Having My Own Personal Summer in the Middle of Winter

One day during my freshman year at college I got a call from my dad. The number one reason I remember this call is that my dad didn’t call me alot and it was almost never because he had a reason. On this day however, he called me and said, “your mom is on the back porch - she walked straight in the house and out to the back porch and took her shirt off. Do you think she could be in menopause?” Given that my Mom would be 52 in a few weeks, it was a pretty likely reason for this new behavior. I confirmed that he wasn’t making this up when I came home for Thanksgiving a few weeks later. This was quickly fixed at her next annual exam and I never saw it again. That conversation happened 23 years ago - and I still haven’t forgotten it. This was my introduction to the world of menopause. Perfectly sane, highly educated, professional women may suddenly come home, walk outside and rip their clothes off. Only something serious could cause this kind of behavior. So, what happens to cause this?

Well, hot flashes and their co-consiprator night sweats are actually caused by a disruption in a part of the brain called the hypothalamus. The body’s thermoregulatory system senses a slight rise in core tempature - triggered by activity, stress, alcohol, any external heat, etc - and interprets that as though you have a temp of 104 and it must rapidly cool the body. All or our body’s natural cooling mechanisms then kick in to overdrive. The blood vessels under the skin dilate to rush blood to the surface where it can be more easily cooled - meaning you suddenly look like an oompah loompah, your heart starts pounding to move that blood to the surface faster and sweat mechanisms kick in and cool via evaporation. We know that all of this plays haywire with the immune system and appears to change both immune system function and what types of immune cells are body is making. The 4th and 5th decades of life are the number one time for women to develop autoimmune disease and these same mechanism may be responsible. (More research is absolutely needed in this area before we draw causal links, but there are definitely casual associations.)

So, what can we do to vanquish these unpleasant attacks on our normal physiology and sanity? The good news is there are alot of options. The number one fastest and most effective way to relieve hot flashes is HRT - hormone replacement therapy. By replacing the estrogen whose depletion is at the heart of the symptoms, we can effectively relieve almost all hot flashes. Typically this doesn’t require matching estrogen at peak levels. You just need a high enough background level. This can best be achieved via a topical application (patch, cream, lozenge - yep, it’s still topical) because it avoids the clotting risk associated with oral estrogen. In a woman who has her uterus, it’s imperative that we given something to stop the thickening of the lining - typically progesterone. Exactly what formulation and dose is something you should discuss with your doctor.

For women who have a history of breast cancer or another contraindication to estrogen therapy, the next best option is a new drug to the market called Veozah (felizolinetant) and there are more coming in this class. These drugs work at the level of the central nervous system to stop hot flashes where they start. It’s the first drug to come anywhere close to estrogen in stopping the flashes. In the words of one of my pateint’s “this drug is a miracle worker.” There are a few limitations and it’s important to monitor liver functions and make sure they start and stay normal, but for women who can’t take HRT, we finally have a really good alternative.

In the less effective category, we have Brisdelle. It’s paroxetine/Paxil, but they lowered the dose and gave it a new name. It offers something of a 20% reduction in hot flashes, but truthfully, my personal experience is I don’t know anyone who thinks its really worked. If you have postpartum depression on the hand, paxil works quite well. It’s also important if you are in the perimenopausal years that you be using effective contraception if you are on paxil, but that’s probably not most people who have read this far.

Don’t doctors ever recommend anything other than medicine? Why yes, and I’m glad you asked. You can, cut the wine - esp red, cut the caffiene, do aerobic exercise 30 min 4-5x/week and loose weight if you are overweight/obese. There are also those attractive fans you can wear on a string aound your neck or now - self mounting. I don’t mean to sound sarcastic and I absoultely think that doing all of the above is a fantastic idea for your overal health, but this conditon happens becasue the estrogen you have had since puberty is declining and there is simply no way to bring it back.

So, I hope that this has been a helpful explanation of where hot flashes come from and what we can do about them. One of the most satisfying experiences I have is when someone walks in an emotional mess because they feel like they are going crazy, can’t fix their hair for the sweats and feels miserable and then we start some HRT and she comes back 3 months later a new woman - or an old woman - her old self.