.1097/GME.000000000000 0546
https://doi.org/10.1097/GME.000000000000...
Both SSRIs and SNRIs bring mild to moderate improvement in symptoms and 25% to 69% reduction in hot flashes.77 [No authors listed]. Nonhormonal management of menopauseassociated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11): 1155-1172, quiz 1173-1174. doi: 10.1097/GME.000000000000 0546
https://doi.org/10.1097/GME.000000000000...
88 Stearns V, Ullmer L, López JF, Smith Y, Isaacs C, Hayes D. Hot flushes. Lancet. 2002;360(9348):1851-1861. doi: 10.1016/ s0140-6736(02)11774-0
https://doi.org/10.1016/...
99 Wisniewska I, Jochymek B, Lenart-Lipinska M, Chabowski M. The pharmacological and hormonal therapy of hot flushes in breast cancer survivors. Breast Cancer. 2016;23(2):178-182. doi: 10.1007/s12282-015-0655-2
https://doi.org/10.1007/s12282-015-0655-...
For the treatment of VMS, the North America Menopause Society (NAMS) recommends paroxetine (recommendation level I), citalopram, escitalopram, venlafaxine and desvenlafaxine (level II),77 [No authors listed]. Nonhormonal management of menopauseassociated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11): 1155-1172, quiz 1173-1174. doi: 10.1097/GME.000000000000 0546
https://doi.org/10.1097/GME.000000000000...
although only paroxetine has been approved by the FDA and is recommended by the American College of Obstetrics and Gynecology (ACOG).1010 Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin N. 126: Management of gynecologic issues in women with breast cancer. Obstet Gynecol. 2012;119(3):666-682. doi: 10.1097/AOG.0b013e31824e12ce
https://doi.org/10.1097/AOG.0b013e31824e...

Regarding fluoxetine and sertraline, publications present conflicting results. Some authors argue that these medications are less effective and should be considered as a second line treatment.1111 Handley AP, Williams M. The efficacy and tolerability of SSRI/ SNRIs in the treatment of vasomotor symptoms in menopausal women: a systematic review. JAm Assoc Nurse Pract. 2015;27(1): 54-61. doi: 10.1002/2327-6924.12137
https://doi.org/10.1002/2327-6924.12137...
In some studies, less consistent results were observed with no statistically significant improvement in hot flashes.77 [No authors listed]. Nonhormonal management of menopauseassociated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11): 1155-1172, quiz 1173-1174. doi: 10.1097/GME.000000000000 0546
https://doi.org/10.1097/GME.000000000000...
In contrast, other studies have shown a reduction in VMS,1212 Loprinzi CL, Sloan JA, Perez EA, Quella SK, Stella PJ,Mailliard JA, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol. 2002;20(6):1578-1583. doi: 10.1200/JCO.2002.20. 6.1578
https://doi.org/10.1200/JCO.2002.20...
1313 Takahashi TA, Johnson KM. Menopause. Med Clin North Am. 2015;99(3):521-534. doi: 10.1016/j.mcna.2015.01.006
https://doi.org/10.1016/j.mcna.2015.01.0...
including in women with breast cancer.1414 Kimmick GG, Lovato J, McQuellon R, Robinson E, Muss HB. Randomized, double-blind, placebo-controlled, crossover study of sertraline (Zoloft) for the treatment of hot flashes in women with early stage breast cancer taking tamoxifen. Breast J. 2006;12 (2):114-122. doi: 10.1111/j.1075-122X.2006.00218.x
https://doi.org/10.1111/j.1075-122X.2006...
1515 Irarrázaval O ME, Gaete G L. [Antidepressants agents in breast cancer patients using tamoxifen: review of basic and clinical evidence]. Rev Med Chil. 2016;144(10):1326-1335. doi: 10.4067/S0034-98872016001000013
https://doi.org/10.4067/S0034-9887201600...
For these reasons, prescriptions are recommended in various services,1616 Leon-Ferre RA, Majithia N, Loprinzi CL. Management of hot flashes in women with breast cancer receiving ovarian function suppression. Cancer Treat Rev. 2017;52:82-90. doi: 10.1016/j. ctrv.2016.11.012
https://doi.org/10.1016/j...
and in Brazil these medications are provided for free by the Ministry of Health; hence, they are more accessible to the entire population, especially those with low purchasing power.

