A Beginner’s Guide to Hot Flashes

Q

When does menopause start?

A

Menopause is when you don’t have a menstrual period for one full year. The average age for menopause in our country is fifty-one. The only things that change that are genetics and smoking; menopause before forty is considered premature ovarian failure.

Q

What about perimenopause?

A

Changes in your body from perimenopause start ten years before menopause. But most people often don’t feel or recognize symptoms until three or four years before menopause.

Patients usually don’t come to me until they’re forty-five, forty-six. Just this week I saw a forty-six-year-old woman whose hormones and blood work match her perimenopausal symptoms: Her FSH and LH—chemical messengers secreted by the hypothalamic-pituitary axis of the brain—are elevated. It’s a signal: As the ovaries slow down and are less responsive to messages from the brain, the brain turns up the volume. In most labs, an FSH above 20 is consistent with menopause.

I also saw somebody who’s fifty-two this week and is just starting to feel symptoms. Her first symptom is loss of period. She’s not feeling the hot flashes or recognizing other menopausal symptoms.

Q

What are the first signs?

A

You could have some vaginal dryness, some irritability. You could have a decrease in libido and changes in sleep. It can be subtle, so you don’t initially think, Oh, this is perimenopause. A lot of people start to notice their periods getting closer together, and they may be heavier. You might notice premenstrual symptoms becoming exacerbated, stronger, more recognizable. For some women, hot flashes are the first sign.

Q

If you’re experiencing some of those symptoms before menopause, should you work to figure out if there’s another cause (before assuming it’s perimenopause)?

A

Absolutely. They’re common symptoms, so you’ve got to make sure it’s not something else. Hormonal imbalances, due to things like thyroid abnormalities, can have the same symptoms. You might start finding it’s a little harder to lose weight, and that can be due to perimenopause—but obviously that can also be due to various other issues. Rule out other things first. It could be side effects of medications, too. A lot of people come to me and say, “Well, I’m gaining weight,” but it’s the medications they’re taking that are changing their metabolism and causing weight gain.

Q

What’s going on biologically when you have a perimenopausal hot flash? Is it different from a menopausal hot flash?

A

No, they’re the same. What’s happening is you’re having surges of estrogen that are making you have that momentary flash. There’s a dysregulation of body temperature, so your body senses you’re cold and need to be warmed up, causing a flush. It typically happens in the face, the back of the neck, the arm—and often lasts only a few seconds. Some people are acutely aware of it, and some are less aware of it.

You know it’s a hot flash and not just hot in the room because it’s short and recurrent. Typically, with a hot flash, you’ll notice you’re very comfortable, and everyone around you is very comfortable, then all of a sudden you’re uncomfortable and taking off a layer. It can be subtle but happens recurrently, at odd times. Most people, for whatever reason, experience hot flashes more at night than in the daytime. It might just be that you notice it more at night.

But it is momentary—it really lasts for only a few seconds to a minute, and then it starts to regress. That’s the other way you can recognize a hot flash. If you’re hyperthyroid and you run a little hot as opposed to someone with a normal or underactive thyroid, you feel dysregulated more consistently.

Q

And what’s the normal frequency of hot flashes?

A

There is no normal. There are people who go through menopause and have hot flashes for a year or two. Hot flashes become a regular part of their day; they adjust and just go along with their life, considering this a natural stage. Then there are other people who experience hot flashes differently and probably more frequently and more severely. They find hot flashes completely dysregulating, disarming, or totally disturbing—it can impact sleep, everything.

Q

Do all women get them?

A

Almost all women do to some degree. The difference is how we experience them.

Q

Are there any levers you can pull to diminish hot flashes?

A

There’s nothing you can do to diminish the frequency. You can take medications to relieve symptoms, but you’re not actually getting rid of hot flashes completely unless you’re doing certain medical treatments. This includes hormonal therapy, or sometimes people take selective serotonin reuptake inhibitors. SSRIs are antidepressants sometimes used to treat hot flashes, among other things. By increasing the serotonin in our neural synapses, SSRIs change the way people experience the hot flashes.

