What are hot flashes

Hot flashes or hot flushes are onset of reddening of the skin (as if you’re blushing) over the head, neck and chest accompanied by a feeling of warmth, often associated with spontaneous sweating, palpitations and anxiety, resulting from a vasomotor response caused by decreased beta-estradiol [estrogen] levels ¹⁾. Hot flashes are typically described as sudden waves of heat that usually start in your chest, face and the back of your neck, and spread throughout your whole body. Hot flashes can make your skin look blotchy and red, and cause you to sweat. Some women feel their heart race at the same time. This does not usually have anything to do with heart disease. The duration of these hot flashes last from a few seconds to several minutes [3 minutes on average] and rarely they can last up to one hour. When hot flashes happen at night, they are called night sweats. Hot flashes are more frequent and severe at night (night sweats) or during times of stress ²⁾.

Hot flashes is followed by measurable increased heat over the entire body surface. Some women find that hot flashes interrupt their daily lives. The earlier in life hot flashes begin, the longer you may experience them. Research has found that African American and Hispanic women get hot flashes for more years than white and Asian women. How often hot flashes occur varies among women and can range from a few a week to several an hour.

Hot flashes are probably triggered in the part of the brain that regulates body temperature. If your body temperature increases too much, your brain can send signals that temporarily make the blood vessels in your skin widen (“dilate”). This process is called vasodilation. It allows more blood to flow through your skin, so more heat is released and your body can cool off. This is felt as a hot flash. Scientists believe that the reduced hormone beta-estradiol [estrogen] production in the ovaries during menopause affects the regulation of women’s body temperature. But it is not known for sure what causes hot flashes.

Although other medical conditions can cause them, hot flashes most commonly are due to menopause — the time when menstrual periods become irregular and eventually stop. Many women start having hot flashes around the time of their last menstrual period. In fact, hot flashes are the most common symptom of the menopausal transition. Other common symptoms associated with menopause are night sweats, sleep disturbance, vaginal atrophy, vaginal dryness and dyspareunia (painful sexual intercourse) ³⁾. In most women, hot flashes and menopausal symptoms persist for a year or two after the menopause, but in some they may continue for 10 or more years ⁴⁾.

There are a variety of treatments for particularly bothersome hot flashes.

What causes hot flashes

The physiology of hot flashes symptoms is still not yet completely understood, but they apparently originate in the hypothalamus and are brought about by a decline in beta-estradiol. However, not all hot flushes are due to beta-estradiol deficiency. The correlation between the onset of flushes and beta-estradiol (estrogen) reduction is clinically supported by the effectiveness of beta-estradiol therapy and absence of flushes in permanent hypo-estradiol states, such as gonadal dysgenesis ⁵⁾. Among the many theories to explain why hot flushes occur, one of the most accepted ⁶⁾ hypothesizes that hot flushes are thermoregulatory events that aim to keep the body´s temperature within a narrow thermoneutral zone. The brain has a thermoregulating centre, or thermostat, that constantly checks the body’s core temperature to ensure that it is within a specific range. Small increases in body temperature above a certain upper threshold trigger the brain to induce disseminated peripheral cutaneous vasodilation and sweating to dissipate heat and to lower the body’s temperature again. In many menopausal women, for reasons related to beta-estradiol fluctuation not yet completely understood, this upper threshold of the brain’s thermostat is lowered thus leading the brain to trigger heat dissipating mechanisms several times during the day and night, causing the repeated episodes of hot flushes that are typically reported by women in this period of their lives. The relationship between the luteinizing hormone (LH) surge and the brain’s lowering of the sweating threshold is not yet completely clear ⁷⁾.

Risk factors of hot flashes

Not all women who go through menopause have hot flashes, and it’s not clear why some women do have them. Factors that may increase your risk include:

• Smoking. Women who smoke are more likely to get hot flashes.
• Obesity. A high body mass index (BMI) is associated with a higher frequency of hot flashes.
• Ethnicity. More African-American women report menopausal hot flashes than do women of European descent. Hot flashes are less common in women of Japanese and Chinese descent than in white European women.

