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#

Hot Flashes Associated with Hormone Therapy for Prostate Cancer: What Doesn’t Work

Ray Flash Ring Test-1
Photo credit: puck90

Face flushed? Sudden rush of heat? Hot flashes are often the bane of men receiving male hormone-lowering therapy as a part of management for prostate cancer. In fact, 80% of men who have such hormonal manipulation will get hot flashes.

Study: Investigators at Wake Forest Baptist Medical Center (USA) conducted a Phase III, double-blind  study. Patients were randomly assigned to one of four daily regimens: 1) placebo pill + milk powder; 2) venlafaxine (an anti-depressant commonly used as treatment for hot flashes in women) + milk powder protein; and 3) placebo + soy protein powder; and 4) venlaxifine and milk powder.

Results: Neither venlafaxine nor soy protein alone or in combination reduced hot flashes in men. I’m Dr. Michael Hunter.

Reference: Vitolins MZ, Griffin L, Tomlinson WV, et al. J Clinical Oncology, 2013

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.

Hot Flashes: Management Options

Full of Soy Lunch
Full of Soy Lunch (Photo credit: Bunches and Bits {Karina})

Long blog warning: I wish I could be more like the Dadaist Marcel Duchamp, who once offered: I shall be so brief that I am now done!

There are a wide variety of options for those with hot flashes. These may be conveniently divided into pharmaceuticals, neutraceuticals, surgical ones (stellate ganglion blacked). Complementary/behavioral therapies include acupuncture, exercise, yoga, and others. In today’s blog, we will look at neutraceuticals. Neutraceuticals include herbal remedies, vitamins, and phytoestrogens.

Herbals: Black cohosh is an herb made from a North American perennial plant, and has been well-studied among women with menopausal symptoms (bit not for men with prostate cancer). Black cohosh is not estrogenic, instead acting on serotonin receptors. A study of studies (meta-analysis) showed that in 6 of 9 randomized trials, black cohosh as the potential to reduce hot flashes. But, more recent trials show no effectiveness among women without cancer. Potential side effects include mild gastrointestinal upset, headaches, vomiting, and dizziness at higher doses.

St. John’s Wort is a perennial herb from Europe, and has been reported to have anti-depressant properties. Most of the studies regarding hot flashes have been limited to women experiencing natural or surgical menopause. The data is mixed on its efficacy. Because it can activate certain enzymes (called cytochrome P450 enzymes), you must check with your health care provider before taking it.

Vitamins: Vitamin E has been investigated for hot flashes: There have been 3 randomized trials, and to me it seems that vitamin E has minimal efficacy. It appears to reduce the number of hot flashes per day by only 1 to 2. A study of studies (meta-analysis) of 57 trials showed no relationship between death rates (all-cause mortality) and vitamin E. Those with heart disease, diabetes, and high blood pressure should take heed. And there is some concern about a possible increase in cancer incidence. Multivitamins with minerals may help hot flashes improve for a few months, but the advantage over placebo disappears by the 3 month mark. Folic acid is under investigation, but there are some hints that it may reduce hot flashes by reducing levels of a byproduct of norepinephrine.

Phytoestrogens: Soy products have been analyzed in a meta-analysis of 19 randomized controlled trials of soy isoflavones. Soy did appear to reduce hot flashes, when compared to a placebo. The median dose across the studies was 54 mg. The effects on men are not clear, but at least one report has not shown a benefit among men with prostate cancer. And the safety for men has not been established.

Similar to soy, red clover results have not been especially impressive. A recent randomized trial of black cohosh, red clover, placebo, and hormone therapy showed red clover didn’t work (at a dose of 398 mg per day). Among men, it has not been well-studied. Flax seed is a rich source of lignans. Three randomized trials have shown no benefit for hot flashes (women). It has not been well-investigated among men.

My take: For these interventions, differences in information about product purity, dosing, and side effects makes comparisons across studies difficult. Unfortunately, there is a lack of standardization (the US Food and Drug Administration) has minimal oversight. Multivitamins with minerals may temporarily improve symptoms, and soy seems to have some activity against hot flashes in women. For many, neutraceutical do not have the desired reduction in hot flash frequency or severity. Next, we’ll turn to surgical therapies such as a stellate ganglion block. Hint: It may work(!), but the data is limited.

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.

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

Reference: Fisher WI et al. CA: A Journal for Clinicians, vol 63 (3).

Hot Flashes: Physiology

hot flashes

Don’t blame the messenger! The physiological mechanisms of hot flashes are unknown. However, we have some clues that they are linked to 1) thermoregulatory disruption; and 2) neurochemical disruption.

Thermoregulatory Disruption: Hot flashes have been described to be an exaggerated response to changes in the thermoregulatory system. What does that mean? Thermoregulation maintains your body temperature. Did you know that the threshold point between sweating and shivering can occur with a 0.4 degree (C) change in internal temperature: Sweating happens at higher-than threshold temperatures, with shivering at lower temperatures. In individuals with hot flashes, this thermoregulatory system is disrupted. This disruption may be due to changes in neurochemicals such as estrogen, norepinephrine, serotonin, glucose, and others.

Neurochemical Disruption: Estrogen is a strong suspect neurochemical linked to hot flashes. Unfortunately, while estrogen is the most effective drug intervention for hot flashes, we cannot offer it is your cancer is hormone-dependent. Estrogen appears to stabilize thermoregulatory disruption. It may reduce spontaneous fluctuations in core boy temperature after ovary removal. Estrogen therapy raises the sweating threshold.

