29 mars 2007

Should Selective Serotonin-Reuptake Inhibitors be Prescribed to Prevent Menopausal Hot Flashes?

Extrait de Medscape

Several studies have shown that SSRIs such as paroxetine help to relieve menopausal hot flashes in a number of women. And in fact, serotonin is believed to play a role in regulating body heat. But on closer examination, there are some concerns that need to be resolved before promoting this class of drugs for the management of hot flashes during menopause.

A major consideration is that some of the possible side effects of these drugs include many of the same symptoms experienced by women beginning menopause. For example, headaches are a common side effect of SSRIs. For some women, the changes in estrogen during menopause will trigger similar withdrawal-type headaches. Adding an SSRI may increase this problem. Another common side effect of SSRIs is sexual dysfunction. Already a very complex pathology, this disorder can become even more difficult to manage with the addition of serotonergic drugs.

Although insomnia is also a potential side effect of SSRIs, some scientists believe that the nighttime prevalence of menopausal hot flashes may be due to the conversion of serotonin to melatonin, resulting in an overall lower circulating serotonin level. So in this instance, supplementing with a serotonergic drug may be effective.

Management of hot flashes with SSRIs is currently an off-label use of these drugs because the US Food and Drug Administration has not approved them for this purpose. The management of menopause is, by its very nature, highly individualized. Although several studies report improvement of hot flashes with SSRIs, there is a reported case of a woman who found no relief after 17 years. Interestingly, when switched to gabapentin, she had a markedly positive response.This illustrates the need to carefully individualize the management of menopausal hot flashes.

Even in the best-case scenarios, the reported decrease in the number of hot flashes with SSRI use is only 1 per day. Although this may be a statistically significant finding, the actual effect on a woman's life may be much less profound. It's imperative to weigh the potential side effects with the achieved outcome to determine if SSRI therapy is truly beneficial.

Based on the science we have to date, there is no question that there is an intimate relationship between serotonin and estrogen. However, we have yet to define exactly what that relationship is on a molecular level; therefore, clinical applications involving this relationship should be entered into cautiously.

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