Outside of medication, to ease menopause, we recommend exercise; good diet; good sleep; drinking a lot of water, less alcohol, and less caffeine; and adding in plant-based products. I recommend that people in perimenopause focus on exercise and a well-balanced diet. Weight-bearing exercise is really crucial during this period, because it’s an important way to maintain bone health. Yoga, weight-lifting, running, and walking are all great options. Too often, people wait to start an exercise program, but weight loss and improving bone health are much more challenging to address when you’re already in menopause.

Q

When do you prescribe something more to help?

A

That’s subjective: It’s when the patient needs help. Some people come in and say, “This is happening, but it’s part of life, and I’m dealing with it.” Other people are calling me frequently for help, and those people need to be treated; they need to ease their symptoms.

Q

What’s a typical course of treatment?

A

The treatment fits the patient. It depends on family history—what your mom’s experience was, which will often relate to what your experience will be. Also, your medical health: Do you have high blood pressure? Did you have a stroke? Do you have a family history of breast cancer, ovarian cancer, or endometrial cancer? These things will help guide my decision of how to treat your menopausal symptoms. Not one prescription fits all. Sometimes we go about treating symptoms individually, and sometimes we turn to hormone replacement therapy.

Q

Can you walk us through what hormone replacement therapy does to the body?

A

The hot flashes, emotional instability, decreased metabolism—all that is hormonally driven. During the perimenopausal years, you’ll have surges of hormones, followed by the decrease in production of estrogen and progesterone, the hormones the ovary produces. In hormone replacement therapy, we give back those hormones.

You have to be mindful of what’s safe to give, though, because we know now, through the Women’s Health Study, that hormone replacement therapy has been linked to breast cancer. So we have to be very careful and judicious in our prescription. If a patient has her uterus still, then you have to be protective, because estrogen can stimulate the uterine lining to grow and can be a risk factor for uterine cancer and endometrial cancer. We can reduce endometrial cancer risk by adding progesterone. I also find that people really like getting back progesterone because it helps with sleeping and insomnia, so a lot of my patients want that anyway, whether they have a uterus or not.

We also take into consideration your bone health, because the estrogen your ovaries produce helps keep your bones healthy. Your bones are alive and constantly in a process of breaking down and building up. Once you reach menopause and estrogen diminishes, your bones continue to break down, but the substance that helps them repair is no longer there. That’s what leads to bone loss—osteopenia and osteoporosis. It’s important to support your bone health; some people will take an estrogen supplement or something else if they can’t take estrogen for one reason or another. We recommend calcium supplements and weight-bearing exercise. There are also many new medications on the market targeted to bone health to treat osteoporosis.

My patients come to me in their mid to late forties—in their perimenopausal time—and often say, “What can I do to prepare for menopause?” And that’s the first thing I tell them: “Let’s make sure we’re keeping your bones healthy, because that’s the biggest change we’re going to see in menopause.”

Q

Are there foods or drinks that can trigger hot flashes?

A

Wine in particular, hard alcohol, and too much caffeine can all increase hot flashes, but it’s more that they last longer and/or are more consistent.

I’ve read that fatty meats can have a similar effect—it might be the uric acid in the meat that causes increased flushing. People also think sugary foods can cause flushing.

Q

Beyond “eat healthy,” are there any specific foods that can help you through hormonal transitions?

A

Foods that are estrogenic, like soy products (soy nuts, soy beans, edamame, tofu, etc.), yams, flaxseeds, and other plants containing phytoestrogens can be really good. They have a chemical structure that looks very much like estrogen, so they function like estrogen in your body.

People also talk a lot about black cohosh, a very well-studied herb used to treat hot flashes. But you have to be careful because even though black cohosh doesn’t have estrogenic activity in the body, it does support and maintain hormonal changes, which are what may limit the severity of your hot flashes.

Vitamin E helps alleviate symptoms; B vitamins are really helpful to take. There’s a new supplement, called Relizen, made from bee pollen and honey that’s supposed to be good for hot flashes—something to ask your doctor about.