Hot Flashes and Menopause: All you need to know

Menopause is a stage of transitioning hormones. Most women attain natural menopause between 40-55 years of age. The ovaries stop producing the hormone estrogen, producing many changes in the female, known as the menopausal changes. For example, your periods stop (menopause), you may experience vaginal dryness (see Vaginal Atrophy), anxiety, depression, mood swings, etc. Some of these symptoms are mild and well tolerated; others are troublesome and annoying. One such annoying symptom is the occurrence of hot flashes at menopause.

What are hot flashes?

Hot flashes refer to episodes of sudden, intense bursts of warmth in the upper part of the body, especially the face, neck, chest, and back. These happen due to decreasing levels of estrogen hormone and can start anytime just before, during, and just after menopause. These episodes may last from 30 seconds to 10 minutes and may be accompanied by profuse sweating, erythema (redness) of the skin, and an increase in heart rate. Sweating causes the body temperature to drop down, leading to a feeling of chill or cold afterward.

When hot flashes occur in the night, they are called night sweats and can wake you up from sleep. This unexplained continuum of symptoms can make you very uncomfortable, nervous, embarrassed, and anxious.

Why do hot flashes occur?

There is a gland called the Hypothalamus in our brain, which is responsible for temperature regulation of our body. Its job is to maintain our body temperature constantly at 37^oC, irrespective of any internal or external temperature changes. Absence or reduction in levels of estrogen hormone, somehow causes the hypothalamus to become too sensitive to even mild changes in body temperature, causing it to malfunction and hyperreact, causing the hot flashes.

Why is a hot flash so uncomfortable?

The most dreaded and uncomfortable symptom of menopause is having hot flashes. The sudden feeling of heat radiating from your body, with a feeling of fast heartbeat and profuse sweating can be extremely uncomfortable and distressing for anyone, inducing intense anxiety. Feeling chilly and cold a few minutes later causes further discomfort and anxiety. Most females have no idea why are they getting these symptoms. Many times, these hot flashes don’t just happen during the day but can also happen in the sleep and are called night sweats. Night sweats can be particularly distressing as they wet your clothes, make you feel very cold, and disturb your sleep.

What are the natural causes of hot flashes?

• Natural Menopause: Although hot flashes can be caused by any condition which reduces estrogen hormone levels, they are most commonly seen with menopause. Menopause means that your ovaries stop producing eggs and the production of hormone estrogen starts decreasing and finally stops. You also stop having periods. Decreasing estrogen levels before, during or after menopause are the most common cause of hot flashes.
• Perimenopause: There is a transition phase during which your body starts preparing for actual menopause. This transition phase during which the estrogen levels starts falling and changes of menopause start appearing is called Perimenopause. During this time, you may have hot flashes, in addition to irregular periods, too scanty or heavy periods, vaginal dryness, mood changes etc. It can last anywhere from a few months to 5 years.
• Surgical menopause: When the ovaries are removed surgically before natural menopause has occurred, the estrogen production suddenly stops, producing menopausal changes. This is known as surgical menopause and may be associated with hot flashes, just like natural menopause.
• Pregnancy: Pregnancy is associated with intense hormonal changes in your body. These hormonal changes may present as hot flashes and most pregnant females experience hot flashes at some time of their pregnancy, most commonly in first or third trimester.
• Periods: During your menstrual cycles, there is a cyclical change in your hormonal levels with an aim to release an egg and prepare your uterus for pregnancy. When pregnancy does not happen, the hormone levels fall and uterus sheds it’s lining during your periods. You may experience hot flashes just before your periods due to sudden fall in the hormones.

Which medical conditions can cause hot flashes?

