Hot Flashes: What You Need to Know

I recently got several requests (from women suffering from hot flashes) to blog about possible remedies. Apologies for the blog length, but there is much to address.

What You Need to Know: No matter how disruptive and frustrating they may be, hot flashes are not a sign of a medical problem. They are a normal response to natural hormonal changes in your body. Hot flashes usually subside after the first or second year following menopause, when estrogen levels stabilize at a low level.

  • Tobacco use, heavy alcohol use, stress, spicy foods, and heat tend to make hot flashes worse. By avoiding these risk factors, exercising regularly, and eating well, you can prevent or reduce hot flashes.
  • The body-mind connection is a powerful element of hot flashes and emotional symptoms. Rhythmic breathing exercises (paced respiration), which help you meditate and relax, may reduce your hot flashes.
  • Background: Most women experience hot flashes at some point before or after menopause, when their estrogen levels are declining. While some women have few to no hot flashes, others have them numerous times each day. If hot flashes are disrupting your sleep or daily life, you are no doubt looking for relief. Fortunately, you have a number of self-care and medical treatment options that can help you manage your symptoms.

If you have experienced hot flashes, you’re already well aware that they are sudden sensations of intense body heat, often with heavy sweating and reddening of the head, neck, and chest or the entire body. At night, they commonly cause drenching “night sweats,” making them a cause of sleep problems for perimenopausal and postmenopausal women. During a typical hot flash, your skin temperature rises. Although you may feel very warm during a hot flash, because of the heat lost by your body’s cooling mechanism (perspiration), your body temperature may actually drop. Some women feel chilly after a hot flash, and some women feel the chill without the flash.

The biochemical cause of hot flashes is not well understood. But they are linked to declining estrogen levels, and they do seem to be made worse by stress, heavy alcohol use, and cigarette smoking. Although menopausal hot flashes can be disruptive, frustrating, and at times embarrassing, they are medically harmless. They are not a sign of a medical problem, nor do they cause medical problems.

It is normal for hot flashes to:

  • Happen in women of all ages when they are upset or embarrassed.
  • Happen during the perimenopausal years before menopause, when estrogen levels fluctuate. They are most common, most frequent, and most intense during the 2 years following menopause (postmenopause), when estrogen declines.
  • Be accompanied by mild to severe heart palpitations, anxiety, or irritability. In rare cases, panic attacks are triggered at the same time as hot flashes, usually in women who have a history of panic attacks.
  • Be especially severe in women who become menopausal from chemotherapy, antiestrogen treatment for breast cancer, or surgical removal of the ovaries.
    Subside within a couple of years after menopause. But some women do continue to have hot flashes for years after menopause. There is no reliable method for predicting whether, when, or how long you will have hot flashes.
  • Hot flashes are uncommon in various places around the world. More research is necessary before experts can identify specific factors about American women’s environment and lifestyle that make hot flashes a common problem.

Lifestyle choices for preventing or reducing hot flashes

  • Eat and drink well, and avoid smoking.
  • Limit your intake of alcohol.
  • Drink cold beverages rather than hot ones.
  • Eat smaller, more frequent meals to avoid the heat generated by digesting large amounts of food.
  • Make healthy eating a priority.
  • Do not smoke or use other forms of tobacco.
    Stay cool.
  • Keep your environment cool, or use a fan.
    Dress in layers, so you can remove clothes as needed.
    Wear natural fabrics, such as cotton and silk.
    Sleep with fewer blankets.
  • Reduce stress.
  • Get regular physical exercise.
  • Use relaxation techniques, such as breathing exercises, yoga, or biofeedback. Using a breathing-for-relaxation exercise called paced respiration may reduce hot flashes and emotional symptoms.

Medical treatment options for hot flashes

Short-term, low-dose hormone therapy (HT) can reduce or stop hot flashes and other perimenopausal symptoms by raising your body’s estrogen level. Use the lowest dose needed for the shortest possible time and have regular checkups. This is because HT may increase the risk of blood clots, stroke, heart disease, breast cancer, ovarian cancer, and dementia in a small number of women. Risk varies based on when you start HT in menopause and how long you take it. Short-term use of hormone therapy in early menopause has less risk than when it is started later in menopause. If you have a history of cardiovascular disease or breast cancer, avoid using estrogen for hot-flash relief—other options are available.