Regarding adverse events, in a systematic review and meta-analysis published in 2014, no difference was found between the most cited side effects when comparing SSRIs with the placebo group.1717 Shams T, Firwana B, Habib F, et al. SSRIs for hot flashes: a systematic review and meta-analysis of randomized trials. J Gen Intern Med. 2014;29(1):204-213. doi: 10.1007/s11606- 013-2535-9
https://doi.org/10.1007/s11606-...
However, in several other studies, nausea, dry mouth, constipation, headache, and loss of appetite were the most frequently reported side effects with the use of SSRI/SNRI.99 Wisniewska I, Jochymek B, Lenart-Lipinska M, Chabowski M. The pharmacological and hormonal therapy of hot flushes in breast cancer survivors. Breast Cancer. 2016;23(2):178-182. doi: 10.1007/s12282-015-0655-2
https://doi.org/10.1007/s12282-015-0655-...
1818 L'Espérance S, Frenette S, Dionne A, Dionne JY; Comité de l'évolution des pratiques en oncologie (CEPO). Pharmacological and non-hormonal treatment of hot flashes in breast cancer survivors: CEPO review and recommendations. Support Care Cancer. 2013;21(5):1461-1474. doi: 10.1007/s00520-013-1732-8
https://doi.org/10.1007/s00520-013-1732-...
1919 Al-Safi ZA, Santoro N. Menopausal hormone therapy and menopausal symptoms. Fertil Steril. 2014;101(4):905-915. doi: 10.1016/j.fertnstert.2014.02.032
https://doi.org/10.1016/j.fertnstert.201...
Anorexia, vomiting, sexual dysfunction and insomnia1919 Al-Safi ZA, Santoro N. Menopausal hormone therapy and menopausal symptoms. Fertil Steril. 2014;101(4):905-915. doi: 10.1016/j.fertnstert.2014.02.032
https://doi.org/10.1016/j.fertnstert.201...
or improved sleep were also reported with use of with paroxetine.2020 Simon JA, Portman DJ, Kaunitz AM, et al. Low-dose paroxetine 7.5mg for menopausal vasomotor symptoms: two randomized controlled trials. Menopause. 2013;20(10):1027-1035. doi: 10.1097/GME.0b013e3182a66aa7
https://doi.org/10.1097/GME.0b013e3182a6...
2121 Pinkerton JV, Joffe H, Kazempour K, Mekonnen H, Bhaskar S, Lippman J. Low-dose paroxetine (7.5mg) improves sleep inwomenwith vasomotor symptoms associated with menopause. Menopause. 2015;22(1):50-58. doi: 10.1097/GME.0000000000000311
https://doi.org/10.1097/GME.000000000000...
2222 Capriglione S, Plotti F, Montera R, Luvero D, Lopez S, Scaletta G, et al. Role of paroxetine in the management of hot flashes in gynecological cancer survivors: Results of the first randomized single-center controlled trial. Gynecol Oncol. 2016;143(3): 584-588. doi: 10.1016/j.ygyno.2016.10.006
https://doi.org/10.1016/j.ygyno.2016.10....

