Treatment for hot flushes in women receiving tamoxifen.

Clinical question " What treatments are available for hot flushes in women receiving tamoxifen? " A 62-year-old woman asked her radiation oncologist this question. She was taking tamoxifen as adjuvant treatment for node-positive breast cancer, but was experiencing persistent and frequent hot flushes. The search question was refined to " What treatments can be added to tamoxifen to reduce the frequency or severity of hot flushes? What are the benefits and risks? " The ideal study to answer these questions is a randomised controlled trial that compares various treatments in women taking adjuvant tamoxifen for breast cancer and prospectively assesses changes in flushing. Search We used a comprehensive strategy to search electronic databases , including MEDLINE, the Cochrane Library and SUM-The search terms " hot flashes " / " hot flushes " and " tamoxifen " were combined to identify the relevant trials. Summary of findings Seven agents have been tested in randomised, placebo-controlled trials. Appropriate randomisation procedures included stratification for tamoxifen use where applicable. Sample sizes ranged from 85 to 194 women, and the duration of baseline and evaluation periods ranged from 4 to 7 days and 28 to 84 days, respectively. Concurrent tamoxifen was an eligibility requirement in two studies, but otherwise between 59% and 81% of women were taking tamoxifen. Each study used frequency of hot flushes, as well as " activity scores " (which incorporate frequency and severity of flush episodes), to evaluate the medications. These were assessed using daily patient diaries, with a similar format in each study. Megestrol acetate (40 mg/day), 1 venlafaxine (37.5– 150 mg/day), 2 transdermal clonidine (at a dose eqivalent to 0.1 mg/day orally) 3 and oral clonidine (0.1 mg/day) 4 were all significantly more effective than placebo at reducing the frequency of flushes after four weeks (P < 0.05). They resulted in reductions in the median number of flushes by 73%, 30%–58%, 44%, and 34% from baseline levels, respectively (ie, 4.5–2.7 fewer flushes daily from baselines of 6.1–8.0). The activity scores showed greater percentage reductions. Oral clonidine was also effective at eight weeks, but long-term effectiveness was not examined in any study. The three other agents examined — soy phytoestro-gens, 5 vitamin E 6 and a " herbal remedy " black cohosh (Cimicifuga sp.) 7 — were found not to be useful. Hormone replacement therapy is an established treatment for postmenopausal flushing. However, no ran-domised trials assessing its value in …