Chilling Out Hot Flashes

For many women, hot flashes are synonymous with menopause.

About the time menstrual cycles become irregular (in most women, occurring about every 25 days instead of every 28), women begin to experience episodes of flushed skin, perspiration, and heat commonly known as hot flashes. It's not at all unusual to experience hot flashes. About 92 percent of women going through menopause do for one to five years and sometimes more. Women going through perimenopause, the transition to menopause, often experience irregular menstruation, weight gain and bloating, intimate dryness, headaches, insomnia, breast pain, and depression, but the nearly universal symptom of menopause is hot flashes.

What Can Doctors Do For Hot Flashes?

For women, hot flashes during menopause, hot flashes while pregnant, and hot flashes during the menstrual period are all linked to fluctuating levels of estrogen. For decades, the most common prescription for hot flashes has been supplemental estrogen. Estrogen replacement therapy doesn't eliminate hot flashes for most women who use it, but on average it reduces the number of hot flashes by about 75 percent. Not absolutely every woman who has hot flashes, however, actually needs estrogen replacement therapy.

• Sometimes hot flashes, in both women and men, are caused by hyperthyroidism, an overactive thyroid.
• Sometimes hot flashes are complicated by obesity. Weight loss, however, is never enough to get rid of hot flashes.
• Sometimes hot flashes are due to the use of estrogen sequestration agents in the treatment of cancer. Unfortunately, estrogen replacement therapy would subvert the cancer treatment.

There are certain commonsense practices that usually improve symptoms. Cutting back on caffeine usually reduces the severity of hot flashes, as does reducing consumption of alcohol. Smoking cessation usually results in fewer hot flashes that are less severe. Having a portable fan, using the air conditioner, and dressing layers can all be helpful.

On the other hand, some approaches usually don't work really well.

• Herbs like St. John's wort usually help, but aren't enough for moderate to severe hot flashes. Black cohosh (Remifemin) typically produces fewer side effects (such as diarrhea or sun sensitivity) than St. John's wort.
• Exercise programs don't hurt, but usually don't help a lot, either.
• Acupuncture and relaxation programs tend to work in women who expect them to work, which suggests a strong placebo effect. Of course, if it works, women don't care whether it's a placebo or not.

There are drugs that help women who have hot flashes. Some women respond well to a class of drugs known as norepinephrine reuptake inhibitors, a group of medications including Effexor (venlafaxine). Some women respond to selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Brisdelle, Zoloft, Lexapro, and Priligy. Women may respond to gabapentin or clonidine.

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• Giving women testosterone may boost their sex drives (women are given much smaller doses than men), but it will do very little for hot flashes.
• Sometimes the hormone replacement therapy contains both estrogen and progestin, but progestin alone is usually not successful.
• Estrogen replacement therapy itself has a serious downside.

One of the serious problems with estrogen replacement therapy is that it is associated with increased risk of blood clots that cause deep vein thrombosis. These are blood clots that usually form in the legs and can travel to the heart. Another of the serious problems with estrogen replacement therapy is that it slightly increases the risk of estrogen receptor positive breast cancer. There is a way, however, of minimizing these risks.

Minimizing The Risks Of Estrogen Replacement Therapy For Hot Flashes

There are women who essentially tell their doctors "I don't care if estrogen can cause cancer! Just make my hot flashes stop!" It's not necessary, fortunately, to assume a high level of risk from hormone replacement therapy during the transition to menopause to stop its more troubling symptoms. Many doctors have begun to use a low-dose approach.

The Smallest Dose Necessary for the Shortest Time Possible

To minimize risks of hormone replacement therapy, doctors now offer hormone therapy to a select group of patients going through menopause.

• Candidates for hormone replacement therapy should have "moderate to severe" hot flashes.
• Candidates for hormone replacement therapy should have had their last period in the last ten years. Typically they will be 60 or younger.
• Hormone replacement therapy should be limited to the lowest possible dose that relieves symptoms. Doctors will start with the lowest possible dose.
• Women should be asked to wean off hormone replacement therapy every six months. In most cases, hormone replacement should be discontinued after 5 years or the age of 65, whichever comes first.

When estrogen replacement therapy is used for just one to three years, by women in their fifties, the risk of blood clots and breast cancer is almost unmeasurable. Women who already have a history of blood clots or estrogen receptor positive breast cancer, of course, usually cannot receive hormone replacement therapy.

What Doctors Will Expect Women to Do Before Getting Hormone Replacement Therapy

As part of prescribing the lowest possible dose of estrogen or estrogen plus progestin, there are certain things most doctors will ask their female patients to do to make that lowest possible dose effective.

• Doctors usually ask their patients to learn a breathing exercise called paced respiration. When hot flashes are coming on, take slow, deep, abdominal breaths in through the nose, and then exhale slowly through the mouth. The idea is to take 5 to 7 deep, slow breaths per minute. This slows down the pulse, and reduces circulation of blood to the skin, so it will take longer to warm up.

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• Most doctors will ask patients who have hot flashes to invest in some products for cooling the skin during hot flashes. The most commonly recommended purchase is the Chillow, which is a water-filled pillow. It absorbs heat from the head into the water within. A Chillow can heat up during the night, but it usually provides several hours of relief. Most users find it reduces the need for pillow flipping to just two or three times a night. Sprays, foams, and cooling gels also work, but are messier and have to be bought over and over again. Putting a package of frozen peas in your pillow also cools the head, but breaking the package results in a major bedtime cleanup problem.
• Doctors appreciate patients who make an effort at diet. Losing just a few pounds can make a real difference in the severity of hot flashes, and make lower doses of medication more effective.