In addition to the normal physiological processes mentioned above, certain medical conditions can also produce hot flashes. For example:

• Thyroid disorders: Thyroid disorders, especially hyperthyroidism (an over functioning thyroid gland), can cause hot flashes. Less commonly, hypothyroidism (an under functioning thyroid gland), can also cause hot flashes.
• Diabetes Mellitus: Patients with diabetes and insulin resistance have been found to have a greater incidence of vasomotor symptoms like hot flashes and night sweats. Conversely, perimenopausal patients who have hot flashes, have increased risk of developing insulin resistance and diabetes.
• Primary ovarian insufficiency: Primary ovarian insufficiency (POI) is an idiopathic condition in which the ovaries stop functioning prematurely, before the age of 40 years. This leads to an early menopause and is associated with menopausal symptoms, including hot flashes.
• Anxiety disorders: Anxiety and it’s associated disorders like panic disorder, posttraumatic stress disorder (PTSD) and mood disorders, can all produce vasomotor symptoms like hot flashes, profuse sweating and tachycardia (increase in heart rate). The severity of symptoms vary with the severity of underlying disorder.
• Neurological conditions: The autonomic nervous system in our body controls our involuntary functions like breathing, blood pressure, heart rate, temperature control etc.
  • Many neurological conditions like Autonomic neuropathy, Autonomic dysreflexia, Multiple sclerosis, Parkinson’s disease, Spinal cord injury etc. affect our autonomic system and affect it’s control over the involuntary functions. When temperature regulation is affected, it may cause hot flashes.
  • Diabetes is one of the most common conditions affecting our autonomous nervous system and causing autonomic neuropathy.
  • Cerebrovascular accident (CVA) OR stroke is another common condition in which a clot or bleeding in the brain, causes injury to our brain and can affect the temperature regulation, producing hot flashes.
• Infections: Any bacterial or viral infection can initiate a systemic inflammatory cascade in the body. The inflammatory mediators so released produce a flushing, in addition to other symptoms.
• Fever: Fever of any cause, causes the blood vessels in our body to dilate (loosen up), so as to be able to dissipate the heat to the environment. This causes flushing. This is also the reason that your skin becomes hot and flushed after intense exercise.
• Cancers: Certain cancers like leukemias, brain tumors, lymphomas can produce vasomotor symptoms and cause hot flashes.
• Cancer treatment: Chemotherapy, radiotherapy, cancer drugs like tamoxifen, aromatase inhibitors (like letrozole, anastrozole) or androgen treatment, can all produce the so called Chemical menopause.
• Other drugs: like steroids eg prednisolone), opioids (eg tramadol), antidepressants (tricyclic antidepressants), viagra (sildenafil) etc. are known to cause hot flashes.
• Alcohol and drug abuse

What are the risk factors or triggers of hot flashes?

Although majority of women undergoing menopause have hot flashes at some time or the other, not all women have them. Certain risk factors increase your chances of getting hot flashes. Avoiding these triggers can reduce your chances of getting hot flashes or at least reduce their frequency and intensity:

• Intake of spicy food
• Intake of caffeine
• Intake of alcohol and other drugs of abuse
• Smoking
• Wearing tight clothes
• Taking hot beverages
• Intense physical activity like exercise or sports
• Hot weather
• Obesity: Obese women (Body mass index >30) have more chances of developing hot flashes than lean women.
• Race: Hot flashes are more frequently seen in black women and least frequently in Asian women.
• Type A personality: Stress often manifests as flushing (hot flashes), anxiety, palpitations and increase in heart rate. Women with type A personality are more stressful and have a greater incidence of having hot flashes.

How are hot flashes diagnosed?

Hot flashes are diagnosed by your doctor primarily based on your history. In addition, your doctor may order blood, urine or radiological tests, based on the likely cause of your hot flashes.

How to stop hot flashes?

In the absence of any other diseases, hot flashes are the result of the absence of estrogen hormone at menopause. Menopause is a natural process in a woman’s life and there is nothing to prevent or stop it. However, we can definitely reduce the chances of getting hot flashes or at least reduce their frequency or severity by taking certain precautions and avoiding the triggers that we discussed above:

• Avoid typical trigger factors like hot or spicy food, alcohol, smoking, caffeine and tobacco.
• Reducing your stress levels will not only help in reducing hot flashes but also improve your general well-being. Practice breathing techniques and meditate daily.
• Avoid sitting in a closed or heated room. Always sit in a well ventilated room with windows.
• If you are overweight, then you must lose weight by regulating your diet and inculcating an exercise schedule, so that your breathing and activity becomes better. Hot flashes tend to be worse in overweight people.
• Always wear clothes in layers so that the moment a hot flash starts, you can remove upper layers of your clothes.
• Non exercisers are more prone to hot flashes. Exercise regularly so that your metabolism and temperature regulation become better. Always exercise in a well ventilated and cool room. Exercise should be done in moderation as intense physical exercise may trigger a hot flash.