Sexual dysfunction caused by SSRIs/SNRIs occurs in 32.5% to 73% of patients.2323 Williams VS, Baldwin DS, Hogue SL, Fehnel SE, Hollis KA, Edin HM. Estimating the prevalence and impact of antidepressant-induced sexual dysfunction in 2 European countries: a cross-sectional patient survey. J Clin Psychiatry. 2006;67(2):204-210 2424 Montejo AL, Llorca G, Izquierdo JA, Rico-Villademoros F. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Spanish Working Group for the Study of Psychotropic-Related Sexual Dysfunction. J Clin Psychiatry. 2001;62(Suppl 3):10-21 According to some authors, sexual dysfunction appears to be more related to medication dose or prior depression.2525 Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet. 2007;369(9559):409-424. doi: 10.1016/ S0140-6736(07)60197-4
https://doi.org/10.1016/...
Since increased blood pressure is a side effect that may arise with the use of SNRIs, there should be caution in the use by hypertensive patients,2626 Stubbs C,Mattingly L, Crawford SA,WickershamEA, Brockhaus JL, McCarthy LH. Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women. J Okla State Med Assoc. 2017;110(5):272-274. and these drugs are not recommended as a first line treatment in hypertensive women.2727 Heerlein A. Antidepressant pharmacologic treatments. Rev Chil Neuro-psiquiatr. 2002;40(Suppl 1):21-45. doi: 10.4067/S0717- 92272002000500003
https://doi.org/10.4067/S0717-...
Nowadays, the rise in antidepressant prescriptions has been a cause for much concern worldwide. In France, the overall prevalence of prescriptions increased from 6.5% in 1999–2000 to 10.4% in 2009–20102828 Olié JP, Elomari F, Spadone C, Lépine JP. [Antidepressants consumption in the global population in France]. Encephale. 2002;28 (5 Pt 1):411-417. and in the US, from 5.84% in 1996 to 10.52% in 2005.2929 Olfson M, Marcus SC. National patterns in antidepressant medication treatment. Arch Gen Psychiatry. 2009;66(8):848-856. doi: 10.1001/archgenpsychiatry.2009.81
https://doi.org/10.1001/archgenpsychiatr...
In the Netherlands, the use of these drugs almost doubled between 1996 and 20123030 Verhaak PFM, de Beurs D, Spreeuwenberg P. What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis. BMJ Open. 2019;9(2):e024051. doi: 10.1136/bmjopen- 2018-024051
https://doi.org/10.1136/bmjopen-...
and in the United Kingdom, from 1995 to 2011, prescriptions increased from 61.9% to 129.9% per 1,000 people-year.3131 Mars B, Heron J, Kessler D, Davies NM, Martin RM, Thomas KH, Gunnell D. Influences on antidepressant prescribing trends in the UK: 1995-2011. Soc Psychiatry Psychiatr Epidemiol. 2017;52(2): 193-200. doi: 10.1007/s00127-016-1306-4
https://doi.org/10.1007/s00127-016-1306-...

In the Netherlands, between 1996 and 2012, long-term therapy was higher among women than men (two thirds of patients) with predominance in the age group of 45 to 64 years old (45% of them).3030 Verhaak PFM, de Beurs D, Spreeuwenberg P. What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis. BMJ Open. 2019;9(2):e024051. doi: 10.1136/bmjopen- 2018-024051
https://doi.org/10.1136/bmjopen-...
Selective serotonin reuptake inhibitors accounted for 52% of prescribed antidepressants, and among prescriptions in general, 47% were for depression, 23% for anxiety and ~ 25% for somatic reasons (ill defined).3131 Mars B, Heron J, Kessler D, Davies NM, Martin RM, Thomas KH, Gunnell D. Influences on antidepressant prescribing trends in the UK: 1995-2011. Soc Psychiatry Psychiatr Epidemiol. 2017;52(2): 193-200. doi: 10.1007/s00127-016-1306-4
https://doi.org/10.1007/s00127-016-1306-...
This age group covers both peri- and postmenopausal patients and it is very likely that women with vasomotor and neurovegetative symptoms characteristic of this climacteric phase were included, as anxiety and depression are often associated with hot flashes.

However, the prolonged and justified use for estrogen therapy does not apply to alternative SSRI or SNRI therapy for the treatment of postmenopausal women. According to some authors, there is no conclusive evidence on the safety of antidepressants over time and their use could be more dangerous than beneficial, because it could interfere with the adaptive processes regulated by serotonin.3232 AndrewsPW, Thomson JA Jr, Amstadter A, Neale MC. Primumnon nocere: an evolutionary analysis of whether antidepressants do more harm than good. Front Psychol. 2012;3:117. doi: 10.3389/ fpsyg.2012.00117
https://doi.org/10.3389/...
The menopausal transition is an adaptive process of physiological mechanisms exerted by serotonergic neurons that are “poorly regulated” in this period, as a result of the estrogen level drop.3333 Stearns V, Beebe KL, Iyengar M, Dube E. Paroxetine controlled release in the treatment of menopausal hot flashes: a randomized controlled trial. JAMA. 2003;289(21):2827-2834. doi: 10.1001/ jama.289.21.2827
https://doi.org/10.1001/...
After some period of hormonal instability, there is a re-adaptation of the organism to the new hypoestrogenic level, and hot flash symptoms and its repercussions on the female organism disappear. As SSRIs would be indicated to restore that balance, they should be prescribed for the shortest possible time.

