Hot flash

Hot flashes (also known as hot flushes) are a form of flushing due to reduced levels of estradiol. Hot flashes are a symptom which may have several other causes, but which is often caused by the changing hormone levels that are characteristic of menopause. They are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may typically last from two to thirty minutes for each occurrence.

Signs and symptoms

Hot flashes, a common symptom of menopause and perimenopause, are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may typically last from two to thirty minutes for each occurrence, ending just as rapidly as they began. The sensation of heat usually begins in the face or chest, although it may appear elsewhere such as the back of the neck, and it can spread throughout the whole body. Some women feel as if they are going to faint. In addition to being an internal sensation, the surface of the skin, especially on the face, becomes hot to the touch. This is the origin of the alternative term "hot flush", since the sensation of heat is often accompanied by visible reddening of the face. Excessive flushing can lead to rosacea.

The hot-flash event may be repeated a few times each week or every few minutes throughout the day. Hot flashes may begin to appear several years before menopause starts and last for years afterwards. Some women undergoing menopause never have hot flashes. Others have mild or infrequent flashes. The worst sufferers experience dozens of hot flashes each day. In addition, hot flashes are often more frequent and more intense during hot weather or in an overheated room, the surrounding heat apparently making the hot flashes themselves both more likely to occur, and more severe.

Severe hot flashes can make it difficult to get a full night's sleep (often characterized as insomnia), which in turn can affect mood, impair concentration, and cause other physical problems. When hot flashes occur at night, they are called "night sweats". As estrogen is typically lowest at night, some women get night sweats without having any hot flashes during the daytime.^[1]

Young women

If hot flashes occur at other times in a young woman's menstrual cycle, then it might be a symptom of a problem with her pituitary gland; seeing a doctor is highly recommended. In younger women who are surgically menopausal, hot flashes are generally more intense than in older women, and they may last until natural age at menopause.^[2]

Men

Hot flashes in men could have various causes. It can be a sign of low testosterone.^[3] Another is andropause, or "male menopause".^[4] Men with prostate cancer or testicular cancer can also have hot flashes, especially those who are undergoing hormone therapy with antiandrogens, also known as androgen antagonists, which reduce testosterone to castrate levels.^[5] There are also other ailments and even dietary changes which can cause it.^[4] Men who are castrated can also get hot flashes.^[6][7][8]

Types

Some menopausal women may experience both standard hot flashes and a second type sometimes referred to as "slow hot flashes" or "ember flashes". The standard hot flash comes on rapidly, sometimes reaching maximum intensity in as little as a minute. It lasts at full intensity for only a few minutes before gradually fading.

Slow "ember" flashes appear almost as quickly but are less intense and last for around half an hour. Women who experience them may undergo them year round, rather than primarily in the summer, and ember flashes may linger for years after the more intense hot flashes have passed.

Mechanism

Research on hot flashes is mostly focused on treatment options. The exact cause and pathogenesis, or causes of vasomotor symptoms (VMS)—the clinical name for hot flashes—has not yet been fully studied.^[9][10] There are hints at reduced levels of estrogen as the primary cause of hot flashes.^[11] There are indications that hot flashes may be due to a change in the hypothalamus's control of temperature regulation.^[12]

Treatment

Hormone replacement therapy

Hormone replacement therapy may relieve many of the symptoms of menopause. However, oral HRT may increase the risk of breast cancer, stroke, and dementia and has other potentially serious short-term and long-term risks.^[13][14] Since the incidence of cardiovascular disease in women has shown a rise that matches the increase in the number of post menopausal women, recent studies have examined the benefits and side effects of oral versus transdermal application of different estrogens and found that transdermal applications of estradiol may give the vascular benefits lowering the incidences of cardiovascular events with less adverse side effects than oral preparations.^[15][16]

Women who experience troublesome hot flashes are advised by some to try alternatives to hormonal therapies as the first line of treatment. If a woman chooses hormones, they suggest she take the lowest dose that alleviates her symptoms for as short a time as possible.^[17] The US Endocrine Society concluded that women taking hormone replacement therapy for 5 years or more experienced overall benefits in their symptoms including relief of hot flashes and symptoms of urogenital atrophy and prevention of fractures and diabetes.^[18]

When estrogen as estradiol is used transdermally as a patch, gel, or pessary with micronized progesterone this may avoid the serious side effects associated with oral estradiol HRT since this avoids first pass metabolism (Phase I drug metabolism).^[19] Women taking bioidentical estrogen, orally or transdermally, who have a uterus must still take a progestin or micronized progesterone to lower the risk of endometrial cancer. A French study of 80,391 postmenopausal women followed for several years concluded that estrogen in combination with micronized progesterone is not associated with an increased risk of breast cancer.^[20] The natural, plant-derived progesterone creams sold over the counter contain too little progesterone to be effective. Wild yam (Dioscorea villosa) extract creams are not effective since the natural progesterone present in the extract is not bioavailable.^[21]

