Hot Flashes

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Hot flashes are the most common symptom of menopause and are arguably the single symptom of menopause that aggravates women the most.  Some women never have hot flashes.  Others have mild or infrequent flashes.  The worst sufferers experience dozens of hot flashes each day.  Severe hot flashes can make it difficult to get a full night's sleep, which in turn can affect mood, concentration, and cause other physical problems.  Just like other menopausal symptoms, hot flashes can be transient, lasting only until our bodies adjust from the premenopausal to postmenopausal state.  Hot flashes can also be variable: some women can get them every day, and then they can be gone for a month or two before coming back.  For most women, hot flashes eventually get better even without treatment.  This makes it difficult to know if treatment is effective without a trial comparing the treatment to a placebo.1   Women with severe distress turn to several types of therapy for relief, some of which have been well-studied and others less so.

Hormones for Hot Flashes
There are many years of research and clinical experience confirming that hormone therapy is an effective way to treat hot flashes, but recent research has shown that even short-term use for the relief of menopause symptoms carries some risk.  Although the breast cancer risk associated with hormone therapy takes several years to show up in studies, the Women’s Health Initiative (WHI) Estrogen and Progesterone trial conclusively showed that an increased risk of heart disease and stroke emerges within the first year of use, with risks remaining elevated up to 2 and 5 years of use. 2,3,4  Moreover, taking estrogen alone increases the risk of stroke and thromboembolism.5  In the estrogen only trial of the WHI, even though the long term effects were neutral, there was an elevated risk of coronary events in the first two years after initiation of estrogen therapy.4  In light of the adverse effects of hormone therapy (HT), the FDA advises patients to use the smallest effective dose for the shortest duration possible.6   
 
We recommend that women who experience troublesome hot flashes try non-hormonal therapies as the first line of treatment.  If a woman chooses hormones, we suggest she take the lowest dose that alleviates her symptoms for as short a time as possible.  Women who have been taking hormones to relieve hot flashes can work with their health care providers to reduce the amount they are taking and find the lowest effective dose.  Some women will find that they can taper down to nothing if they've lived past the hot flash stage of menopause, which usually lasts between a few months and a few years.  Women initiating hormone therapy should understand that hot flashes may recur after cessation of hormone therapy, especially if a woman stops taking the drug suddenly.   
 
Hormone treatments for hot flashes can be taken as pills, or applied to the skin via sprays, gels or patches that have to be changed every few days.  Women who have had a hysterectomy can use just estrogen.  Women who have not had their uterus removed need to take a synthetic or natural progesterone in addition to estrogen to protect themselves from the increased risk of cancer of the uterine lining (endometrial cancer) caused by taking estrogen.
 
 Natural hormones: Women hear a lot about the supposed benefits and lack of side effects of “natural”hormones.  Celebrity endorsements, pharmacy ads, and clinician recommendations all claim that the risks of HT can be completely avoided by using “natural” or “bio-identical” hormones.  Natural hormones are the exact chemical replicas of those produced in the human body (estrone, estradiol, estriol and progesterone).  Proponents of using natural hormones often encourage women to get them from compounding pharmacies.  Compounding pharmacies are not FDA-regulated, and in a 2001 study, the FDA found that two of the eight hormone samples purchased from compounding pharmacies were not what they claimed to be.  In fact, the FDA does not recognize the term “bio-identical” and acknowledges that several compounding pharmacies use it as a marketing ploy to imply that effects are identical to those hormones made by the body.7
 
Many of the proponents of “natural” hormones encourage women to use estriol, a weak estrogen that can be used in high doses to treat hot flashes.  However, there is no evidence proving that it is safer than other forms of estrogen.  In fact, the FDA has not approved any drug containing estriol, as the safety and effectiveness are untested and unknown to them.8  
 
It is possible to use natural hormones that have gone through the FDA approval process.   Products containing estradiol (Alora, Climera, Divigel, Estrace, Estraderm, Estrogel, Evamist, Vivelle and others) have all been approved to treat hot flashes.9
 
There is some evidence to show that natural or micronized progesterone, often marketed in a cream, is effective for relieving hot flashes.  These creams are marketed often as cosmetics and are thereby not subject to FDA regulation.  There is currently a paucity of evidence for the safety and effectiveness of progesterone creams10,11 to prevent hot flashes.  There is one brand of FDA-approved natural micronized progesterone pill (Prometrium) that is prescribed concurrent with estrogen therapy.  It has been proven to protect the uterus, but it hasn’t been thoroughly studied for its effectiveness against hot flashes.
 
Alternatives to Hormones
 
Although the research supporting the use of alternative treatments for hot flashes is not as strong as the evidence proving the effectiveness of hormones for this problem, many women look for alternate ways to handle hot flashes in order to avoid the risks of hormone therapy.  Women who want to try a non-hormonal alternative should remember that what works for one woman may not be best for another.  If one strategy doesn't provide relief, try another. 
  • Staying cool.  Several studies have shown that exposure to cold can relieve a hot flash.12   Sipping cold fluids and maintaining a cooler environment can prevent and quickly relieve hot flashes.  Wearing clothes in layers - both during the day and at night - allows you to shed clothes quickly when your internal temperature rises.  Make sure that the layer beneath the jacket you wear to work is something you won't mind showing if you need to take your jacket off during a meeting.  Sleeping nude helps to dissipate the heat of night sweats, and several layers of light bedclothes can make it easier to cool off.  Keeping a portable battery-powered fan with you can also help you cool down when a hot flash strikes.
  • Dietary strategies.  Many women make dietary changes and use natural products to relieve hot flashes.  Try avoiding caffeine, chocolate, spicy or hot foods and alcohol which often trigger or aggravate hot flashes.  Randomized control assessing the effectiveness of foods containing phytoestrogens (such as those contained in soy protein) in reducing hot flashes have shown mixed results.  According to anecdotal reports, some women find that eating plant foods containing natural estrogens (phytoestrogens) is helpful for reducing hot flashes.  
Behavioral techniques:
 
