SSRIs for Hot Flashes

How it works

Low-dose paroxetine (7.5 mg) is approved by the FDA for moderate-to-severe menopause hot flashes and night sweats. It works by affecting serotonin and other neurotransmitters involved in temperature regulation, which can reduce hot flash frequency and severity.

How well it works

In Phase 3 trials (n=1184), paroxetine 7.5 mg reduced daily hot flash frequency by a median of 5.6 to 5.9 episodes per day at 12 weeks, compared to 3.9 to 5.0 with placebo. The median treatment difference was 0.9 to 1.7 episodes per day, which the FDA described as a modest effect. The Menopause Society (NAMS 2023) lists it as a Level I recommendation. Other SSRIs and SNRIs are also used off-label for hot flashes, but low-dose paroxetine has FDA approval for this use.

Side effects and cautions

Paroxetine carries an FDA boxed warning about suicidal thoughts and behaviors, which applies to antidepressants including the low dose used for hot flashes. Paroxetine should not be taken within 14 days of using an MAOI antidepressant or with thioridazine or pimozide. Use caution if you take tamoxifen for breast cancer, because paroxetine inhibits the CYP2D6 enzyme that converts tamoxifen to its active form. If you have severe liver disease, talk to your clinician about whether paroxetine is appropriate and what dose is safe. Common side effects include nausea, headache, and fatigue or malaise.

Where to get it

You need a prescription, which you can get through telehealth or your primary care provider. You take it as a daily pill at bedtime.