What are hot flashes?

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Disclaimer: This information isn’t a substitute for professional medical advice, diagnosis, or treatment. If you have any questions or concerns, please talk to your doctor.

What are hot flashes?

Hot flashes are short episodes of intense heat sensation of the head, neck, and chest. When it occurs with a red face, neck, and/or chest it is called a hot flush. Some women experience sweating and/or palpitations (a sense of the heart beating irregularly) during these episodes. They can occur at any time without warning and usually last 3–5 minutes. However, they can vary from 30 seconds to 30 minutes. Some women have hot flashes/flushes up to 20X/day or more. Hot flashes/flushes can disturb sleep and can be awkward when they occur inexplicably in social situations.

The most common symptom of menopause and perimenopause is hot flashes/flushes, which are estimated to occur in up to 80% of women. Bothersome hot flashes can occur day or night. Nighttime hot flashes often cause night sweats and can interrupt a woman’s sleep.

What causes hot flashes?

The cause of hot flashes/flushes is not completely understood. It is believed that the hypothalamus, a part of the brain involved in temperature regulation, undergoes changes that make it more sensitive to minor increases in body temperature. It inappropriately sends out signals telling the body to rid itself of body heat even when it should not. Blood vessels in the skin swell trying to discharge body heat. This causes redness (flushing) and a sense of warmth. The heart rate can increase leading to palpitations, and sweating can be pronounced as the body tries to cool itself.

Declining estrogen levels play a role in the disrupted temperature regulation by the hypothalamus. This is why symptoms occur around menopause and why estrogen is an effective therapy.

Brain chemicals called neurotransmitters also play a role. In particular serotonin, norepinephrine, and endorphins are thought to be involved in the generation of hot flashes/flushes. Nonhormonal treatment modalities may help by modulating these systems of neurotransmitters.

How common are hot flashes/flushes?

Estimates vary, but it’s estimated that up to 80% of women experience hot flashes/flushes during perimenopause and after menopause. Hot flashes/flushes are the most common symptom of perimenopause and menopause. Fortunately, there is effective treatment available for those whose quality of life is affected.

How long do most women continue to have hot flashes/flushes?

When women begin to experience hot flashes/flushes and the duration of these symptoms varies. One study showed that the average duration of hot flashes/flushes was 7.4 years. They can start a few years before menopause and continue for about 4 years after a woman’s last menstrual period (LMP). In this study, a number of factors were associated with the length of time participants experienced hot flashes/flushes. Among others, black women, women who experienced symptoms at a younger age, and women with more anxiety and depression tended to have a longer duration of symptoms.

The Study of Women’s Health Across the Nation (SWAN study) looked at women in five different ethnic groups in the U.S. to characterize symptoms of hot flashes before, during, and after menopause. It showed four different patterns of hot flashes/flushes that women may experience.

  1. 27% of women had a low probability of having hot flashes throughout perimenopause and menopause. These women were more likely to have symptoms right around their LMP that improved within 2–4 years after menopause.
  2. 18.4% of women had symptoms that began long before their LMP (about a decade), but their hot flashes/flushes began to improve shortly after they entered menopause.
  3. 29% of women had symptoms that increased shortly before menopause, peaked right after their LMP, and then gradually declined over several years.
  4. 25.6% of women had a high probability of having hot flashes starting long before their LMP that continued for over a decade after their LMP.

As you can see, there is a wide range of when and for how long women experience hot flashes. Whenever your symptoms began and however long they lasted, there are many women with similar experiences. Fortunately, there is effective treatment for this very common and bothersome symptom.

Overview of menopause

Menopause is defined as a woman not having her period for 12 months in the absence of another cause (e.g., nursing, birth control, eating disorders). This happens when ovaries stop producing large amounts of estrogen (and progesterone) and women no longer ovulate. Hormonal changes and symptoms usually begin before this happens, during a time called perimenopause.