Complications of hot flashes

Nighttime hot flashes (night sweats) can wake you from sleep and, over time, can cause chronic insomnia. There is some association with hot flashes and increased risk of heart disease and bone loss.

Hot flashes symptoms

During a hot flash, you might have:

• A sudden feeling of warmth spreading through your upper body and face
• A flushed appearance with red, blotchy skin
• Rapid heartbeat
• Perspiration, mostly on your upper body
• A chilled feeling as the hot flash lets up

Hot flashes can vary in frequency and intensity. How long symptoms last varies greatly. On average, symptoms persist for more than seven years. Some women have them for more than 10 years.

Diagnosis of hot flashes

Your doctor can usually diagnose hot flashes based on a description of your symptoms. Your doctor might suggest blood tests to check whether you’re in menopausal transition.

Hot flashes treatment

Deciding whether and how to treat the symptoms of the menopausal transition can be complicated and personal. Discuss your symptoms, family and medical history, and preferences with your doctor.

No matter what you decide, see your doctor every year to talk about your treatment plan and discuss any changes you want to make.

However, the most effective way to relieve the discomfort of hot flashes is to take estrogen, but taking this hormone carries risks. If estrogen is appropriate for you and you start it within 10 years of your last menstrual period or before age 60, the benefits can be greater than the risks.

Medications such as antidepressants and anti-seizure drugs also might help reduce hot flashes, although they’re less effective than hormones.

Discuss the pros and cons of various treatments with your doctor. If hot flashes don’t interfere with your life, you probably don’t need treatment. Hot flashes subside gradually for most women, even without treatment, but it can take several years for them to stop.

Natural and Lifestyle Remedies to Improve Hot Flashes

Before considering medication, first try making changes to your lifestyle. Doctors recommend women make changes like these for at least 3 months before starting any medication.

If hot flashes are keeping you up at night, keep your bedroom cooler and try drinking small amounts of cold water before bed. Layer your bedding so it can be adjusted as needed. Some women find a device called a bed fan helpful. Here are some other lifestyle changes you can make:

• Keep cool. Slight increases in your body’s core temperature can trigger hot flashes.
• Open windows or use a fan or air conditioner. Lower the room temperature, if you can. If you feel a hot flash coming on, sip a cold drink.
• Dress in layers, which can be removed at the start of a hot flash.
• Carry a portable fan to use when a hot flash strikes.
• Avoid alcohol, spicy foods, and caffeine. These can make menopausal symptoms worse. Hot and spicy foods, caffeinated beverages, and alcohol can trigger hot flashes. Learn to recognize your triggers and avoid them.
• If you smoke, quit smoking, not only for menopausal symptoms, but for your overall health. Smoking is linked to increased hot flashes. By not smoking, you might reduce hot flashes, as well as your risk of many serious health conditions, such as heart disease, stroke and cancer.
• Try to maintain a healthy weight. Women who are overweight or obese may experience more frequent and severe hot flashes.
• Try mind-body practices like yoga or other self-calming techniques. Early-stage research has shown that mindfulness meditation, yoga, and tai chi may help improve menopausal symptoms.
• Relax. Some women find relief from mild hot flashes through meditation.
• Deep breathing, relaxation breathing, and paced respiration all refer to a method used to reduce stress. It involves breathing in (inhaling) deeply and breathing out (exhaling) at an even pace. Do this for several minutes while in a comfortable position. You should slowly breathe in through your nose. With a hand on your stomach right below your ribs, you should first feel your stomach push your hand out, and then your chest should fill. Slowly exhale through your mouth, first letting your lungs empty and then feeling your stomach sink back. You can do this almost anywhere and several times during the day, whenever you feel stressed. You can also try this if you feel a hot flash beginning or if you need to relax before falling asleep. Even if these approaches don’t quell your hot flashes, they might provide other benefits, such as easing sleep disturbances that tend to occur with menopause.
• Paced breathing you take only 5 to 7 breaths a minute. The paced breaths are slow, smooth and deep enough to move your diaphragm — the muscular wall located beneath your lungs — as you take deeper breaths. The goal of paced breathing is to reduce the stress chemicals your brain produces and facilitate a relaxation response. Some evidence shows that paced breathing may be effective in reducing menopausal hot flashes, including how often they occur and how severe they are. Paced breathing may also help lower blood pressure, decrease anxiety and promote relaxation. You can teach yourself paced breathing — for instance, from an app, podcast or Web-based program — or you can seek the help of an expert. Paced breathing may not be appropriate if you experience dizziness or have hyperventilation problems. Otherwise, paced breathing is a generally safe mind-body approach to enhance relaxation.
• Lose weight. If you’re overweight or obese, losing weight might help ease your hot flashes.

