As I sit here worrying about the Middle East and talk to my family in Israel, I’m experiencing hot flashes. Admittedly, they are from anxiety and not a hormonal imbalance, but they have made an editorial I read this week in the Journal Menopause more compelling. It’s titled “Hot flashes: is a hot flash just a hot flash?” The author, Dr. Lila Nachtigall a professor from New York University, has long been an advocate of hormone therapy and has written multiple articles and given many lectures on menopause. Her current editorial highlights issues that may be of interest to many of my patients.
Studies conducted in 1990 have shown that among untreated women, 80% of hot flashes will stop in three years and 90% of hot flashes will be over after six years. A few women, however, can have them for 40 years or more. In more recent studies of women who have hot flashes, 25% reported that the symptoms remained for more than five years and 10% reported that the symptoms continued for more than 10 years. Why? Well, we know it’s lack of estrogen that causes these vasomotor symptoms. The brain has an inner thermostat zone that impacts the body’s ability to heat or cool with minimal temperature changes. There is a hormone; norepinephrine (now aptly called brain norepinephrine) which is released from brain estrogen receptors when they are not receiving estrogen. This hormone sets off responses in the body to impose heat regulation and cool the body though dilation of superficial blood vessels (flushing) and evaporation of fluids (perspiration). Women who are recently or suddenly postmenopausal have more of these used-to-work-estrogen receptors. Estrogen deprivation together with what we call up-regulated receptors cause these women to have more frequent and more severe hot flashes. (I know this doesn’t explain why 10% continue to have significant hot flashes. We do know if the hot flashes were severe from the start they are more likely to continue…perhaps because the estrogen receptors remain robust.)
There have been studies that have shown that the severity of hot flashes is associated with lower levels of health and even work productivity. One study called The Study of Women’s Health Across the Nation has shown that hot flashes are associated with a higher incidence of insulin resistance. Other studies including the Women’s Health Initiative have shown that there are higher risks of cardiovascular disease in women with significant menopausal symptoms. Those experiencing severe hot flashes have an increased risk of coronary heart disease by a factor of five compared with their counterparts who had less or no symptoms. Similarly, the risk of stroke was elevated by a factor of almost 4. Brain PET scans have shown that there is a significant decrease in cerebral blood flow during a hot flash. The author goes on to state that this may explain a woman’s inability to continue her tasks during a severe hot flash.
As a result of some of this data the American College of Obstetricians and Gynecologists has added new clinical guidelines for the management of menopausal symptoms. This directive encourages physicians to treat vasomotor symptoms i.e. hot flashes and not use age as a guideline, stating that the decision to treat should be individualized and there is no need to discontinue medication if a woman is still symptomatic after age 65.
Although it’s clear that estrogen will indeed prevent those brain receptors from releasing vasomotor causing norepinephrine there are other pharmacologic medications that are available to help diminish or stop the hot flashes. One of these is a low-dose SSRI (Paxil) called Brisdelle. A new formulation of gabapentin was found in a recent phase 3 study to statistically reduce frequency and severity of hot flashes.
The pros and cons of hormone therapy, types of hormone therapies, and alternatives to hormones have become a major subspecialty in the treatment of women over the age of 50. It’s difficult to give an assessment of what can and should be done in one article or one exam. Like everything in medicine, symptoms, personal and family history, health risks and of course symptoms have to be properly assessed by both the patient and her physician. New studies and expert insights improve our ability to make more informed decisions. So I thought I would share …and no, I have no ready solutions, despite copious reading, that helps me cope with my Middle East anxiety.