Hot Flashes: Part 2 Talkin’ ‘bout Treatments

Hello and welcome to The Cancer Pod. This Podcast is for education, entertainment, and informational purposes only. Do not apply any of this information without first speaking to your doctor. The views and opinions expressed on this podcast by the hosts and their guests are solely their own.

Leah: Hey Tina.

Tina: Hey Leah.

Leah: How are you doing?

Tina: I'm doing well today. How are you doing?

Leah: Not bad. Thanks for asking.

Tina: Well, let's get right on top of things and start talking hot flashes again.

Leah: Well, I was thinking about what we were talking about with caffeine and cold brew. And so I looked up the caffeine content of cold brew and hot brew coffee actually has just a little bit more of caffeine, it depends on what you read. And some people, they make like a super concentrated cold brew, so then that obviously would have more. But, what I found out, which was super interesting, is hot brewed has more antioxidants.

Tina: Oh.

Leah: That's so interesting.

Tina: I did not know that.

Leah: Yeah, me neither. And then the cold brew is slightly less acidic, as you had mentioned. So if it's the caffeine that's bothersome, then, there really is no difference, but if it's the acidity, then there you go...

Tina: All right. Well, thank you for clarifying that. So that was our last episode on triggers. And today we're going to talk more about treatments, with a kind of an emphasis on the big dogs and treating hot flashes, which are pharmaceuticals and phytoestrogens. With that, why don't you start us off?

Leah: So, there are pharmaceutical things and the thing most people think about Is hormone replacement therapy, but that's not an option when you've had hormonal cancer. So we will just throw that one right out the window. There are other pharmaceutical drugs that address different things. And I would think of them as, you know, like, so there are antidepressant drugs that are prescribed. That's—trying not to use brand names, but I might have to just so people know if they are—like citalopram (Celexa), venlafaxine (Effexor), fluoxetine, which Is Prozac. Those types of drugs, when I would prescribe them for patients, I would see what else is going on.

So, if there was an element of depression or difficulty sleeping, or some other indication for prescribing one of these drugs, then I would prescribe them. And it's a much lower level than what one would prescribe if someone was actually depressed. I would always refer to a psychiatrist if there was something else going on, and then maybe the side effect of them being on that prescription from the psychiatrist would also, you know, like we could get rid of your hot flashes too, you know. So...

Tina: So on that note...

Leah: Go ahead.

Tina: I'm sorry to interrupt. Go ahead.

Leah: Oh, I was going to say, for some of those drugs, it is an off-label use. But those can be helpful for some people.

Tina: So did I hear you right when it's an off-label use and it's being prescribed, not for mood, but for hot flashes specifically, it's a different dose than a therapeutic dose.

Leah: Yes.

Tina: Okay.

Leah: Yeah.

Tina: You know, the reason I'm asking that is, it's kind of older data, but there was some information back about a decade ago, coming out, showing that those who were on Paxil, which is paroxetine, women who were taking paroxetine had a dose and duration-dependent increase in the risk of deaths from breast cancer. The higher dose they took and for the longer time they took it, if they were also on tamoxifen. So one of the things with these SSRIs is that they figured out from then onward was they looked at the data and some SSRIs, not all of them, but Prozac is one of them, can interfere with tamoxifen activation.

Leah: Absolutely. Through (CYP) 2D6. Yeah. Yeah, absolutely. And so that's, I believe it's the venlafaxine that has the least effect on that, but yeah, cause I'm thinking tamoxifen and I'm thinking like AIs and stuff. So I'm thinking kind of like, you know...like...

Tina: ...yeah,the whole shebang...

Leah: ...yeah sometimes it's, it's, you know, you might not even be on hormonal therapy. You may have had, you know, a hysterectomy and you don't have, you know, your, your (were) ovaries removed, which would allow you to be able to, to be on one of these medications. And then, you know, these are, can also work for men (with prostate cancer).

Tina: Yeah. And the reason I'm bringing that up is because I want to make sure, cause I have had plenty of women who did not know this. They had already been taking such a drug before their diagnosis. They continue down a drug that could interfere with their tamoxifen Is activation in the liver. And they were never told, you know, there may be a different drug Is a better option on tamoxifen. So, sometimes what happens because there's more than one doctor, of course, in the mix. sometimes people get on something and they just stay on it, which Is understandable. Especially if it's, you know, mood-stabilizing, for example, you don't want to exactly go off of it. but just to throw that out there, cause sometimes, you know, we have to look out for ourselves and neither the doctors and sometimes not even the pharmacist notices. But this does bode for using one pharmacy. I'm a huge advocate of trying, I know cost can be an issue, but trying to go to one pharmacy or at least having one pharmacy know all of your medications so that if there's any potentials, so that should be flagged. They should see it.