What do do when I get a hot flash?

When you get a hot flash, do the following:

• First of all, practice not to panic or getting anxious.
• Remove extra layers of clothes
• Open the windows of your room and let the air cross ventilate.
• Switch on the fan or air conditioner.
• Sip some cold beverage.
• Practice meditation and breathing techniques regularly, so that when you have a flash, you can easily mitigate it with self mind control.

What food options help protect against hot flashes?

Many natural food items provide nutrients which are effective against the undesirable side effects of declining hormones. Following is a list of foods you must include in your diet:

Plant-based estrogens: Many naturally occurring food items contain weak estrogens which help to mitigate the symptoms of menopause, including hot flashes but do not have the side-effects of pharmacological estrogen preparations. It has indeed been seen that women who consume vegetarian diets, especially Asian women who consume lots of soya products, have very less menopausal symptoms as compared to other women. Some common foods that contain plant estrogens are as follows:

• Soy products: Soybean is a plant which belongs to the legume family. It is a rich source of plant based estrogen, known as phytoestrogen. So soya and its products can be used to replace estrogen loss naturally without having the side effects of chemical hormone replacement therapy. Eating soya based foods reduces the risk of hot flashes, cardiovascular diseases, heart attacks, some cancers and improves bone health. Some common soya based foods are:
  • Soya milk: used as a beverage or can be consumed in the form of tea, coffee and shakes.
  • Soya flour can be easily added to your roti or bread flour, cakes and pastries.
  • Soya paneer or tofu is a popular meal which can be added to salads and snacks and can be cooked into any way you want to.
  • Soya chunks are cooked as a vegetable and are extremely delicious.
• Chickpeas: Chickpeas also belong to the legume family. In addition to being a very good source of protein, vitamins and minerals like manganese, folic acid, copper, iron, zinc, phosphorus, magnesium, Vit B complex, they are a very good source of phytoestrogens. They help in alleviating hot flashes and other symptoms of menopause. They also help to reduce mood swings and help to maintain sex drive after menopause.
• Flaxseed: Flaxseed is also a great source of phytoestrogens, along with fiber and omega-3 fatty acids. Therefore these are great for treating menopausal symptoms like hot flashes, constipation, obesity and high cholesterol levels. Flaxseeds can be roasted and added to breads, muffins and rotis. Flaxseeds can also be ground into a powder and added to cakes, biscuits and different food items. Roasted flaxseeds are also very delicious to munch.
• Fish oils or cold water fishes: Fish oil supplements freely available in the market and cold water fishes like mackerel, salmon and sardines are rich source of omega-3 which help in regulating hormones.

Natural supplements for hot flashes:

Many natural supplements and herbs are used in different parts of the world as a natural treatment of menopausal symptoms. They are presumed to be free to any side effects. However, like any other medicine, some effects of herbs or natural products may be desirable in a particular individual and may be undesirable in another. Moreover, they may cause drug interactions with the medicines you may be already taking. So it is strongly advised to consume any product under the supervision of your doctor for best results. Following natural supplements are commonly used for alleviation of menopausal symptoms:

• Vitamin E
• B complex vitamins and Vit C
• Evening primrose oil
• Omega-3 fatty acids
• Ginseng
• Black cohosh: This is a herb available in North America and is popular as an effective remedy in many symptoms of menopause and for dysmenorrhea.

When should I seek Medical treatment of hot flashes?

A few simple facts first: Hot flashes start during the perimenopausal time when the hormones start declining. Some women have very brief duration of these symptoms, lasting only a couple of months. But majority women have these symptoms for about 4-5 years, with some having them for as long as 10 years. Most women have 4-5 episodes a day, with each episode lasting 1-5 minutes.

