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Hot Stuff: What’s New About Hot Flashes?

by JoAnn Pinkerton | Aug 14, 2017

We're pleased to have a guest post from Dr. Rebecca Thurston.

Rebecca C. Thurston, PhD
NAMS Board Member

Most women transitioning through menopause know what hot flashes are (sometimes referred to as night sweats or vasomotor symptoms). It’s the sudden onset of heat that comes out of nowhere, the embarrassing flushing and sweating that comes at the most inopportune times, or the heat, sweating, and sleep disturbance of those overnight hot flashes.

Who Gets Them?
About 75% of women will have hot flashes. In the United States, African American women get the most severe and persistent hot flashes. Hispanic and non-Hispanic white women fall in the middle, and Asian women in the United States have the fewest hot flashes. However, many, if not most, women will get them. Smoking is a clear risk factor for hot flashes, so if you are a smoker, stopping may help. Body fat appears to be a mixed story and depends on age or stage of menopause. Women who are overweight or obese have more hot flashes when they are younger and having either regular or irregular menstrual cycles. Yet once these women are well past their final menstrual period, they don’t necessarily have more hot flashes. Stressed and anxious women consistently report having more hot flashes over the subsequent years.

Are You a Super Flasher?
It was long thought that hot flashes would last just a few years, right around the last menstrual period. However, we now know that they last much longer. For most women, hot flashes will last about 7 to 10 years; milder hot flashes likely last much longer. However, when women have hot flashes varies dramatically. Some women will have them primarily in their 40s and 50s, when they are still having menstrual cycles, and others will start having hot flashes only when their cycles have stopped. A lucky few (about a quarter of women) will have no or few hot flashes over the menopause transition. Finally, another quarter of women are what investigators for this research have dubbed “Super Flashers.” These women will begin having hot flashes when they are still having menstrual cycles and will continue to have them well after their cycles have stopped. These “Super Flashers” will have hot flashes for well over a decade.

What Causes Hot Flashes?
Hot flashes are marked by increased skin temperature, sweating, flushing, and heart rate. We’re sure anyone who has had a hot flash can tell you that. But what causes them? The underlying biology of hot flashes is not fully worked out yet. We know that hormones play a role. Those dramatic hormone changes that signal menopause clearly matter. However, hormones are not the whole story.

Getting in the Zone
The body’s internal thermostat also matters. Like the thermostat in your home, your body keeps its core temperature in a zone—like the temperature you set for your home. When your core temperature goes above that zone, you sweat, and when it goes below that zone, you shiver. Like the air conditioning and the heat, this sweating and shivering function is trying to bring your body temperature back into the zone. The sweating during a hot flash can be seen as your body’s attempt to get rid of heat. However, this hot flash often occurs when the internal body temperature is just fine (well within the zone). So it appears that the internal thermostat of women having hot flashes is malfunctioning and detecting small changes in body temperature as too hot. Why this happens is not totally clear, but likely involves an interplay between those changes in hormones and the body’s thermostat (its controller lives in the brain). There is likely more to the story, and we are working on it, so stay tuned.

Are Hot Flashes Such a Big Deal?
For some women, hot flashes are no big deal and are pretty mild. But for many other women, having severe or frequent hot flashes really interferes with life. Women with hot flashes, particularly frequent or severe hot flashes, have poorer sleep quality and may be more likely to have depression or anxiety during the menopause transition. For these women, quality of life and even work productivity are diminished. Hot flashes do matter.

So What Can You Do About It?
There are two broad approaches to treating hot flashes: medical and behavioral. Because I don’t prescribe medications myself, I will only briefly comment on medication approaches.

  • Hormone therapy remains the most effective treatment for hot flashes during menopause; however, hormone therapy may not be for everyone. NAMS has prepared the consumer-oriented MenoNote “Deciding About Hormone Therapy Use” to help you to decide whether hormone therapy is for you. MenoNotes are available on the NAMS website.
  • Another FDA-approved medication for treating hot flashes belongs to a class of drugs called selective serotonin reuptake inhibitors (SSRIs). You may know them as antidepressants.
  • Beyond SSRIs, other medications have shown some effectiveness and are widely used for helping women manage hot flashes, including serotonin norepinephrine reuptake inhibitors and gabapentin. These are not FDA-approved for treatment of hot flashes, but they are often used for this purpose.

This isn’t the complete list of available medications, and keep in mind that everyone is different, so you may need to experiment with different approaches to find what works best for you. Hang in there and try different things.

Are Drugs the Only Answer?
You have options. I am a proponent of behavioral approaches, because although these approaches may take more active engagement from you, they can eliminate the need to take a medication and may have other mental or physical health benefits. Menopause is the time to adopt positive health behaviors. These behaviors can help not only improve quality of life, but also improve health later in life. Although much more research is needed on behavioral treatments for hot flashes, here are some of my personal recommendations that I often discuss with women:

  • Hypnosis has the potential to help reduce both the occurrence of hot flashes and their effect on a woman’s life. It’s one of the few approaches that can do both. However, there is a very specific protocol that your healthcare provider should follow.
  • Mindfulness-based stress reduction. This 8-week program involves meditation, relaxation, and gentle yoga and has helped some to cope with hot flashes and, importantly, improve sleep. This is particularly relevant because many women report that the primary irritant for them with hot flashes is the disrupted sleep. This approach has been tested for a lot of different mental and physical health issues, so it may help with more than your hot flashes. Meditation is the cornerstone of this approach, so if you want to learn meditation, this is the way to go.
  • Cognitive-behavioral therapy has shown similar effects in helping women cope with hot flashes. This approach helps women to target what they are telling themselves about their hot flashes and also engage proactively in activities that may be helpful.
  • Weight loss may have some beneficial effect on hot flashes for women who are overweight or obese when they are early in the menopause transition (but not necessarily when they are years past their final menstrual period). Weight loss matters for many aspects of health. For women who need to lose weight, menopause is the time to do it for the prevention of obesity-related diseases later in life.
  • Keep your environment cool, especially for sleep. This is particularly important if you are having nighttime hot flashes and problems with sleep. We know that in order to get a good night’s sleep, a drop in core body temperature is critical. A woman’s internal thermostat is malfunctioning during menopause, so women need all the help they can get from the environment. If you get grumbling from your bed partner, keep extra blankets handy!
  • Yoga has had very mixed findings on helping with hot flashes and likely depends on the type of yoga. Yoga does have some support for improving sleep, quality of life, and overall well-being, but may or may not decrease the hot flashes themselves. If you are new to yoga, make sure you are working with a certified yoga instructor who has experience working with midlife women. I say this as a yoga teacher myself to prevent yoga-related injuries. Go slow and listen to your limits.
  • What about exercise? Moderate physical exercise (eg, brisk walking) sadly does not appear to improve hot flashes. However, exercise is so important to many aspects of health, that this should not discourage exercising! Keep your exercise routine strong. It is important to your brain, heart, and bones (among other things).

What we know about hot flashes is constantly evolving. You may need to try multiple approaches or switch them up as you age. The bottom line is that you don’t have to suffer in silence. Get help if you need it. We as a scientific community want to offer you a range of effective approaches and are working hard on developing new treatment options. Stay tuned!


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