  • Estrogen-progestin birth control pills (before menopause) can reduce or stop hot flashes and other perimenopausal symptoms by evening out fluctuating hormones. Don’t use estrogen for hot-flash relief if you are older than 35 and smoke; have diabetes, cardiovascular disease, or breast cancer; or have a family history of breast cancer.
    Antidepressant medicine can reduce the number and severity of hot flashes by improving the brain’s use of serotonin, which helps regulate body temperature. Side effects are possible. This type of medicine is a good choice if hot flashes, irritability, or mood swings are your only perimenopausal symptom.
  • Clonidine may relieve hot flashes for some women. But studies have not shown that clonidine makes hot flashes less severe or less frequent. This type of medicine is a good choice if hot flashes are your only perimenopausal symptom, especially if you have high blood pressure.
  • Gabapentin, an antiseizure medicine, may lower the number of hot flashes each day and the intensity of hot flashes.
  • Black cohosh may reduce or prevent hot flashes, depression, and anxiety. As with HT, have regular checkups when taking black cohosh. The use of black cohosh during pregnancy has not been rigorously studied. Thus, it would be prudent for pregnant women not to take black cohosh unless they do so under the supervision of their health care provider. Women with breast cancer may want to avoid black cohosh until its effects on breast tissue are understood. In the United States, the U.S. Pharmacopeia (the standards-setting organization for foods and drugs) advises that black cohosh products be labeled with the following cautionary statement: “Discontinue use and consult a healthcare practitioner if you have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice.” Individuals with liver disorders should avoid black cohosh. Individuals who develop symptoms of liver trouble such as abdominal pain, dark urine, or jaundice while taking the supplement should discontinue use and contact their doctor.
  • Some women eat and drink a lot of soy to even out hot flashes and other perimenopausal symptoms. So far, studies have used many different soy sources and different measures of success, which are hard for experts to compare. Soy isoflavone (rather than soy protein) studies have shown the most promise for hot flash treatment.

I’m Dr. Michael Hunter. I hope that this post helps you.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: http://www.webmd.com/menopause/managing-hot-flashes#

Chemotherapy and Neuropathy: What Can You Do?

American Society of Clinical Oncology Clinical Practice Guidelines

Bald woman chemotherapy patient white woman

What You Need to Know: Although the chemotherapy–induced peripheral neuropathies (CIPN) trials are inconclusive regarding tricyclic antidepressants (such as nortriptyline), gabapentin, and a compounded topical gel containing baclofen, amitriptyline HCL, and ketamine, these agents may be offered on the basis of data supporting their utility in other neuropathic pain conditions given the limited other CIPN treatment options.

The Study: A systematic literature search identified relevant, randomized controlled trials (RCTs) for the treatment of CIPN. Primary outcomes included incidence and severity of neuropathy as measured by neurophysiologic changes, patient-reported outcomes, and quality of life.

Details:

  • A total of 48 RCTs met eligibility criteria and comprise the evidentiary basis for the recommendations.
  • Trials tended to be small and heterogeneous, many with insufficient sample sizes to detect clinically important differences in outcomes.
  • Primary outcomes varied across the trials, and in most cases, studies were not directly comparable because of different outcomes, measurements, and instruments used at different time points.
  • The strength of the recommendations is based on the quality, amount, and consistency of the evidence and the balance between benefits and harms.

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad: Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Journal of Clinical Oncology, 18 April 2014

TASTE: Using Diet to Fight Cancer-Related Side Effects

In The Cancer-Fighting Kitchen, Rebecca Katz lists specific foods that can be recommended to patients experiencing many of the common side effects of cancer treatment. Today, let’s look at a symptom commonly associated with cancer treatment, including chemotherapy.

Dysgeusia, or altered sensation of taste, is a common oral side effect of cancer therapy. Few effective treatments have been found for this side effect, which can significantly affect a patient’s quality of life. With the right techniques, you can restore good taste to food. Katz developed an acronym — FASS — which stands for fat, acid, salt, and sweet. These 4 flavors (what Katz calls “fast fixes for taste-bud troubles”) can make food taste better when a patient is experiencing dysgeusia. Food tastes best when these 4 flavors are in balance.

Here’s how it works. For patients who have a persistent metallic taste in their mouths, or who find that foods taste bitter, a little sweetener (Katz recommends grade B organic maple syrup) can counteract the bad taste. If food tastes too sweet, patients should add a few drops of acid (lemon or lime juice). Lemon juice also balances the taste of overly salty foods. If the patient complains that all food is tasteless, or “tastes like cardboard,” the best fix is adding a little sea salt, and possibly a spritz of lemon juice. Patients with mucositis, however, might find the addition of salt or citrus painful. For those with mouth sores or difficulty swallowing, Katz suggests soothing, nonspicy foods, such as broths, soups, and smoothies.

I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minute; Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Hovan AJ, Williams PM, Stevenson-Moore P, et al; Dysgeusia Section, Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer. 2010;18:1081-1087.

Yoga in Menopause May Help Insomnia – But Not Hot Flashes

yoga lotus meditationWhat You Need to Know: Taking a 12-week yoga class and practicing at home was linked to less insomnia, but not to fewer or less bothersome hot flashes or night sweats. This association of yoga and better sleep was the only statistically significant finding in the MsFLASH (Menopause Strategies: Finding Lasting Answers for Symptoms and Health) Network randomized controlled trial.

Background: Hormone therapy is the only treatment approved by the US Food and Drug Administration for the management of hot flashes and night sweats, and fewer women are opting for hormone therapy recently. In this context, the MsFLASH tried to see whether three more natural approaches – yoga, exercise, or fish oil – might help. The study assigned 249 healthy, previously sedentary women at multiple sites (including Group Health Medical Center, USA) to do yoga, a moderate aerobic exercise program, or neither – and to take an omega-3 fatty acid supplement or a placebo.