The first few hot flashes are scary for everyone as they suddenly start manifesting out of the blue and are pretty dramatic in their presentation. But as time passes, both their frequency and intensity decrease. Avoiding triggers, changing your lifestyle, choosing right food options and natural supplements often help.

However, you must seek medical management if:

• The hot flashes are very distressing and are affecting your daily life activities.
• The night sweats (night time hot flashes) disturb your sleep daily and you are suffering from consequences of chronic sleep deprivation.
• Hot flashes persist and do not decrease in intensity or frequency, despite avoiding triggers and changing your lifestyle and food options.

What are the medical treatment options for hot flashes?

There are hormonal as well as non hormonal therapies available for treating hot flashes.

Hormone Replacement Therapy (HRT): Since estrogen deficiency is the root cause of menopausal symptoms, estrogen hormone replacement is the treatment of choice for hot flashes. Estrogen alone or and combination with Progesterone is given as hormone replacement therapy, depending on certain criteria as mentioned below. The target of HRT is to use the lowest possible doses of hormones to abate the symptoms and improve the quality of life.

• Estrogen is the hormone of choice when your uterus has been removed.
• But if you have your uterus, then estrogen therapy alone increases the risk of cancer of the uterus (endometrial cancer). In that case, estrogen is given in combination with progesterone to protect against the risk of endometrial cancer.

Non hormonal treatment: These therapies can be used alone or in combination with hormone replacement therapy. They are usually less effective than hormonal treatment and are used to supplement hormonal treatment so as to reduce the dose of hormones or used without hormonal treatment in cases where hormonal treatment is contraindicated.

• Antidepressants: A category of anti depressant drugs called Selective Serotonin Reuptake Inhibitors (SSRI’s) are being used for treatment of hot flashes. These drugs increase the levels of the neurotransmitter serotonin which stabilizers the temperature regulation and therefore helps in treating hot flashes. SSRIs commonly used for treatment of hot flashes are Paroxetine, Citalopram, Escitalopram and Venlafaxine.
• Antiepileptics: Gabapentin and Pregabalin are antiepileptic drugs. They decrease the nerve transmission and are very effective in reducing hot flashes, especially night sweats. A major side effect is daytime sleepiness and decreased concentration due to their sedative effect.
• Oxybutynin: It relaxes the urinary bladder muscles and is used for treatment of overactive bladder. It decreases the symptoms of urge incontinence (condition in which you feel the urge to pass urine but urine leaks out before you can reach the washroom). One of the effects of this drug is decreased sweating. This property of oxybutynin is used for treatment of hot flashes. Side effects include drying of mouth and eyes, constipation.

Do hot flashes happen in pregnancy?

Yes hot flashes can occur in pregnancy. Pregnancy is the state of changing hormones which leads to increase in blood supply due to dilatation of blood vessels. The increased blood supply and dilatation of vessels leads to flushing of the skin and many times intense sweating, causing symptoms similar to hot flashes during pregnancy. The chances of having hot flashes in pregnancy are more in women who are obese or have medical conditions like thyroid disturbances. It may occur in first trimester but is more common in second and third trimester of pregnancy. Treatment is by staying in a cool, well ventilated environment, avoiding common triggers and wearing layers of clothes so that extra layers can be removed once the sweating starts happening.

Carry home message

Occurrence of hot flashes is very common in women of perimenopausal age group. There is a huge interpersonal variation in the occurrence, duration and intensity of hot flashes in women. Some women my have very brief symptoms and some some women may have symptoms for as long as 10 years. Some women may have mild symptoms and some women may have symptoms severe enough to disrupt their daily routine.

Avoiding triggers of hot flashes, avoiding stress, staying in cool well ventilated places, exercising regularly, maintaining ideal weight, wearing clothes in layers, practicing meditation and breathing techniques go a long way in reducing the severity of symptoms. In addition, both hormonal and nonhormonal treatments are available in cases of severe symptoms.

Many conditions can mimic hot flashes like panic syndrome and hyperthyroidism. It is important to visit your health care practitioner to identify any the cause of your symptoms so that they can guide you through the available options regarding the management of the same. Stay healthy!

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