Hot Flushes
HOT FLUSHES (FLASHES) IN BREAST CANCER PATIENTS
A hot flush (also known as a hot flash in the US and some other countries) is a transient sensation of heat with or without objective signs of skin vasodilation (becoming red) and is often accompanied by varying degrees of sweating, flushing, palpitations, anxiety, irritability and even panic.
These symptoms represent one of the most prominent complaints encountered by approximately 55% of treated breast cancer patients and may occur as a side effect of Tamoxifen or other hormonal treatment. It is worth noting that Tamoxifen associate hot flushing steadily becomes less severe and may disappear spontaneously in three to six months.
Some women report their hot flushes are worse in warm humid weather and can ease the symptoms by standing in front of an open refrigerator, by air conditioning or an open window. However, not all studies have shown the severity and frequency of hot flushes to correlate positively with local temperatures, although in laboratory conditions there was a significant effect. Particular foods may trigger individual hot flushes and those include spicy foods, alcohol, caffeine and others.
One study showed that women who belonged to a gymnastics club reported fewer hot flushes. Behavioural methods, including paced respiration, progressive muscle relaxation studies and biofeedback training have been studied with variable results. Acupuncture has been used successflilly for reducing hot flushes. Any trained practitioner will be familiar with treating this condition. Dr Mary O'Brien, Consultant Medical Oncologist, practises this and can be contacted through her secretary at the Kent Cancer Centre, Maidstone Hospital on ext. 5014
(01622 225014).
There is no single therapeutic intervention which will prevent these problems in all those affected, but the following treatments have all been suggested and may help in many cases. Some, but by no means all, have been subjected to study in controlled clinical trials.
It should be noted that some homeopathic preparations for hot flushes contain oestrogens and should be checked carefully. If in doubt we recommend you discuss this with your Oncologist.
Non-prescription remedies
1. Tamoxifen - Change the dose of Tamoxifen from 20mg once daily to 10mg twice daily (the tablet can be broken in half or ask for the 10mg tablets). Some patients have benefited by changing the brand of Tamoxifen. Several drug companies now produce Tamoxifen. For example, try Nolvadex if taking another brand or vice versa.
2. Ginseng - 2 tabs. daily.
3. Pulsatilla - 2 tabs. 3 times daily.
4. Agnus castus - Fruit extract (dry extract tablets) 1 tab. daily (Ze-440 extract). A prospective randomised placebo controlled study from Germany showed improvement in premenstrual symptoms in the active group compared with placebo.
5. Gamolenic Acid - Although it has been suggested by anecdotal cases that GLA may help with hot flushes, a study by Chenoy et al showed no significant benefit over placebo.
6. Soy Dietary Supplements - Epidemiological data indicates that women in geographical areas with a high diet in soy protein have lower incidences of hot flushes, as well as a lower incidence of breast cancer. A study by Albertazzi et al from Bologna, Italy, demonstrated that soy protein isolate added to the diet substantially reduced peri- and post-menopausal flushes.
7. Vitamin E - 400-800 iu daily has been recommended as a treatment for hot flushes in women's health literature and nursing journals and was shown to produce a significant hot flush reduction in a prospective evaluation by Debra Barton et al in a study by the North Central Cancer Treatment Group Clinic in the US.
Prescription Medications
1. Clonidine - This is a centrally acting adrenergic agent that reduces vascular activity and is used mainly in the treatment of hypertension (raised blood pressure).
Several studies have shown beneficial effects on hot flushes in a dose of 50 micrograms (range 25 - 75 micrograms) twice daily and Clonidine patches reduced hot flush frequency in a study by Goldberg et al from the Mayo Clinic and other centres. Dr Clayden, a GP from Yorkshire, has written widely on Clonidine and menopausal flushing.
2. Methyldopa - Was shown to be effective in a study by Nasheim and Saetre from Norway in 1981 in a dose of 250 - 5OOmg.
3. Propanolol - and other betablockers have also been proposed as potentially useful drugs, but were shown to be no better than a placebo in controlled trials.