Therefore, some questions arise: how often do doctors offer the discontinuation of SSRI or SNRI therapy when the patient reports being well after the start of medication? Is there any control over the duration of the use of these drugs? The literature on the use of SSRIs/SNRIs in climacteric women addressing this aspect of therapy is scarce. Prolonged use of these drugs may result in ineffectiveness and possible risks. In women, especially older women, are reported higher risks for falls and fractures, stroke, suicide attempts, epileptic seizures and digestive bleeding.3434 Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley- Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ. 2011;343:d4551. doi: 10.1136/bmj.d4551
https://doi.org/10.1136/bmj.d4551...
According to the literature, two thirds of outpatients with anxiety and/or depression receive treatment with psychotherapy, notably antidepressants, and these are generally used for long periods.3535 Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H, et al. Use of mental health services in Europe: results fromthe European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 2004;(420):47-54. doi: 10.1111/j.1600-0047.2004.00330.x
https://doi.org/10.1111/j.1600-0047.2004...
In the Netherlands, 30% of patients taking antidepressants do so for at least one year; in England, half of patients and in the USA, two thirds use the medication for at least two years. Only 10% of the patients discontinue the use of these drugs each year.3636 Meijer WEE, Heerdink ER, Leufkens HGM, Herings RMC, Egberts AC, Nolen WA. Incidence and determinants of long-term use of antidepressants. Eur J Clin Pharmacol. 2004;60(1):57-61. doi: 10.1007/s00228-004-0726-3
https://doi.org/10.1007/s00228-004-0726-...
3737 Johnson CF, Macdonald HJ, Atkinson P, Buchanan AI, Downes N, Dougall N. Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study. Br J Gen Pract. 2012;62(604):e773-e779. doi: 10.3399/bjgp12X658 304
https://doi.org/10.3399/bjgp12X658...
3838 Petty DR, House A, Knapp P, Raynor T, Zermansky A. Prevalence, duration and indications for prescribing of antidepressants in primary care. Age Ageing. 2006;35(5):523-526. doi: 10.1093/ ageing/afl023
https://doi.org/10.1093/...
3939 Mojtabai R, Olfson M. National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry. 2014;75(2): 169-177. doi: 10.4088/JCP.13m08443
https://doi.org/10.4088/JCP.13m08443...

With regard to climacteric symptoms, information on overprescription of these drugs is not conclusive. Literature data specifically focused on the time of use and monitoring of patients receiving this treatment for climacteric VMS are frustrating. Side effects of antidepressants are underreported in the literature because they result from short-term studies. Thus, gynecologists who treat women in the climacteric period should be alert to common and persistent side effects with long-term use.4040 Bet PM, Hugtenburg JG, Penninx BW, Hoogendijk WJ. Side effects of antidepressants during long-term use in a naturalistic setting. Eur Neuropsychopharmacol. 2013;23(11):1443-1451. doi: 10.1016/j.euroneuro.2013.05.001
https://doi.org/10.1016/j.euroneuro.2013...
When treating climacteric VMS, the most rational should be the use for short periods of time. When SSRIs or SNRIs are prescribed, patients should return in short time intervals for an initial assessment of therapeutic outcomes and side effects.

According to international consensus, the discontinuity of antidepressants should be addressed at six to 18 months after symptom remission in case of anxiety and four to 12 months in case of depressive disorders. Unnecessary continuation of antidepressant use may result in severe side effects and harm the health of patients.3434 Coupland C, Dhiman P, Morriss R, Arthur A, Barton G, Hippisley- Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ. 2011;343:d4551. doi: 10.1136/bmj.d4551
https://doi.org/10.1136/bmj.d4551...
Therefore, the recommendation is an individualized treatment based on international guidelines.4141 Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ; WFSBP Task Force on Treatment Guidelines for Anxiety, Obsessive- Compulsive and Post-Traumatic Stress Disoders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision. World J Biol Psychiatry. 2008;9(4):248-312. doi: 10.1080/1562297080 2465807
https://doi.org/10.1080/1562297080...
4242 Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015;29(5):459-525. doi: 10.1177/0269881115581093
https://doi.org/10.1177/0269881115581093...

