Progesterone (not Estrogen) is Optimal Therapy for Hot Flushes

Question

I’m having really bad night sweats waking me at least once every night and sometimes three or four times. I was given estrogen therapy for them when I was still having periods and it not only didn’t help, it made my flooding and breast tenderness worse. I’m now about two years since my last period and just dying for a good night’s sleep! I tried one of those new anti-depressants and it helped a bit but didn’t take the night sweats away. In fact, I think it made my sleep worse! My doctor says estrogen is what Canadian and USA experts recommend for hot flushes. I have seen so much conflicting stuff that I don’t know what to think. All I know is that I’m scared of estrogen. Are there any other good options?

Answer

Thanks for your questions. They are important because women with night sweats chronically disturbing sleep are women who definitely need effective therapy. I know that from personal experience. Take a look at the CeMCOR website article, “Progesterone, not Estrogen, is the best treatment for Hot Flushes for Perimenopausal and Menopausal Women”. In that article I’ve tried to outline the drawbacks of estrogen therapy and describe the reasons why I think progesterone therapy is both as effective and safer.

You had difficulty taking estrogen therapy when you were in perimenopause because at that time your own estrogen levels were very high. (See “Perimenopause, the Ovary’s Frustrating Grand Finale”.) Our own estrogen levels are not well suppressed by outside estrogen in perimenopause. Therefore, it sounds like estrogen therapy at that time of your life gave you an estrogen overdose.

It was reasonable to try one of the serotonin re-uptake inhibiting (SSRI) anti-depressants because there is good evidence from randomized controlled trials that several of them help hot flushes (1;2). In general they decrease flushes by 55-70 percent (1;2).

Your doctor is right that the Canadian Society for Obstetrics and Gynecology just published a consensus document stating that estrogen with progestin is the best therapy for “menopausal symptoms” (JSOGC February, 2006) and a National Institutes of Health conference in the USA recommended the same (3). There is strong evidence from many controlled trials in women who are a year beyond their final period (menopausal) that estrogen taken in pill form improves hot flushes by about 80 to 90 percent (4). The control of hot flushes is even better and close to 100 percent if both estrogen and progestin are taken together (4). However, as outlined in the article on progesterone and hot flushes I mentioned earlier, there are definite problems with estrogen therapy for hot flushes:

1. causes excess estrogen symptoms in perimenopause;
2. hasn’t been shown to be effective in perimenopause;
3. causes a rebound increase in hot flushes when you stop it;
4. causes abnormal, falsely abnormal mammograms leading to fear and unnecessary testing; and
5. causes increased risks from strokes, heart attacks, breast cancer and blood clots.

So—what do I recommend? I strongly recommend oral micronized progesterone either compounded by a local pharmacist or as Prometrium®. The dose needs to be 300 mg every night. It must be that high to be equivalent to the luteal phase level during the luteal phase (post-ovulation) and progesterone time of the menstrual cycle and because that is the dose that has been shown to help sleep (5). You also need that 300 mg dose because your night sweat symptoms are so severe. Obviously you will need a prescription from your physician for progesterone therapy.

Menopausal women (who are one year past their final menstrual period) with less intense hot flushes and whose sleep is not upset every night could try progesterone cream in a dose of at least 20 mg twice a day—this has been shown to improve hot flushes in a randomized controlled trial (6). Again, you need a prescription for progesterone cream in Canada (although it is over the counter in the USA). I wouldn’t recommend the cream for you right now because you need the sleep benefit and the stronger action of oral progesterone.

If your doctor pressures you to take estrogen with progesterone, accept the prescription, say thank you, but only fill the progesterone at the pharmacy. Once you are menopausal (which requires two years without flow if taking progesterone therapy every day) only use estrogen administered through the skin as a patch, gel or cream, use the lowest dose of estrogen possible, and continue to take the higher dose of progesterone.

The good news is that your hot flushes will eventually become less intense, fewer and finally disappear. That is especially true if you only use progesterone. If you take estrogen with progesterone, remember that to successfully stop it and also control the hot flush rebound from stopping estrogen, you must stop estrogen gradually and with full progesterone support. (See “Stopping Estrogen Therapy”.)

Hope this is helpful for you,

All the best!

Reference List

1. 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):2827-34.
2. Loprinzi CL, Kugler JW, Sloan JA, Mailliard JA, LaVasseur BI, Barton DL et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet 2000;356(9247):2059-63.
3. National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms. Ann.Intern.Med 2005;142(12 Pt 1):1003-13.
4. MacLennan A, Lester S, Moore V. Oral estrogen replacement therapy versus placebo for hot flushes: a systematic review. Climacteric. 2001;4(1):58-74.
5. Friess E, Tagaya H, Trachsel L, Holsboer F, Rupprecht R. Progesterone-induced changes in sleep in male subjects. Am.J.Physiol. 1997;272:E885-E891.
6. Leonetti HB, Longo S, Anasti JN. Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstetrics and Gynecology 1999;94:225-8.