The Results: Exercise slightly improved sleep and (to a lesser degree) insomnia and depression, but these effects were not statistically significant. The omega-3 fatty acid did not help with any of the symptoms under study. Yoga was linked to better sleep.

I’m Dr. Michael Hunter, and (even though I am not menopausal), I really should think about doing yoga for health!

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: Newton KM, et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause, September 2013.

Aromatase Inhibitors & Joint Stiffness: Walking Program Shows Promise

woman holding wrist arthritis joint stiffness

Summary: A self-directed walking program shows promise in easing joint stiffness among older women who experience these symptoms while taking the “anti-estrogen” drugs known as aromatase inhibitors. This is the conclusion of research present this week at the America College of Rheumatology Annual Meeting in San Diego (USA).

Background: Postmenopausal women with breast cancer whose treatment often includes an aromatase inhibitor (AI) often experience joint pain or stiffness as a side effect. Some studies have suggested that up to 20-32% will stop taking the drug because of this side effect. But the incorporation of these drugs into the breast cancer management program has led to impressive reductions in breast cancer recurrence and death.

Researchers at the University of North Carolina at Chapel Hill (USA) conducted a pilot study to see whether physical activity could improve joint pain or stiffness. Women in the program followed the walking program for six weeks. Twenty patients participated, all of whom were 65 or older, had Stage I-III disease, and reported joint pain or stiffness associated with an aromatase inhibitor.

Results: At the end of the study, 100% of the study participants said that they would recommend the program to other breast cancer survivors experiencing joint pain or stiffness. The average joint pain scoopers among the participants decreased by 10 percent, fatigue decreased by 19 percent, and joint stiffness dropped by 32 percent.

My Take: For selected postmenopausal patients with breast cancers driven by estrogen, aromatase inhibitors can provide improvements in survival and relapse chances. But these women are much more likely to experience side effects such as hot flashes, night sweat, cold swears, joint pain and stiffness, as well as other problems. Simply walking may help with the common side effect of joint pain and stiffness. I typically suggest a minimum of 30 minutes of the equivalent of a brisk walk, 5 to 6 times per week.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: American College of Rheumatology Annual Meeting (San Diego, 2013).

Venous Thromboembolism (Blood Clots) in Patients with Cancer: Risk

B0002113 Electron micrograph of blood clot
Electron micrograph of blood clot (Photo credit: wellcome images)

The close association between cancer and thrombosis (blood clots) has been recognized for over 150 years. Today, I present a risk score for patients with cancer, based on several factors:

Very high risk: Stomach or pancreas cancer: 2

High risk (lung, lymphoma, gynecologic, bladder, testicular): 1

Pre-chemotherapy platelet count at least 350,000: 1

Hemoglobin level less than 10 or use of red blood cell growth factors: 1

Pre-chemotherapy leukocyte count over 11,000: 1

Body Mass Index 35 or higher: 1

High risk score: 3 or higher; intermediate risk = 1-2; low-risk = 0

When this risk model was retrospectively evaluated in large randomized trials, the risk of venous clots among high-risk patients was significantly reduced in those randomized to blood thinning drugs (thromboprophylaxis).

Other risk factors include infection, as well as lung or kidney disease.

The American Society of Clinical Oncology (ASCO) updated guidelines recommend that patients with cancer be educated about the symptoms and signs of blood clots, and that risk be assessed at the time of chemotherapy initiation and periodically thereafter. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.

Reference: The ASCO Post (volume 4, issue 11; 10 July 2013).

Jaw Osteonecrosis and Breast Cancer Treatment

bisphosphonate-associated osteonecrosis of the jaw
Bisphosphonate-associated osteonecrosis of the jaw (Photo credit: paparutzi)

Background: The industry-supported AZURE trial (New England Journal of Medicine 2011;365:1396) showed that the bisphosphonate drug zoledronic acid (ZA), in combination with standard systemic therapy, had no effect on the overall study population of patients with Stage II or III breast cancer. ZA did significantly reduce the risk for recurrence and death among postmenopausal patients.

So, what is the problem? Bisphosphonate therapy has also been linked to osteonecrosis of the jaw, a condition in which there can be exposed bone )most commonly in the mandible, or lower jaw) as well as loose teeth, infections, localized pain, and draining fistulas.

What is the incidence of osteonecrosis? Investigators looked at 3360 women in the AZURE trial. Patients were randomized to get standard systemic therapy, with or without ZA (4mg for 19 doses over 5 years). There were 26 confirmed cases of osteonecrosis, representing a cumulative incidence of 2.1%.

My take: It is comforting that the incidence of jaw necrosis is relatively low. Still, osteonecrosis can be debilitating, and medical treatment with surgical debridement has variable success. If you are offered zoledronic acid or denosumab as a component of your breast cancer management, have a good dialog with your care team about this potential side effect. I’m Dr. Michael Hunter.

The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

Available now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Both can be found at the Apple Ibooks store. Coming Soon for iPad:  Understand Breast Cancer in 60 Minutes; Understand Colon Cancer in 60 Minuteable now: Understand Colon Cancer in 60 Minutes; Understand Brain Glioma in 60 Minutes. Thank you.