Selective estrogen receptor modulators

SERMs are a category of compounds that act selectively as agonists or antagonists on the estrogen receptors throughout the body. Tamoxifen, a drug used in the treatment of some types of breast cancer and which can cause hot flashes as a side effect,^[22] and Raloxifene^[23] are examples of SERMS. Menerba, a botanically derived selective estrogen receptor beta agonist currently under development by Bionovo, works like a SERM, but only activates on the estrogen receptor beta.^[24]

The soy-derived dietary supplement Femarelle may act as a SERM.^[25]

Selective serotonin reuptake inhibitors

SSRIs are a class of pharmaceuticals that are most commonly used in the treatment of depression. They have been found as efficient in alleviating hot flashes.^[26] On 28 June 2013 FDA approved Brisdelle (low-dose paroxetine mesylate) for the treatment of moderate-to-severe vasomotor symptoms (e.g. hot flashes and night sweats) associated with menopause. Paroxetine became the first and only non-hormonal therapy for menopausal hot flashes approved by FDA.^[27]

Clonidine

Clonidine is a blood pressure-lowering medication that can be used to relieve menopausal hot flashes when hormone replacement therapy is not needed or not desired. For hot flashes, clonidine works by helping reduce the response of the blood vessels to stimuli that cause them to narrow and widen.^[28] While not all women respond to clonidine as a hot flash medication, it can reduce hot flashes by 40% in some peri-menopausal women.^[29]

Isoflavones

Isoflavones are commonly found in legumes such as soy and red clover. The two soy isoflavones implicated in relieving menopausal symptoms are genistein and daidzein, and are also known as phytoestrogens. The half life of these molecules is about eight hours, which might explain why some studies have not consistently shown effectiveness of soy products for menopausal symptoms. Although red clover (Trifolium pratense) contains isoflavones similar to soy, the effectiveness of this herb for menopausal symptoms at relatively low concentrations points to a different mechanism of action.^[30]

Other phytoestrogens

It is believed that dietary changes that include a higher consumption of phytoestrogens from sources such as soy, red clover, ginseng, and yam may relieve hot flashes.

• Ginseng: Very few studies exist on the effect of ginseng for relief of menopausal symptoms. In a large double-blinded randomized controlled trial, reduction in hot flashes was not statistically significant but showed a strong trend towards improvement.^[31] Lack of statistical significance suggests future research, but does not meet the scientific bar for ginseng to be deemed effective.
• Flaxseed: There have also been several clinical trials using flaxseed. Flaxseed is the richest source of lignans, which is one of three major classes of phytoestrogen.^[32] Lignans are thought to have estrogen agonist and antagonist effects as well as antioxidant properties. Flaxseed and its lignans may have potent anti-estrogenic effects on estrogen receptor positive breast cancer and may have benefits in breast cancer prevention efforts.^[33][34] One recent study done in France, looked at four types of lignans, including that found in flaxseed (Secoisolariciresinol) in a prospective cohort study to see if intake predicted breast cancer incidence.^[34] The authors report lowered risk of breast cancer among over 58,000 postmenopausal women who had the third highest quartile of lignan intake. There have been a few small pilot studies that have tested the effect of flaxseed on hot flashes. Currently there is a large study sponsored by the National Cancer Institute that is ongoing, but not accepting any new participants.^[35] The rationale for the study is that estrogen can relieve the symptoms of menopause, but can also cause the growth of breast cancer cells. Flaxseed may reduce the number of hot flashes and improve mood and quality of life in postmenopausal women not receiving estrogen therapy.

Lifestyle changes

According to the North American Menopause Society (NAMS)^[36] there are foods and some unhealthy lifestyle habits that can aggravate or trigger hot flashes such as: hot/spicy foods, alcohol, or caffeine. Further, for women who are overweight or obese, a gradual weight loss can have potential benefits for menopausal symptom reduction.^[37]

Acupuncture

Acupuncture has been suggested to reduce incidence of hot flashes in women with breast cancer and men with prostate cancer, but the quality of evidence is low.^[38][39]

Epidemiology

It has been speculated that hot flashes are less common among Asian women.^[40][41]

See also

• Hypoglycemia (low blood sugar) can cause similar symptoms

References

External links

• Hot flashes on Mayo Clinic website
• Hot Flashes on MedicineNet
• Hot Flushes on Patient.info