Leah: Oh, absolutely. No. And that is an excellent point. Yeah, I think I, you know, my brain kind of goes towards like the patient is still in chemotherapy and then they'll get transitioned. But yeah. So, that is, that is an absolute excellent point because there, there was always that trying to transition someone to a different medication because of the fact that they would be on a drug like tamoxifen, which can be so easily affected by what you ingest, medication- and supplement-wise.

So, another category of drug, it's an anti-epileptic, is gabapentin or Neurontin. That also can be helpful. That was something that I would prescribe. When I looked up the dosage to see what was the recommendation for hot flashes, it's like, I think it's pretty high. I would start patients at like 100 milligrams, and then work their way up, you know, after several days work their way up, maybe a 100 milligrams three times a day, but I would start them at night because it can make people sleepy. It can make people, you know, it has side effects it can make people dizzy. When I looked it up, you can go up to 1600 milligrams a day.

Tina: Holy cow.

Leah: I know, that seems really high for something like hot flashes. I mean obviously, if somebody has a neurological issue, you can even go higher on that. But yeah. So, gabapentin is an option. I do know because of certain side effects, including I think weight gain was one, you know, in anything that has the potential for weight gain, especially where you're, you know, going through breast cancer or prostate cancer, you know, that's not what, that's not really what you want. So...but that can be very helpful for some people, even if they just take it at night, you know, I found some patients would just take it at night and it would help them sleep.

And you know, and so my mind was always like, oh, well they do have neuropathy, you know, have trouble sleeping. I would never get—again—I would never go up to that dosage that one would need to manage their neuropathy. That would be a referral to another doctor, but I would start them on it. And then if you know, we'd kind of like go from there.

The one drug, which I think Is fascinating, which is over-the-counter... I should have...but I can't remember which one...it was an antihistamine. I have a friend that I worked with, a nurse practitioner, told me that she said sometimes she would prescribe an antihistamine and I don't remember which one it was, but when I did look it up... cetirizine? Which is that? I'm going to look it up right now...

Tina: Well, that would make sense because didn't you mention histamine as a trigger.

Leah: Yeah, exactly. And that's why I was like, oh, that's so interesting. So this is, this says Zyrtec. I don't recall if that's what she would use, but she would sometimes have had success using an antihistamine in some patients with hot flashes. So that was so...

Tina: At the risk of sounding like a broken record, I'm just going to say one word and that Is "inflammation,"

Leah: 🎶Inflammation.🎶 I knew you were going to say that. So I thought, so that's an interesting kind of thing. Again, do not start any drugs, medications, and even over-the-counter without talking to your doctor, because we are not your doctor. We should have a little thing that we push the button and it goes, "We are not your doctor."

Tina: I was thinking you were going to say, we should have something in here that goes, you know, like a pharmaceutical commercial (makes sound like speaking fast), like really fast...

Leah: Oh yes, I will work on that. So there was one more, there was one more drug when I was, kind of like reviewing and I found it fascinating because again, this is the thing with, with the weight gain... mirtazepine, which is Remeron, which is an old school antidepressant that we used to use at the cancer center for patients as an appetite stimulant,

Tina: I have never had anyone taking that yeah, for hot flashes.

Leah: So, mirtazepine can be used off label apparently at a low dose for hot flashes, which I'd never heard of. But you also use it as a low dose for an appetite stimulant. So unless that Is something that you need, you know, it's more used in palliative care. So yeah, I guess again, my consideration would be if I had a patient who had hot flashes and needed an appetite stimulant, that's where my brain would go, so that you're not doing poly-pharmacy, you're just kind of addressing a lot of different things. And what is interesting, as we cycle out of these pharmaceuticals, is that the natural therapies in some ways can also address the same things, in a way,

Tina: Oh do you mean other symptoms besides the hot flashes?

Leah: Yeah. You, you can have multiple uses, but then there are also things like, I guess we're now transitioning into integrative approaches. So, something like black cohosh, again, check with your doctor before starting black cohosh. I'm not recommending it. I don't know what medications you are taking...but black cohosh works more on serotonin levels than it does hormones. And so again, with the mood, if there's a slight mood issue, I wouldn't say obviously if somebody Is depressed, right? That's kinda how I would determine whether or not to use something like that.

Tina: Yes, in the old herbal books, black cohosh was used for melancholy, that's how they would put it. Which sounds so much nicer than depression.