Mind and body approaches

A growing body of evidence suggests that certain techniques can help ease hot flashes, including:

• Mindfulness meditation. This type of meditation has you focus on what’s happening from moment to moment. Although not shown to relieve hot flashes, it might reduce how much they bother you.
• Acupuncture. Some studies indicate that acupuncture might reduce the frequency and severity of hot flashes, but results are conflicting, with many studies showing improvements in both active and control groups, but no difference between the two groups.
• Hypnosis. Some research indicates that hypnosis might help relieve hot flashes.
• Cognitive behavioral therapy. Some evidence indicates that this type of talk therapy (psychotherapy) might help you cope better with hot flashes.

Meditation – a simple, fast way to reduce stress

If stress has you anxious, tense and worried, consider trying meditation. Spending even a few minutes in meditation can restore your calm and inner peace.

Anyone can practice meditation. It’s simple and inexpensive, and it doesn’t require any special equipment.

And you can practice meditation wherever you are — whether you’re out for a walk, riding the bus, waiting at the doctor’s office or even in the middle of a difficult business meeting.

Understanding meditation

Meditation has been practiced for thousands of years. Meditation originally was meant to help deepen understanding of the sacred and mystical forces of life. These days, meditation is commonly used for relaxation and stress reduction.

Meditation is considered a type of mind-body complementary medicine. Meditation can produce a deep state of relaxation and a tranquil mind.

During meditation, you focus your attention and eliminate the stream of jumbled thoughts that may be crowding your mind and causing stress. This process may result in enhanced physical and emotional well-being.

Benefits of meditation

Meditation can give you a sense of calm, peace and balance that can benefit both your emotional well-being and your overall health.

And these benefits don’t end when your meditation session ends. Meditation can help carry you more calmly through your day and may help you manage symptoms of certain medical conditions.

Meditation and emotional well-being

When you meditate, you may clear away the information overload that builds up every day and contributes to your stress.

The emotional benefits of meditation can include:

• Gaining a new perspective on stressful situations
• Building skills to manage your stress
• Increasing self-awareness
• Focusing on the present
• Reducing negative emotions
• Increasing imagination and creativity
• Increasing patience and tolerance

Meditation and illness

Meditation might also be useful if you have a medical condition, especially one that may be worsened by stress.

While a growing body of scientific research supports the health benefits of meditation, some researchers believe it’s not yet possible to draw conclusions about the possible benefits of meditation.

With that in mind, some research suggests that meditation may help people manage symptoms of conditions such as:

• Anxiety
• Asthma
• Cancer
• Chronic pain
• Depression
• Heart disease
• High blood pressure
• Irritable bowel syndrome
• Sleep problems
• Tension headaches

Be sure to talk to your health care provider about the pros and cons of using meditation if you have any of these conditions or other health problems. In some cases, meditation can worsen symptoms associated with certain mental and physical health conditions.