Many women find that stress exacerbates hot flashes.  Therefore, certain behavioral techniques to relieve stress, such as ‘paced breathing’ and practicing the ‘relaxation response,’ can be effective means of combating hot flashes. 
  • Paced breathing.  Studies have found that slow, deep breathing can reduce the frequency of hot flashes by about 50%, with no adverse effects.13
How to practice paced breathing14: 
 
 
 
  • Practicing ‘relaxation response’.  Relaxation response is a term that describes physiological changes, including slower heart rate and breathing, that are the opposite of the “fight or flight” response.  Relaxation response can be invoked by different techniques, including paced breathing, being in a comfortable posture in a quiet room, fixing one’s gaze to avoid conscious thought, and meditation.  In a randomized control seven week study of women practicing relaxation response, while hot flash frequency did not change, the intensity and severity of their hot flashes decreased significantly.  Moreover, anxiety also decreased significantly.  
Drugs:
 
Non-hormonal drugs.  Venlafaxine, an antidepressant, and clonidine, a high blood pressure treatment, are two non-hormonal drugs that can relieve hot flashes.  Studies show improvement in some populations, especially among women experiencing hot flashes as an adverse reaction to cancer therapy.15,16  However, limited data on adverse effects, lack of consistent evidence from long term trials, and the costs of these medications limit the usefulness of these drugs, except for women a select few with very severe hot flashes and contraindications to estrogen therapy.  Neither drug has been evaluated and approved by the Food and Drug Administration for this use. 
 
Alternative Approaches:
 
Herbs.  Some women get relief from hot flashes by taking black cohosh, but studies assessing its effectiveness in treating hot flashes have had contradictory results.  A recent trial showed that neither black cohosh nor red clover significantly reduced the frequency of symptoms compared with a placebo.17  There have been some studies on dong quai, evening primrose oil, and red clover, but none of the studies have found them to be significantly effective.  Sage is also reputed to help hot flashes and night sweats, but it should not be used because it may cause seizures and other neurological problems.  (For more information see the fact sheet on Phytoestrogens and Herbs)
 
Acupuncture.  Acupuncture has been found to be of benefit in treating hot flashes.  Electro Acupuncture (EA) is effective in reducing both the number and the intensity of hot flashes in menopausal women18,19,20 through mechanisms that are thought to influence the thermoregulatory center.
 
Updated: May 2012
 
References
 
1. Dr. Susan Love’s Menopause and Hormone book. Chapter 11, pg 183
 
2. Women’s Health Initiative Investigators. Estrogen plus Progestin and the Risk of Coronary Heart Disease. N Engl J Med 2003; 349:523-34.
 
3. LaCroix AZ. Estrogen with and without progestin: benefits and risks of short-term use. The American Journal of Medicine;2005;118 (12B), 79S–87S
 
4. Prentice RL, Anderson GL. The Women’s Health Initiative: Lessons Learned. Annu. Rev. Public Health 2007; 29:131–50
 
5. Anderson GL, Limacher M, Assaf AR, et al, for the Women’s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA. 2004;291:1701–1712.
 
6. Josefson D. FDA issues advice to women taking hormone replacement therapy. BMJ 2003; 327 (7416): 641
 
7. FDA “Compounded Menopausal Hormone Therapy Questions and Answers”  accessed May 20, 2012 at
 
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm183088.htm
 
8. FDA “Bioidenticals: sorting myths from facts” accessed on 4/18/2012 at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049311.htm
 
9. FDA “Menopause:  Medicines to Help You”  accessed May 20, 2012 at  http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm118627.htm#estonly
 
10.  Jassim, GA. Strategies for managing hot flashes. The Journal of Family Practice 2011; 60 (6) 333-339.
 
11.  Wren, BG. Transdermal progesterone creams for post menopausal women:  more hype than hope? Medical Journal of Australia, 2005;  182: 237–239
 
12. Kronenberg, F. Hot flashes; Epidemiology and physiology. Annals of the New York Academy of Sciences 1990; 592: 52-86.
 
13. Freedman RR. Hot flashes: behavioral treatments, mechanisms, and relation to sleep. Am J Med. 2005; Dec 19;118 Suppl 12B:124-30.
 
14. Dr. Susan Love’s Menopause and Hormone Book. Three Rivers Press, 2003, pg 186.
 
15. Nelson HD. et al. Nonhormonal Therapies for Menopausal Hot Flashes. Systematic Review and Meta-analysis. JAMA. 2006;295:2057-2071
 
16. Loprinzi CL, Barton DL, Qin R. Nonestrogenic Management of Hot Flashes. Journal of Clinical Oncology 2011, 3842-3846.
 
17. Geller SE, Shulman LP, van Breeman RB, et al. Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms. Menopause. 2009; 16:1156-1166.
 
18. Nir Y, Huang MI, Schnyer R, Chen B, Manber R. Acupuncture for postmenopausal hot flashes. Maturitas. 2007; 56(4):383–395.
 
19. Frisk J, Carlhäll S, Källström AC, Lindh-Åstrand L, Malmström A, Hammar M. Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric. 2008; 11(2):166–174.
 
20. Sandberg M, Wijma K, Wyon Y, et al. Effects of electro-acupuncture on psychological distress in postmenopausal women. Complement Ther Med 2002; 10:161-169.