For the treatment of hot flashes, unfortunately, there are no protocols that clearly determine how long SSRIs/SNRIs can or should be used in climacteric women. In the absence of evidence, patients who would eventually benefit from relief of depressive symptoms in the perimenopause may be reluctant to discontinue therapy for fear of symptom recurrence. Thus, many patients with transient episodes of depression or anxiety resulting from vasomotor phenomena receive antidepressant therapy at the beginning of treatment and prolong it beyond the necessary time, thereby becoming dependent on this therapy, which is often unnecessary and dispensable.4343 Johnson CF, Williams B, MacGillivray SA, Dougall NJ, Maxwell M. 'Doing the right thing': factors influencing GP prescribing of antidepressants and prescribed doses. BMC Fam Pract. 2017;18 (1):72. doi: 10.1186/s12875-017-0643-z
https://doi.org/10.1186/s12875-017-0643-...
4444 Bosman RC, Huijbregts KM, Verhaak PF, Ruhe HG, van Marwijk HW, van Balkom AJ, Batelaan NM. Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care. Br J Gen Pract. 2016;66(651):e708-e719. doi: 10.3399/ bjgp16X686641
https://doi.org/10.3399/...

This question is not intended to restrict the prescription of such drugs, as they are relatively safe products. In Brazil, they are not even included in the group of controlled drugs; hence, far from controlled, addictive drugs, which facilitates the use and prescription. However, the increasing use of antidepressants is worrisome, not because of the increase in indications and prescriptions for new patients, but mainly due to the prolonged use by those already taking the drug. Long-term use is advisable only in cases of chronicity or in patients who experience recurrence of symptoms after withdrawal. In such situations, and if associated with complaints of depression and anxiety, support from psychiatric specialists is advised for the benefit of the patient.

Despite much controversy, SSRIs/SNRIs are yet another therapeutic option for treating hot flashes, although the results are not exciting in most patients. For women who cannot or do not wish to take estrogens, non-hormonal management, such as SSRI or SNRI is a realistic and safe therapeutic option4545 Mintziori G, Lambrinoudaki I, Goulis DG, Ceausu I, Depypere H, Erel CT et al. EMAS position statement: non-hormonal management of menopausal vasomotor symptoms. Maturitas. 2015;81 (3):410-413. doi: 10.1016/j.maturitas.2015.04.009
https://doi.org/10.1016/j.maturitas.2015...
as long as proper precautions are taken to avoid unnecessary prolonged use.

References

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    » https://doi.org/10.1210/jc.2009-2509
  • 4
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    » https://doi.org/10.1002/14651858.CD002978.pub2
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    Freeman EW, Guthrie KA, Caan B, Sternfeld B, Cohen LS, Joffe H et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA. 2011;305(3): 267-274. doi: 10.1001/jama.2010.2016
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  • 7
    [No authors listed]. Nonhormonal management of menopauseassociated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11): 1155-1172, quiz 1173-1174. doi: 10.1097/GME.000000000000 0546
    » https://doi.org/10.1097/GME.000000000000 0546
  • 8
    Stearns V, Ullmer L, López JF, Smith Y, Isaacs C, Hayes D. Hot flushes. Lancet. 2002;360(9348):1851-1861. doi: 10.1016/ s0140-6736(02)11774-0
    » https://doi.org/10.1016/
  • 9
    Wisniewska I, Jochymek B, Lenart-Lipinska M, Chabowski M. The pharmacological and hormonal therapy of hot flushes in breast cancer survivors. Breast Cancer. 2016;23(2):178-182. doi: 10.1007/s12282-015-0655-2
    » https://doi.org/10.1007/s12282-015-0655-2
  • 10
    Committee on Practice Bulletins-Gynecology. ACOG Practice Bulletin N. 126: Management of gynecologic issues in women with breast cancer. Obstet Gynecol. 2012;119(3):666-682. doi: 10.1097/AOG.0b013e31824e12ce
    » https://doi.org/10.1097/AOG.0b013e31824e12ce
  • 11
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Publication Dates

  • Publication in this collection
    27 Mar 2020
  • Date of issue
    Jan 2020
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