4. Medroxyprogesterone and Megestrol - These drugs are progesterones and are sometimes used in the treatment of breast cancer. Several studies have shown a reduction in hot flushes when Megestrol (Megace) and Medroxyprogesterone have been given with Tamoxifen. Megace is prescribed in a dose of 4Omg twice daily, but should only be given after consultation with your Oncologist.
5. Autonomic system stabiliser - A double blind trial of an autonomic system stabiliser, Bellergal spacetabs, produced a significantly effective alleviation of hot flushes. This was undertaken by Lebherz and French from Cleveland and published in 1969. Bellergal is still available in some European countries including Finland, Italy and Switzerland.
6. Anti-depressants - Several studies have investigated the potential benefits of various antidepressants and generally shown a positive effect. These include:-
Trazodone (a triazolopyridine) in a dose of 50mg daily.
Veralipride (derived from the substituted benzamides) l00mg per day.
Venlaxafine (a neuronal serotonin and norepenephric inhibitor) 12.5mg twice daily.
Paroxetine (Paxil) is a selective serotonin re-uptake inhibitor (SSRI) prescribed for hot flushes in a dose of l0mg rising to
2Omg after one week.
Fluoxetine (Prozac) a monoamine-oxidase inhibitor (MAOI) has also been described in this context.
References
Albertazzi P. et al. The effect of dietary soy supplementation on hot flushes. Obstetrics & Gynaecology January 1998. Vol 91 1:6-11
Albrecht B. et al. Objective evidence that placebo and oral medroxyprogesterone acetate therapy diminish menopausal vasomotor flushes. Am. J Obstet. Gynecol. March 1981. Vol 139 No.6631-635
Barton D. L. et al. Prospective evaluation of Vitamin F for hot flashes in breast cancer survivors. Journal of Clinical Oncology February 1998 VoL 16 No.2:495-500
Bullock 3. L. et al. Use of medroxyprogesterone acetate to prevent menopausal symptoms. Obstetrics and Gynecology August 1975 VoL 46 No.2:165-168
Chenoy R. et al. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ 1994; 308:501-503
Clayden I. R. et al. Menopausal flushing: double-blind trial of a non-hormonal medication. BMJ 1974; 1:409-412
Coope Jean et al. A study of the effectivenes of Propanolol in menopausal flushes. British Journal of Obstetrics and Gynaecology June 1978. VolS5:472-475
Erlik Y. et al. Effect of megestrol acetate on flushing and bone metabolism in post-menopausal women. Maturitas 3 (1981)167-172
Goldberg R. M. et al. Transderm~ Clonidine for ameliorating Tamoxifen-induced hot flashes. Journal of Clinical Oncology January 1994 Vol 12 No.1:155-158
Loprinzi C. L. et al. Megestrol acetate for the prevention of hot flashes. The New England Journal of Medicine Vol 331 No.6:347-352
Loprinzi C. L. et al. Pilot evaluation of venlafaxine hydrochloride for the therapy of hot flashes in cancer survivors. Journal of Clinical Oncology July 1998 Vol 16 No. 7:2377-2381
Morrison 3. C. et al. The use of medroxyprogesterone acetate for relief of climacteric symptoms. Am. J Obstet. Gynecol. September 1980 Vol 138 No.199-104
Nasheim B.-I and Sartre T. Reduction of menopausal hot flushes by Methyldopa. Eur. I Clin. Pharmacology (1981) 20:413-416
Pansini F. et al. Trazodone: a non-hormonal alternative for neurovegetative climacteric symptoms. Clin. Exp. ObsA Gyn - JSSN 0390-6663 xxii n.4 1995
Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randornised, placebo controlled study. BMJ2OOJ; 332:134-137
Schiff I. et al. Oral medroxyprogesteron in the treatment of postmenopausal symptoms. JAMA Sept 26 1980 VoL 244 No.13:1443-1445
Steams V. et al. A pilot trial assessing the efficacy of paroxetine hydrochloride
(Paxil) in controlling hot flashes in breast cancer survivors. Annals of Oncology
11:17-22 2000.
Wesel S. et al. Veralipride versus conjugated oestrogens: a double-blind study in the management of menopausal hot flushes. Current Medical Research and Opinion 1984 VoL 8 No.10:696-700