Meditation isn’t a replacement for traditional medical treatment. But it may be a useful addition to your other treatment.

Types of meditation

Meditation is an umbrella term for the many ways to a relaxed state of being. There are many types of meditation and relaxation techniques that have meditation components. All share the same goal of achieving inner peace.

Ways to meditate can include:

• Guided meditation. Sometimes called guided imagery or visualization, with this method of meditation you form mental images of places or situations you find relaxing.

You try to use as many senses as possible, such as smells, sights, sounds and textures. You may be led through this process by a guide or teacher.
Mantra meditation. In this type of meditation, you silently repeat a calming word, thought or phrase to prevent distracting thoughts.

• Mindfulness meditation. This type of meditation is based on being mindful, or having an increased awareness and acceptance of living in the present moment.

In mindfulness meditation, you broaden your conscious awareness. You focus on what you experience during meditation, such as the flow of your breath. You can observe your thoughts and emotions, but let them pass without judgment.

• Qi gong. This practice generally combines meditation, relaxation, physical movement and breathing exercises to restore and maintain balance. Qi gong is part of traditional Chinese medicine.
• Tai chi. This is a form of gentle Chinese martial arts. In tai chi, you perform a self-paced series of postures or movements in a slow, graceful manner while practicing deep breathing.
• Transcendental Meditation. Transcendental Meditation is a simple, natural technique. In Transcendental Meditation, you silently repeat a personally assigned mantra, such as a word, sound or phrase, in a specific way. This form of meditation may allow your body to settle into a state of profound rest and relaxation and your mind to achieve a state of inner peace, without needing to use concentration or effort.
• Yoga. You perform a series of postures and controlled breathing exercises to promote a more flexible body and a calm mind. As you move through poses that require balance and concentration, you’re encouraged to focus less on your busy day and more on the moment.

Yoga

Yoga is a mind-body practice — is considered one of many types of complementary and integrative health approaches. Yoga brings together physical and mental disciplines that may help you achieve peacefulness of body and mind. This can help you relax and manage stress and anxiety.

Yoga has many styles, forms and intensities. Hatha yoga, in particular, may be a good choice for stress management. Hatha is one of the most common styles of yoga, and beginners may like its slower pace and easier movements. But most people can benefit from any style of yoga — it’s all about your personal preferences.

The core components of hatha yoga and most general yoga classes are:

• Poses. Yoga poses, also called postures, are a series of movements designed to increase strength and flexibility. Poses range from lying on the floor while completely relaxed to difficult postures that may have you stretching your physical limits.
• Breathing. Controlling your breathing is an important part of yoga. Yoga teaches that controlling your breathing can help you control your body and quiet your mind.
• Meditation or relaxation. In yoga, you may incorporate meditation or relaxation. Meditation may help you learn to be more mindful and aware of the present moment without judgment.

The health benefits of yoga

The potential health benefits of yoga include:

• Stress reduction. A number of studies have shown that yoga may help reduce stress and anxiety. It can also enhance your mood and overall sense of well-being.
• Improved fitness. Practicing yoga may lead to improved balance, flexibility, range of motion and strength.
• Management of chronic conditions. Yoga can help reduce risk factors for chronic diseases, such as heart disease and high blood pressure. Yoga might also help alleviate chronic conditions, such as depression, pain, anxiety and insomnia.

Yoga precautions

Yoga is generally considered safe for most healthy people when practiced under the guidance of a trained instructor. But there are some situations in which yoga might pose a risk.

See your health care provider before you begin yoga if you have any of the following conditions or situations:

• A herniated disk
• A risk of blood clots
• Eye conditions, including glaucoma
• Pregnancy — although yoga is generally safe for pregnant women, certain poses should be avoided
• Severe balance problems
• Severe osteoporosis
• Uncontrolled blood pressure

You may be able to practice yoga in these situations if you take certain precautions, such as avoiding certain poses or stretches. If you develop symptoms, such as pain, or have concerns, see your doctor to make sure you’re getting benefit and not harm from yoga.