Perimenopause (the time leading up to menopause) generally begins begins when a woman who had regular cycles (with a predictable length and flow) starts having irregular periods. Women enter perimenopause on average about 4 years before they stop having periods altogether. However, there is a broad range for the length of perimenopause. Some women may enter perimenopause up to 10 years before their last menstrual period and some women experience hot flashes/flushes even while they have regular periods. Menopause and perimenopause are normal transitional periods in a woman’s life, but they often cause very bothersome symptoms.

With the onset of perimenopause, fluctuations in hormone levels may cause irregular menstrual cycles, headaches, mood changes, insomnia, weight gain, breast pain (mastodynia), and hot flashes/flushes.

With the onset of menopause, a dramatic decrease in estradiol (the body’s primary estrogen) and progesterone causes more changes, including:

  • Hot flashes: This is the most common symptom of menopause and perimenopause affecting up to 80% of women. They typically last 5–7 years but can last up to 10–15 years.
  • Absence of menstrual cycles: This is the hallmark of menopause. Once women stop ovulating, their uterine linings no longer grow and shed.
  • Loss of bone density: Normally, bone remains strong by having a perfect balance between the cells that make bone (osteoblast) and cells that breakdown bone (osteoclast). Until menopause, estrogen protects bones from being broken down in excess by osteoclasts. When estrogen is lost and osteoclasts go unchecked, bone density is lost. This can result in osteoporosis leading to a higher risk of hip fractures, wrist fractures, and spine fractures, among others.
  • Weight gain and bloating: Estrogen helps regulate the deposit of fat tissue. Many women gain weight during and after the menopausal transition.
  • Mood changes: Mood changes, like depression, are common during perimenopause and menopause.
  • Sleep disturbances: Sleep disturbances can be related to the underlying hormonal changes or simply from night sweats.
  • Increased risk of cardiovascular disease.
  • Genital changes: These include vaginal shrinkage, thinning of the vaginal tissue, loss of vaginal folds, loss of vaginal lubrication, vaginal itching and discomfort, and painful sex (dyspareunia).
  • Urinary symptoms: Women can feel the sudden need to urinate (urgency), frequent urination, and pain on urination—mimicking a urinary tract infection.

Perimenopause and menopause can pose many challenges but certain conditions that are worsened by higher estrogen levels improve after menopause. These include endometriosis, uterine fibroids, adenomyosis, symptoms related to heavy, painful periods, and PMS.

Treatments for hot flashes available through Rory.

Paroxetine, Venlafaxine

Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are drug families most commonly used to treat anxiety and depression. Nevertheless, in low doses they have proven effective in the treatment of hot flashes.

Several SSRIs and SNRIs have been found effective for the treatment of hot flashes. One study showed that the SNRI venlafaxine (at 75 mg/day) and low dose estrogen (0.5 mg of beta-estradiol/day) were equally effective at reducing hot flash frequency at 8 weeks (47.6% in the venlafaxine group vs 52.9% in the estradiol group). Learn more about venlafaxine here.

The North American Menopause Society (NAMS) recommends using paroxetine in doses of 10 mg – 25 mg per day as an affordable option for treating hot flashes. Learn more about paroxetine here.

The use of paroxetine and venlafaxine for the treatment of hot flashes is an “off-label” use. Rory-affiliated physicians have the discretion to prescribe these drugs off-label to meet the needs of individual patients. It is up to the medical judgment of the doctor to decide if such treatment is appropriate based on each patient’s unique medical history, symptoms, and preferences.

While venlafaxine and paroxetine are taken in low does for the treatment of hot flashes, any medication can have side effects. These drugs may not be appropriate for everyone. For more about the safety of venlafaxine and paroxetine, including the boxed warning for increased suicidal thoughts in people under 25, please read paroxetine important safety information and venlafaxine important safety information.