But could it be that estrogen works via other chemicals? For example, changes in estrogen levels alter levels of the brain chemicals norepinephrine and serotonin. Drugs (such as clonidine) that activate norepinephrine can alleviate hot flashes. Drugs (such as  yohimbine) that block norepinephrine can exacerbate the symptoms. Around menopause, serotonin levels are positively correlated to hot flashes. Low blood sugar levels (hypoglycemia) may trigger hot flashes. Eating may provide an average of 90 minutes free from hot flashes.

We will turn to the management of hot flashes in the next blog. Thanks for hanging in there through the biochemistry-speak! 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.

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

Reference: Fisher WI et al. CA: A Journal for Clinicians, vol 63 (3).

Hot flashes: Risk Factors

Mature woman white smiling

Over the next several issues, I’ll turn to hot flashes: What are the risk factors, what is the pathophysiology, and management. Today, we begin with factors associated with hot flashes for patients with or without cancer.

Risk Factors: Both men and women can get hot flashes due to hormonal changes that occur during the natural aging process, although hot flashes are more common among midlife women. Age, race, ethnicity, educational level (equivocal), smoking, genetics, and body mass index can play roles. Some of  my patients see exacerbations with alcohol, exposure to heat, stress, spicy foods, and caffeine.

Race: Some studies point to African Americans having a greater risk for hot flashes (in addition to greater severity) as compared to other races. Here are the results from the Study of Women’s Health Across the Nation for combined hot flash and night sweat prevalence: Japanese 18%; Chinese-Americans 21%; whites 31%; Latinas 21%, and blacks 46%.

Smoking: The few studies that address the issue suggest a link between smoking and hot flashes. Smoking can alter estrogen metabolism in at least 4 ways.

Heart: Women who have hot flashes for 6 days or more over 2 weeks (especially those who are overweight or obese) have a higher cardiovascular risk. The role of weight and body mass index is less clear.

Genes: Research into the link between genetics (estrogen metabolism and receptor genes) and hot flashes appears promising. For example, women with a change (polymorphism) in a gene spot called CYP1B1 are at a 1/3 greater risk of reporting more severe and persistent hot flashes.

Cancer-related risk factors: These are predominantly related to the rapidity of hormone withdrawal. Among women, this is most commonly a drop in internal estrogen levels; with men, it is a drop in testosterone. For women, this may be linked to stopping hormone replacement therapy (HRT) when hormone-dependent breast cancer is diagnosed, the start of anti-estrogen therapies for treatment, chemotherapy-induced disruption of ovarian function, or damage to the ovaries (for example removal or radiation). Younger women are less likely than midlife women to have menopause induced by chemotherapy. In men, hot flashes are most commonly associated with anti-testosterone treatments for prostate cancer.

Certain cancers can be due to secretion of hormones by the cancer itself. Examples include some carcinoid tumors, medullary thyroid cancer, pancreas cancer, and kidney cancer.

I’m Dr. Michael Hunter. In my next blog, I’ll look at the physiology of hot flashes: Why do they occur?

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.

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

Hot flashes in Cancer: Neutraceuticals for Treatment

Image

Over several blogs, I look forward to reviewing the biology of hot flashes, causes, and management tools. Today, let’s take a moment to look at neutraceutical medicines. Neutraceuticals include herbal medicines such as black cohosh and homeopathic herbs. The category also includes vitamins, and phytoestrogens (including soy and flaxseed). Historically, studies have been challenged by lack of standardization for the interventions. Let’s turn to some of these potential remedies for hotflashes.

Black cohosh: This herb is derived from the North American periwinkle plant, and has been well-studied for hot flashes among women with breast cancer, but not very much for symptoms linked to prostate cancer management. It acts on serotonin receptors, but does not have estrogen-like actions. While some historic trials showed effectiveness, modern trials do not show it to work among women without cancer. Some studies show it helps women who are on tamoxifen, but check with your doctor before you considering using it.

St. Johns’ wort: My review leads me to believe that this intervention does not work well. In addition, it can interact with some specific medicines.

Homeopathic herbs: While some observational trials have shown benefit, two randomized, controlled trials have not found homeopathic herbs to be effective against hot flashes, compared to placebo. We do not have high level evidence to suggest you should use this approach.

Vitamins: Vitamin E is one of the most investigated vitamins used to reduce hot flashes. First of all, some women should take caution: Heart disease, high blood pressure, and high blood pressure can present problems. There is some concern about inducing cancer, too. My read: Vitamin E may reduce hot flash incidence by 1 or 2 per day. Folic acid may help alleviate hot flashes, but more studies are needed.

Flax Seed: This rich source of lignans (a class of phytoestrogens) has been investigated in 3 prospective, randomized trials. There appears to be no benefit for women, and no good data for men.

Red clover: A randomized trial showed no benefit among women. No good data for men.

Soy isoflavones: A systematic review of 19 randomized studies (meta-analysis) suggests that soy may reduce hot flashes more than a placebo for women. The median dose was 54 mg per day. We don’t have much data about prostate cancer-related hot flashes and soy among men, but what is available is a bit conflicting.

Well, that’s it for today. Going forward, we’ll turn to other potential interventions. For now, I suggest exercise, and looking for triggers (for example, caffeine, heat, stress, alcohol, and spicy foods). I’m Dr. Michael Hunter.