Yoga – Getting started

Although you can learn yoga from books and videos, beginners usually find it helpful to learn with an instructor. Classes also offer camaraderie and friendship, which are also important to overall well-being.

When you find a class that sounds interesting, talk with the instructor so that you know what to expect. Questions to ask include:

• What are the instructor’s qualifications? Where did he or she train and how long has he or she been teaching?
• Does the instructor have experience working with students with your needs or health concerns? If you have a sore knee or an aching shoulder, can the instructor help you find poses that won’t aggravate your condition?
• How demanding is the class? Is it suitable for beginners? Will it be easy enough to follow along if it’s your first time?
• What can you expect from the class? Is it aimed at your needs, such as stress management or relaxation, or is it geared toward people who want to reap other benefits?

Achieving the right balance

Every person has a different body with different abilities. You may need to modify yoga postures based on your individual abilities. Your instructor may be able to suggest modified poses. Choosing an instructor who is experienced and who understands your needs is important to safely and effectively practice yoga.

Regardless of which type of yoga you practice, you don’t have to do every pose. If a pose is uncomfortable or you can’t hold it as long as the instructor requests, don’t do it. Good instructors will understand and encourage you to explore — but not exceed — your personal limits.

Non-Hormone Options for Treating Hot Flashes

If lifestyle changes are not enough to improve your symptoms, non-hormone options for managing hot flashes may work for you. They may be a good choice if you are unable to take hormones or if you are worried about their potential risks.

The U.S. Food and Drug Administration (FDA) has approved the use of paroxetine, a low-dose selective serotonin reuptake inhibitor (SSRI) antidepressant, to treat hot flashes. Researchers are studying the effectiveness of other antidepressants in this class.

Women who use an antidepressant to help manage hot flashes generally take a lower dose than people who use the medication to treat depression. Side effects depend on the type of antidepressant you take and can include dizziness, headache, nausea, jitteriness, or drowsiness. As with any medication, talk with your doctor about whether this is the right medication for you and how you can manage any possible side effects.

Antidepressants

A low-dose form of paroxetine (Brisdelle) is the only nonhormone treatment for hot flashes approved by the Food and Drug Administration. Other antidepressants that have been used to treat hot flashes include:

• Venlafaxine (Effexor XR, Pristiq)
• Paroxetine (Paxil, Pexeva)
• Fluoxetine (Prozac, Sarafem, others)

These medications aren’t as effective as hormone therapy for severe hot flashes, but they can be helpful to women who can’t use hormones. Possible side effects include nausea, dizziness, weight gain, dry mouth or sexual dysfunction.

Other prescription medications

Other medications that might offer relief for some women include:

• Gabapentin (Neurontin, Gralise, others). Gabapentin is an anti-seizure medication that’s moderately effective in reducing hot flashes. Side effects can include drowsiness, dizziness and headaches.
• Clonidine (Catapres, Kapvay, others). Clonidine, a pill or patch typically used to treat high blood pressure, might provide some relief from hot flashes. Side effects include dizziness, drowsiness, dry mouth and constipation.
• Tibolone. Tibolone (brand name Livial) is a prescription medication that is similar to taking combined hormone replacement therapy (oestrogen and progestogen). It’s taken as a tablet once a day.It can help relieve symptoms such as hot flushes, low mood and reduced sex drive, although some studies have suggested it may not be as effective as combined hormone replacement therapy.

  It’s only suitable for women who had their last period more than a year ago (known as the post-menopause).

  Side effects of tibolone can include tummy (abdominal) pain, pelvic pain, breast tenderness, itching and vaginal discharge.

  Risks of tibolone are similar to the risks of hormone replacement therapy, and include an increased risk of breast cancer and strokes. Talk to your doctor about the risks and benefits of tibolone if you’re considering taking it.