Leah: It does. It does...

Tina: I'm not depressed. I'm just a little, I just have a little melancholy.

Leah: Melancholy...as long as you don't have consumption, then we're good. So yeah, so that's, that's, I think one of the things people think of, and honestly, I can't remember if there is an interaction with tamoxifen and black cohosh?

Tina: Okay. No, there's no interaction or no, let's say, let's say this first, it's not estrogenic, black cohosh does not have any estrogen action, not even a phytoestrogen like soy, it's none of that. There is some cell data that says in vitro, meaning in a dish, it may inhibit cytochrome P 450 2D6, which is the main activating enzyme in the liver for tamoxifen. But gosh, there's a big difference between a dish and a human,

Leah: Right.

Tina: So clinically, weighing the pros and cons, I think black cohosh is high on my list of possibilities.

Leah: So yeah, I think that's really interesting though how the black cohosh does affect "melancholy."

Tina: Yeah. And there have been trials of black cohosh in women with breast cancer. So they (trials) have been around, they're mostly in a very specific extract of black cohosh called, oh, can we say name brands on here?

Leah: I've been...

Tina: I shouldn't...

Leah: I did with pharmaceuticals, but...

Tina: Okay. It's an isopropanolic extract. So it's a very different extract. It's not alcohol, it's not water, it's not carbon dioxide, it's isopropanolic acid. Just to be clear. So if someone wanted to know that's the extraction process of black cohosh that has led to clinical trials, that show benefit. But they did also, I'll tell you now, because I've looked at all the trials on this to my knowledge, the only trials that showed benefit are those that lasted longer than at least two months, preferably six months. So four trials showed diddly-squat.

Leah: And I think that's kind of with herbs all across the board, is that it does seem to take longer. My concern with herbs and medications...and it was interesting because I heard a talk at SIO, the Society for Integrative Oncology, where a medical doctor who was trained as an herbalist spoke. And they mentioned that their concern is less with a whole herb and more with a concentrated extract, in terms of interactions with things.

Tina: Sure. Yeah.

Leah: So, yeah, that's something else to take into consideration.

Tina: Is this a good time to say something about estrogenic or phytoestrogenic herbs in general?

Leah: Yeah. Let's talk about it. Let's talk about phytoestrogenic herbs.

Tina: Okay. So I want to start by putting it in context because phytoestrogens happen in nature. You are eating them whether you like it or not. You're not going to avoid them a hundred percent. It's not going to happen. They're in legumes across the board. They're in all sorts of seeds in other plants and flowers and teas. And so I'm saying that because I think that, there has to be a little context put into the phytoestrogen back to what you were saying and isolate, like isoflavone from soy, which is pulled out of that. It's a phytoestrogen and it's given in high doses, for example, bone health. That's contraindicated. So, we don't want to do an isolate of a phytoestrogen. So, isoflavone is a type of phytoestrogen. That's different than saying, "go ahead, you can have tempeh," that's different.

Right? So, on that note, since I said, isoflavone is one of four different types of phytoestrogens. Most people don't talk about this, but there's actually...phytoestrogens Is a class of compounds. There's four different types of them. Isoflavone is just one. Then there's something from red clover called coumestrans, and then hops, you know, the hops plant, like hops in beer, that has phenol flavonoids in it. I know it's a mouthful, but phenol flavonoids are another type of phytoestrogen that are found in plants. And then flax seeds, is another classic example that has lignans and that's another type of phytoestrogen. So there's four different classes of phytoestrogen under the heading of phytoestrogens. And those are basically, you can take from there, you can put all sorts of plant foods into one of those categories.

Leah: So forever ago, and I'm sure I have it saved somewhere in like on a floppy disc somewhere, showing my age again, there was an article published that looked at the phytoestrogen content of foods and herbs and stuff. And it's crazy. Like, I mean, you see soy and soy is way up there and then they have, you know, all different, like you're saying all different legumes. I mean, I think they even had white bread, you know I mean they just looked at everything and it's just, yeah. If somebody Is like, "I need to avoid it." Like you, you cannot avoid it. If it's a plant, if it's derived from a plant, it most likely has some level of it. But when you see how much soy has, interestingly with all the studies, this is going to segue, if it's okay, I'm going to segue to that one article that I had sent you, that it didn't have to do with hot flashes and cancer patients, it was just hot flashes in, I think post-menopausal women and it looked at a vegan diet, that was kind of, it had soy in it to help with the hot flashes.

