Dr. Joy'El Ballard / Menopause 101

I get it. You’re hot. When someone is asked to describe what to expect in menopause, hot flashes are usually the first things that come to mind. However, hot flashes typically don’t wait for menopause — they actually start during perimenopause, the menopausal transition, and become most frequent and severe within the two years surrounding the final menstrual period.

To better understand when you may begin experiencing hot flashes (if you aren’t already), here’s context: Perimenopause can start as early as one’s late 30s, but on average it starts in the early to mid 40s. After irregular menstrual cycles, hot flashes are the second most frequently reported symptom during perimenopause. Hot flashes occur in as many as 75–80 percent of perimenopausal people in the U.S. Most people who menstruate experience them for six months to two years while others can experience them considerably longer — as long as 10 years. Unfortunately, a small group of folks will experience hot flashes indefinitely, but these instances are rare and when the hot flashes occur, they’re usually mild.

The mechanism that causes hot flashes is still not fully understood but it appears that when estrogen levels fluctuate during perimenopause and, ultimately, declines in menopause, changes occur in the hypothalamus which is the part of the brain that regulates body temperature. The thermoregulatory zone in the hypothalamus senses the body is too warm and starts a chain of events to cool the body down.

It is a sudden sensation of heat that spreads over the body, typically the upper body and face. Some people describe it as feeling like you are actually sitting in an oven. You’re typically the only person in the room who feels extremely hot.

Various symptoms that can occur during a hot flash include:

• Flushing of the face and/or neck which looks like red blotches on the skin which is why hot flush and hot flash are terms used interchangeably.
• Beads of sweat across the forehead.
• Sweating on the upper body, sweating in armpits, beads of sweat running down your back.
• Heart palpitations which feels like your heart is racing or it’s beating out of your chest

After a hot flash ends, you may experience chills as the sensation of heat subsides. Rarely, you will experience chills alone. A single hot flash can last up to five minutes and can occur intermittently (a few times a week or month) or frequently (daily or hourly). Most hot flashes are mild to moderate in intensity, however, about 15 percent of people have severe or very frequent hot flashes. Those who experience surgical menopause (for example, menopause after surgical removal of ovaries) are more likely to experience severe hot flashes.

Night sweats are hot flashes that occur while you’re sleeping — the intense heat, perspiration, or the post-hot-flash chill can wake you up and disrupt your sleep. Many of my patients sleep through a hot flash only to wake up drenched in sweat.

Thankfully there are an array of options for treating hot flashes and it’s important to discuss them with your healthcare provider to determine which is the best option for YOU based on your medical and family history. When deciding on a plan of treatment, here are some things to keep in mind.

Identify your hot flash triggers. Triggers are simply the things that you eat or do prior to having a hot flash. Common triggers include: Sugar, caffeine, spicy food, wine, and stress.

• Eating a healthy diet that includes omega-3 fatty acids (ex.fatty fish like salmon and nuts/seeds) and prebiotics/probiotics will support optimizing gut health. Gut health plays an important role in helping your hormonal balance.
• Keep hydrated to help cool down your body temperature.
• Exercise regularly which will improve physical fitness and heart health, and help you maintain a healthy weight — all of which may help alleviate at least some of your hot flashes.
• Practice slow, deep breathing or other relaxation techniques like yoga or meditation.
• Dress in light layers to keep cool and keep room temperatures on cool settings whenever you can.
• Invest in a fan to place at your bedside and a portable one for your desk and car.
• Refrain from smoking.

These include dietary supplements, herbal remedies, and essential oils. There is limited adequate evidence that any of them actually work but there are certainly those who have benefited from using these types of remedies. Relizen is a hormone-free, plant-based supplement that has been shown to provide relief from hot flashes and night sweats. Amongst the many herbs, Black Cohosh has the most research but its effectiveness is still controversial.

There is limited reliable evidence that suggests Cannabidiol (CBD), the chemical derived from the cannabis plant, improves hot flashes but there are people who report some benefit. Peppermint oil can provide a cooling sensation during a hot flash. Another complementary or alternative therapy that 1–10 percent of people in menopause use is acupuncture. But studies are contradictory and limited in demonstrating its mechanism to alleviating hot flashes and also to its effectiveness.

Please remember to consult a physician before starting any non-prescription remedies.

HT remains the most effective treatment for vasomotor symptoms of menopause. There are different types of HT but every person may not be a good candidate for hormones, particularly those with preexisting conditions like breast cancer, or a genetic predisposition to some cancers. The Women’s Health Initiative (WHI) trial and subsequent Kronos Early Estrogen Prevention Study (KEEPS) suggest appropriate candidates for HT are healthy people within 10 years of the start of menopause and/or less than 60 years old. It is important to have a robust conversation with your physician to determine the best choice of HT and identify the most appropriate dose, formulation, route of administration and duration of use based on your individual risks. Hormone therapies include:

• Low-dose birth control pills — an option if you are perimenopausal.
• HT, formerly known as Hormone Replacement Therapy (HRT) — can be prescribed as estrogen alone (if you no longer have a uterus), estrogen and progesterone ( if you still have a uterus), or progesterone only. These options come in different forms: pill, patch, and topical (cream, gel, or spray).
• Bioidentical Hormone Therapy (BHT) — these are hormones with the same chemical structure as the hormones produced in the human body.

If you are not a candidate for HT or prefer an alternative to HT, low-dose Paroxetine is the only FDA-approved, non hormonal medication for hot flashes. It’s a medication typically used to treat depression.

Other medications that have been shown to improve hot flashes but are not FDA-approved are Venlafaxine, an anti-anxiety medication; Gabapentin, an anti-seizure medication; and Clonidine, a blood pressure medication.

It’s important to know that hot flash intensity and frequency varies from person to person — some won’t experience them at all. If you have hot flashes or night sweats and are not bothered by them, you don’t need any treatment, however, lifestyle changes are always beneficial to your overall health.

But if your symptoms are bothersome and affecting your quality of life, you should consider treatment. Whatever your approach, the best results will come from a shared decision-making conversation between you and your physician.