• Clonidine. Clonidine is a prescription medicine that can help reduce hot flushes and night sweats in some menopausal women. It’s taken as tablets two or three times a day. It doesn’t affect hormone levels, so unlike hormone replacement therapy (HRT) it doesn’t carry an increased risk of problems such as breast cancer. But research suggests it only has a very small effect on menopausal symptoms.Clonidine can also cause some unpleasant side effects, including dry mouth, drowsiness, depression and constipation.

  It may take two to four weeks to notice the effects of clonidine. Speak to your doctor if your symptoms don’t improve or you experience any troublesome side effects.

Medications For Treating Hot Flashes and Night Sweats with Hormones

Some women may choose to take hormones to treat their hot flashes. A hormone is a chemical substance made by an organ like the thyroid gland or ovary. During the menopausal transition, the ovaries begin to work less and less well, and the production of hormones like estrogen and progesterone declines over time. It is believed that such changes cause hot flashes and other menopausal symptoms.

Hormone therapy steadies the levels of estrogen and progesterone in the body. It is a very effective treatment for hot flashes in women who are able to use it. There are risks associated with taking hormones, including increased risk of heart attack, stroke, blood clots, breast cancer, gallbladder disease, and dementia. The risks vary by a woman’s age and whether she has had a hysterectomy. Women are encouraged to discuss the risks with their healthcare provider.

Women who still have a uterus should take estrogen combined with progesterone or another therapy to protect the uterus. Progesterone is added to estrogen to protect the uterus against cancer, but it also seems to increase the risk of blood clots and stroke. Hormones should be used at the lowest dose that is effective for the shortest period of time possible.

• Talk with your doctor before using hormones to treat menopause symptoms. Hormones should be used at the lowest dose and for the shortest period of time they are effective.

Hormones can be very effective at reducing the number and severity of hot flashes. They are also effective in reducing vaginal dryness and bone loss.

Hormone treatments (sometimes called menopausal hormone therapy) can take the form of pills, patches, rings, implants, gels, or creams. Patches, which stick to the skin, may be best for women with cardiac risk factors, such as a family history of heart disease.

There are many types of hormones available for women to treat hot flashes. These include estradiol, conjugated estrogen, selective estrogen receptor modulators (SERMs), and compounded or synthetic hormones. It is a common misconception that synthetic (“bioidentical”) hormones mixed by a compounding pharmacist are safer and less risky than other hormone therapies. This is not the case. We must assume they have the same risks as any hormone therapy.

Some of the relatively mild side effects of hormone use include breast tenderness, spotting or return of monthly periods, cramping, or bloating. By changing the type or amount of the hormones, the way they are taken, or the timing of the doses, your doctor may be able to help control these side effects or, over time, they may go away on their own.

Hormone therapy

Estrogen is the primary hormone used to reduce hot flashes. Women who have had a hysterectomy can take estrogen alone. But if you still have a uterus, you should take progesterone with estrogen to protect against cancer of the lining of the uterus (endometrial cancer).

With either regimen, the therapy needs to be tailored to your needs. Guidelines suggest using the smallest effective dose for symptom control. How long you use the treatment depends on the balance of your risks and benefits from hormone therapy. The goal is to optimize your quality of life.

A combination drug of bazedoxifene with conjugated estrogens (Duavee) has been approved for treating menopausal symptoms. This drug might not increase your risk of uterine cancer and might protect your bones.

Estrogen therapy isn’t a good option if you’ve had a blood clot or breast cancer.

The main benefit of hormone replacement therapy (HRT) is that it can help relieve most of the menopausal symptoms, such as:

• hot flushes
• night sweats
• mood swings
• vaginal dryness
• reduced sex drive

Many of these symptoms pass in a few years, but they can be very unpleasant and taking hormone replacement therapy can offer relief for many women.