Tina: Yeah. Soy is fascinating to me because, I mean, as a clinician, I've had it work, you know, I've seen it help with hot flashes. Studies refute that, I mean, all of the peer publications that I've seen to date really show it is not effective and we're not even talking about, you know, post-breast cancer. I'm just talking across the board, it doesn't show effectiveness. At the same time, I've had patients that, just a serving a day or serving or two a day, they feel like they have less hot flashes. So, there's experience, personal, or for me, it'd be secondhand reporting from patients, and then there's what the data says and they don't match.

Leah: Absolutely. No, I mean, I remember when we met, when I was in my training, having, you know, the recommendation of, especially with gentlemen—because again, hot flashes are very, very challenging for men, as they're for women, but they seem to be even more difficult to, control from my experience in, in male patients—a glass of soy milk a day. And I don't know if it's because maybe they're eliminating a glass of cow's milk a day? Is it because if you're doing soy products, you're doing less...

Tina: Right, hard to tell.

Leah: ...of something else. My caution with soy is it is a common allergen.

Tina: Yeah.

Leah: ...and so you know, if you find that you're not reacting well with soy, then don't, then don't do soy. But, yeah, there was that article, that I think is kind of like making the news in the round, the round in the news-- ooh, my mouth is backwards—that it was like a 12-week trial of a plant-based, vegan diet using soy. And it did, it was pretty...I don't have on my notes. I think the total hot flashes, whether the patient had like severe, moderate, or high, you know, severity, I think overall it was 70% reduction. I think in patients with moderate (hot flashes), it was like an 80-something percent reduction by altering the diet. So that's kind of the big thing, I think for us, when we talk to patients is the diet and lifestyle because so many aspects of diet and lifestyle can trigger them. And that's truly the most affordable, least side-effect way of addressing a hot flash is, you know, like modifying your diet or changing your lifestyle a little bit to maybe include more mindfulness and to reduce that stress or some exercise has been shown to help to reduce hot flashes, as well.

Tina: Yes. You know, that's interesting that you say that because you're right. Avoidance is free. Exercise is free. Meditation is free, deep breathing is free. Like, like it's really interesting that some of the simplest, simplest things that can be done, don't cost anything. Heck , it's kind of like, you have nothing to lose kind of thing, to go try vegan diet for five days or a week and see if it changes anything, and then slowly add things back. So let's say, you know what, you know, I really want my eggs back. So you put the egg back in and you see how you feel. I mean, that's fine. And maybe it's not until you add the chicken that's something happens or there's, you know, whatever. So it's another way to kind of clear the slate and start, and do a little experiment on yourself.

Leah: No, and it, and even though it is free and it is seemingly an easy way to... it's, it's one of the hardest things people can do. Right? It really is difficult. And I've been, I've seen that in myself, too. I mean, it's just, especially when you're a cancer patient, cancer survivor, you've given up so much, you have given up so much. And then you're like, really? I have to give up my chocolate?

Tina: Yeah.

Leah: Like really? Like, I've given up this and this and this and this, you know, like, I mean, who knows, you know, what somebody has been through and then you're recommending like, well maybe you shouldn't have that, that soda pop, you know...

Tina: Right.

Leah: ...so many times a day, like, and they're like, really? You're going to take away my soda pop? I'm like, you gotta kind of weigh, you know, you've got to weigh your options...

Tina: The other thing is...

Leah: ...hot flashes...sugar.

Tina: Yeah, exactly. That's, the ice cream the other night Is a good example of that.

Leah: Yeah. I entered it know what I was going to experience, and, yeah...

Tina: Well, it's interesting because I find that partners, whoever one shares a home with, it could be their kids, their parents, their partner, their spouse, whatever, can either be super supportive and make it easier or very much the challenge, you know, especially when, for example, they like to, I don't know, make special dishes or they like to bake and that's the way they show that they care Is by baking you cookies and cakes and you know, providing things. And it's really hard to change old habits and old dynamics and kind of shift that. And that I find that to be the social aspects of food are much more challenging than any of the logistical aspects. I think people could do anything if they were in isolation. I think the social pressures around diet are what really make it more, challenging.

Leah: Oh, absolutely. Absolutely.

Tina: Yeah. All right, so the other, I don't want to stop before we say red clover is another thing that controls hot flashes, but is fairly phytoestrogenic and there's not great data. There was a systematic review a few years ago, but basically what it says is the evidence was really limited. The limited evidence we have doesn't show that it's contraindicated. I dunno, for me, I feel like it's a little bit of an unknown. I would put red clover with a question mark next to it.

