SSRI (SSRIs) in the menopause

Last edited 02/2020 and last reviewed 03/2020

  • selective serotonin and noradrenaline reuptake inhibitors (SSRIs & SNRIs)
    • SSRIs as an alternative to HRT - general principles
    • (1)
      • in general baseline effectiveness 20-50%
      • class effect of SSRIs are of antidepressant benefit and improved quality of life
      • class effect of SSRIs include initial side effects such as nausea, dizziness, shortterm aggravation of base-line anxiety and mood, so encourage your patient to persevere and if necessary take on alternative days, even ½ tablet
      • class effect of all SSRIs is sexual dysfunction- no one SSRI is better than any other in this respect and there is great individual variation in response
      • some SSRIs (paroxetine, fluoxetine, paroxetine, sertraline) interact with cytochrome P450, so avoid in patients on Tamoxifen

    • SSRI’s such as paroxetine (12.5-25mg daily) has shown to reduce flushes in 50%, while fluoxetine (20mg daily) has also been reported to reduce in 60%  (2)
      • paroxetine
      • (1)
        • dosage 10-20mg - baseline improvement 50-60%. Paroxetine has best evidence for vaso-motor control and has maximal benefit achieved at 10mg
        • class effect of SSRIs are of antidepressant benefit and improved quality of life
        • interacts with enzyme cytochrome P450 (CYN10) thereby rendering Tamoxifen less effective

      • fluoxetine (1)
        • dosage 20mg - baseline effectiveness 10-20mg
        • class effect of SSRIs are of antidepressant benefit and improved quality of life
        • like Paroxetine should be avoided in patients taking Tamoxifen

      • citalopram (Escitalopram) (1)
        • dosage 20mg - baseline benefit 40-50%
        • class effect of SSRIs are of antidepressant benefit and improved quality of life
        • much less effect on enzyme cytochrome P450 so can be used in patients on Tamoxifen

      • sertraline (1)
        • dosage 25-50mg - baseline benefit - little information
        • sertraline is the best anti-anxiety SSRI
        • least well tolerated with an increase in anxiety at the outset. Interacts with cytochrome P450, so avoid in patients on Tamoxifen

    • SNRIs (venlafaxine) (1) - dosage 37.5mg -150mg sustained release preparations recommended; baseline benefit quoted 20-66%
      • often poorly tolerated at outset with dizziness and other associated SSRI side effects including sexual dysfunction, slow titration may be the answer
      • no interaction with cytochrome P450 so may be safest choice for patients on Tamoxifen

Notes (3):

  • Finding Lasting Answers for Symptoms and Health (i.e., MsFLASH) studies revealed a significant reduction in hot flashes of 54% for escitalopram, 48% for estradiol, and 49% for venlafaxine
    • sexual desire was minimally better with estradiol than SSRI treatment, while venlafaxine was better than estradiol for therapy of anorgasmia, pain, and vaginal dryness
    • improvement in sleep quality and duration was minimally and equally improved with both forms of therapy
  • in a separate study, paroxetine 7.5 mg daily was shown to improve hot flashes without weight gain or sexual dysfunction

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