DOI: 10.1097/gme.0b013e31812714c8
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PMID: 17667151
Issn Print: 1072-3714
Publication Date: 2007/09/01
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Excerpt
Interest has been increasing in the antidepressant agents selective serotonin reuptake inhibitors (SSRIs) and/or serotonin norepinephrine reuptake inhibitors (SNRIs) as possible alternate approaches to the management of hot flashes. Early pilot studies with breast cancer populations showed promise of these agents in managing hot flashes.11,12 Subsequent randomized, controlled trials have generally indicated significant but modest reductions in hot flashes (reductions averaging one to two hot flashes per day and 25%-30% over placebo),13-15 with findings most pronounced among women with a history of breast cancer (particularly studies with women reporting selective estrogen-receptor modulator use).16 Studies among menopausal women without a history of breast cancer have been fewer and have yielded more variable findings.17-20 For example, while Stearns et al21 showed significant reductions in the frequency of hot flashes with paroxetine over placebo in a primarily noncancer population, three other notable studies with noncancer populations found no significant effects of SSRI/SNRIs on the frequency or severity of hot flashes.17,18,20
The study by Kerwin et al22 in this issue of Menopause adds to this literature. This study is secondary analysis of data from a randomized, double-blind, placebo-controlled, crossover trial of 97 women with hot flashes (without a history of breast cancer) randomized to 50 mg of the SSRI sertraline or placebo. The findings of the main study showed statistically significant but modest reductions with sertraline. Among women reporting an average of 46 hot flashes per week (six to seven per day) at baseline, sertaline was associated with reductions of less than one hot flash per day and 18% in the combined hot flash frequency/severity index over placebo.19 The study by Kerwin and colleagues explored the pronounced variability in this treatment response.Specifically, of the 87 study completers, 31% showed greater than a 30% reduction, 32% showed less than a 30% reduction, and 37% of women actually showed an increase in hot flashes in response to sertraline. Although not consistently observed,14,23 as the authors note, their findings were not unlike those of Loprinzi et al, who found 27% of participants reporting more hot flashes in response to fluoxetine.13
This variability in treatment response raises an intriguing question. Are there subgroups of women who may be more or less responsive to serotonergic agents? Can we identify these women and tailor treatments accordingly? Kerwin et al do attempt to isolate characteristics that may identify subgroups of women, noting variations according to mood, educational level, physical activity level, and/or menstrual status. However, the small number of women in these subgroups as well as the limited univariate statistical approach to this question does not leave the reader with answers. It may be possible to identify women who are likely to be responders, but it appears we have not done so yet.
It is important to exercise caution in interpreting these results. This study is a post hoc exploratory analysis of a study not designed to answer the question that the authors pose.
