Tibolone is a synthetic steroid that is inactive until metabolized to products with oestrogenic, progestogenic, and androgenic activity. Tibolone does not stimulate the endometrium and is therefore not prescribed with a progestogen. In a large clinical trial, tibolone was as effective as continuous hormone replacement therapy (17ОІ-oestradiol 2 mg plus norethisterone acetate 1 mg) for hot flushes, sweating, and vaginal dryness; the bleeding pattern was superior, in that almost no women had bleeding or spotting after the third month of tibolone, compared with an average of 7 months of bleeding with hormone replacement therapy.

Other prescription medications shown in clinical trials to relieve hot flushes include high-dose medroxyprogesterone acetate (medroxyprogesterone acetate) (20 mg/day) or megestrol acetate (20 mg b.i.d.) (used for breast cancer patients), selective serotonin reuptake inhibitors including sertraline, venlafaxine (25 mg/day) and paroxetine; the antihypertensive clonidine, either oral (0.1 – 0.4 mg/day) or transdermal (0.1 mg/day); and veralipride 100 mg per day (used in patients treated with GnRH agonists).

Complementary management of vasomotor symptoms

Many women wanting to avoid oestrogen seek “natural” relief of symptoms. Black cohosh extract is now available in teas and tablets; the most favourable clinical trial results are reported for a German quality-controlled product, Remifemin. A dose of 40 mg twice a day compares favourably with a standard dose of oestrogen for relief of menopause symptoms. Clinical trials have not shown that dong quai or evening primrose oil (gamolenic acid) is more effective than placebo for the treatment of hot flushes. Vitamin E has only a small benefit (about one fewer hot flush per day).

The infrequency of hot flushes reported by Asian women has been attributed to phyto-oestrogens in their high soya diet, but clinical trials show mixed results. For example, one study of 94 women found no significant difference in symptoms after 3 months of treatment with phytooestrogen-rich soya supplements compared with casein placebo, but another study of similar size and duration found isolated soya protein reduced hot flushes by 45%, compared to a 30% reduction in women treated with casein (P <0.01). Different results may relate to differences in women (not all women absorb phyto-oestrogens equally well) or differences in the products tested.

Some small lifestyle changes may be helpful, including wearing layered clothing that can be removed as necessary; reducing the intake of spicy foods, caffeine and alcohol; not smoking; and increasing physical activity.


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