Vitamin E & Black Cohosh

Vitamin E is an essential nutrient needed for healthy vision, reproduction, and immunity. It is a fat-soluble vitamin that is also an antioxidant. Black Cohosh is a plant whose roots are used as an herbal supplement. Both have been found in several studies to be effective in the treatment of hot flashes. Learn more about black cohosh and vitamin E here.

What are other treatments for hot flashes?

Many therapies have been studied for the treatment of hot flashes/flushes. The treatments fall into three broad categories:

  1. Behavioral techniques
  2. Nutritional supplements
  3. Prescription medications, including:
    1. Hormone replacement therapy estrogen +/- a progestin
    2. Non-hormonal, prescription medications that have been studied for the treatment of hot flashes/flushes.

Many behavioral techniques and modifications have been studied. Some have robust evidence indicating that they are effective while others have little, or weaker evidence, but are still recommended by healthcare providers because they are very safe and may help. The following are some behavioral techniques that can be attempted though there is no strong evidence of benefit.

Various cooling techniques can be tried. These include wearing layers so that they can be removed as needed, wearing light breathable clothing (i.e. cotton), keeping fans and cold water handy, using devices that cool your blanket or comforter at night, and keeping an ice pack near the bed that can be placed under your pillow as necessary.

Some have suggested avoiding hot beverages, spicy foods, and caffeine is helpful. However, there is no evidence that avoiding them is effective. Smoking and alcohol have also been proposed as triggers of hot flashes. It is recommended that all women who smoke should quit regardless of whether it will help with hot flashes. Moderate alcohol consumption (no more than one drink per day) is also recommended as part of a healthy lifestyle.

Weight gain is one of the dreaded consequences of menopause, and many women feel that their bodies are rebelling against them. The same diet and exercise regimen that kept their weight stable through the years suddenly results in added pounds. Weight loss is difficult during this stage of life and may require the help of a professional dietician.

However, several studies have shown that weight loss is an effective treatment for decreasing the severity of hot flash/flush frequency. Weight loss was also associated with a greater chance of eliminating hot flashes at one year. Furthermore, weight gain was associated with an increased risk of moderate to severe hot flashes/flushes. These studies tell us that weight loss, when feasible, should be recommended for the management of hot flashes.

Exercise is an important part of a healthy lifestyle as long as there are no contraindications. Speak to your primary care physician before starting an exercise program.

Mind Body Techniques

Various mind body techniques have been studied including cognitive behavioral therapy (CBT), relaxation training, paced breathing, mindfulness-based stress reduction (MBSR), and clinical hypnosis. Of these, CBT and clinical hypnosis have the best evidence showing effectiveness.

CBT is a form of psychotherapy that aims to modify dysfunctional thoughts, behaviors, and beliefs. Two studies showed its effectiveness at improving the symptoms of hot flashes/flushes, and the improvements were maintained after 26 weeks.

Clinical hypnosis involves achieving a deeply relaxed state through imagery and suggestion from a practitioner. It has been shown to decrease the frequency and severity of hot flashes/flushes.

CBT and clinical hypnotherapy are both recommended by the North American Menopause Society (NAMS). The downsides of these approaches are the time investment and cost, and access to practitioners may be limited in some areas. They are definitely worth a try if you  have the finances, time, and access to a competent practitioner.

Nutritional Supplements

Phytoestrogens are chemicals found in plants that are similar to human estrogen. They are able to bind to estrogen receptors and produce the same effects to a greater or lesser extent. One of the foods highest in phytoestrogens is soy. Soy contains several phytoestrogens, including genistein, daidzein, glycitein, biochanin A, and formononetin. Genistein and daidzein are the two most well known of these compounds.

Soy products and supplements vary greatly in the amount and potency of the phytoestrogens in them. In addition, only about 30% of North American women can metabolize daidzein into equol, which may be the beneficial compound in soy for hot flashes. NAMS does not recommend the use of soy foods or supplements for the treatment of hot flashes, although whole soy foods are safe to use as part of a healthy diet for those who do not have a sensitivity or allergy to soy.

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