Leah: Okay. I typically avoided red clover with my patients just because there isn't necessarily a study showing that it isn't harmful. Like, you know, it's that whole thing about, I couldn't find any studies showing it isn't harmful, but you know, I couldn't find any studies that showed that it, you know, it helped. I mean, I definitely, definitely weigh on the side of caution and there are certain things and red clover is one of them that I do avoid.

Tina: Yeah, I'd put that under "absence of evidence."

Leah: Yeah.

Tina: Another one is hops...

Leah: That you avoid?

Tina: No, it's another one that the hops have actually better data than any of them. I don't avoid it. I put it in the "maybe" column because weighing the pros and cons, because hops have more than just hot flash, it's anti-anxiety, it's a sleep aid all by itself, it helps with digestion because it's a bitter. It may actually be useful for the slight increase in blood clotting risk when people are on tamoxifen, specifically.

Leah: Oh, interesting.

Tina: And there was even one study that used CT scans to look at fat and visceral fat specifically. And it was only 12 weeks long, and people on this study took, I don't remember how many people were on it, but they took a hops extract and three months later, those who were on the extract versus the controls, the people who are on that hop extract actually reduced their visceral fat. So there are a lot of little other like pros to it. None of them are like, well, sleep really does, sleep and what we call old fashioned name, a stomachic, you know, an herb that is bitter and helps the digestion. Those two are pretty big, I think because we are concerned about liver function and digestion with tamoxifen. So hops are on my maybe column. I feel like the risk-benefit is, is pretty close and it's been proven to reduce hot flashes in women who, you know, they, these were not populations who were on tamoxifen or aromatase inhibitors or anything like that. They're just generic. but anyway, so it's got a lot of pros in its column and I think it's less estrogenic in a general sense than red clover.

Leah: And I, yeah, and I'm sure I've mentioned to you—because I have reduced my alcohol intake—I now drink, these kinds of craft, non-alcoholic beers, as well as like, sparkling hops, drinks, not mentioning any brands here. I don't have them all the time, but it is nice to have something that tastes like a beer and it's a non-alcoholic beer. It's lower in calories because it doesn't have the alcohol, but it does have hops. And so that's something that I've just kind of done to kind of get rid of another cancer risk factor, you know, by really reducing that alcohol intake, which is a whole 'nother show. But yeah, I do enjoy my hop tea and there's one that has chamomile, which is nice at night. It's a sparkling hop drink, it's made from a hop, from a tea infusion. So yeah, I do enjoy that.

Tina: We should, I should preface all this with phytoestrogen preferentially bind a different estrogen receptor than tamoxifen binds to. So just to complicate it more, I don't mean to do that, but I can't make it any less complicated than it actually is. Estrogen...tamoxifen binds as your receptor alpha, as you know, in most of these almost well, all the phytonutrients, they bind estrogen receptor beta, and those are two totally different receptors in the body. They don't match, they don't have the same effects on the body and the cell. So there's that. So that's why we really...the ideal is that you have the evidence that shows whether these are safe or not. And really we only have enough evidence to conclude soy. Like we can look at soy and say women who ate a serving of soy—not excessive amounts and not isolates of soy—but women who ate a serving of soy derived benefit. Women with a history of breast cancer—that was regardless of they're on aromatase inhibitors, tamoxifen, or neither. Even ER-negative estrogen receptor-negative women still derive benefits. So soy has some, soy food as a whole food, a serving a day, has some benefits that, that we know at this point. There's so many, since 2009, we have study after study, after study at it cumulatively. I think we're up to 20,000 women right now.

Leah: Oh, wow.

Tina: Yeah. It's plenty of data on soy. I've actually written about that enough that if someone really wanted to know, just Google that with my last name spelled correctly, you'll find it.

Leah: Are you going to spell it? K-A...K-A-C-Z-O-R. Kaczor.

Tina: Kaczor. Okay, there you go. So let's talk about the next episode.

Leah: On the next episode, we are going to continue with hot flashes and we're going to talk about nutritional supplements for hot flashes.

Tina: Perfect. I think that's, that'd be great. I think I'm excited to talk about that.

Leah: My favorite things to talk about sincerely, because I talk about it all the time.

Tina: All right. So next time we will talk about nutritional supplements that people could use to possibly manage hot flashes. Awesome. See you then.

Thanks for listening to the cancer pod. Remember to subscribe, review and rate us wherever you get your podcasts. Follow us on social media for updates and as always, this is not medical advice. These are our opinions. Talk to your doctor before changing anything related to your treatment plan. The Cancer Pod is hosted by me, Dr. Leah Sherman, and by Dr. Tina Kaczor. Music is by Kevin MacLeod. See you next time.