It can also help prevent weakening of the bones (osteoporosis), which is more common after the menopause.

Some women should not use hormones for their hot flashes.

You should not take hormones for menopausal symptoms if:

• You have had certain kinds of cancers, like breast cancer or uterine cancer
• You have had a stroke or heart attack, or you have a strong family history of stroke or heart disease
• You have had blood clots
• You have had problems with vaginal bleeding or have a bleeding disorder
• You have liver disease
• You have untreated high blood pressure – your blood pressure will need to be controlled before you can start hormone replacement therapy
• You think you are pregnant or may become pregnant. It’s still possible to get pregnant while on hormone replacement therapy, so you should use contraception until two years after your last period if you’re under 50 or for one year after the age of 50
• You have had allergic reactions to hormone medications

Talk with your doctor to find out if taking hormones to treat your symptoms is right for you.

Types of hormone replacement therapy

There are many different types of hormone replacement therapy and finding the right one for you can be tricky.
If you’re considering hormone replacement therapy, talk to your doctor about the options suitable for you, as well as possible alternatives to hormone replacement therapy.

There are different:

• hormone replacement therapy hormones – most women take a combination of the hormones estrogen and progestogen, although women who don’t have a womb can take estrogen on its own
• ways of taking hormone replacement therapy – including tablets, skin patches, gels and vaginal creams, pessaries or rings
• hormone replacement therapy treatment regimens – hormone replacement therapy medication may be taken continuously without a break, or in cycles where you take estrogen continuously and only take progestogen every few weeks

Your doctor can give you advice to help you choose which type is best for you. You may need to try more than one type before you find one that works best.

Hormone replacement therapy hormones

Hormone replacement therapy replaces the hormones that a woman’s body no longer produces because of the menopause.

The two main hormones used in hormone replacement therapy are:

• Estrogen – types used include estradiol, estrone and estriol
• progestogen – a synthetic version of the hormone progesterone, such as dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel

Hormone replacement therapy involves either taking both of these hormones (combined hormone replacement therapy) or just taking estrogen (estrogen-only hormone replacement therapy).

Most women take combined hormone replacement therapy because taking oestrogen on its own can increase your risk of developing womb (endometrial) cancer. Taking progestogen alongside oestrogen minimises this risk.

Estrogen-only hormone replacement therapy is usually only recommended for women who have had their womb removed during a hysterectomy.

Ways of taking hormone replacement therapy

Hormone replacement therapy is available in several preparations that are taken in different ways. Talk to your doctor about the pros and cons of each option.

Tablets

Tablets, which are usually taken once a day, are one of the most common ways of taking hormone replacement therapy.

Estrogen-only and combined hormone replacement therapy tablets are available. For some women this may be the simplest way of having treatment.

However, it’s important to be aware that some of the risks of hormone replacement therapy, such as blood clots, are higher with tablets than with other forms of hormone replacement therapy (although the overall risk is still small).

Skin patches

Skin patches are also a common way of taking hormone replacement therapy. You stick them to your skin and replace them every few days. Oestrogen-only and combined hormone replacement therapy patches are available.

Patches may be a better option than tablets if you think you might find it inconvenient to take a tablet every day.

Using patches can also help avoid some side effects of hormone replacement therapy, such as indigestion, and unlike tablets they don’t increase your risk of blood clots.

Estrogen gel

Estrogen gel is an increasingly popular form of hormone replacement therapy. It’s applied to the skin once a day and is absorbed by the body.

Like skin patches, this can be a convenient way of taking hormone replacement therapy while avoiding an increased risk of blood clots.

But if you still have your womb, you’ll need to take some form of progestogen separately too, to reduce your risk of womb cancer.

Implants

Hormone replacement therapy can be given using small pellet-like implants inserted under your skin (usually in the tummy area) while your skin is numbed with local anaesthetic, although these aren’t widely available and aren’t used very often.

The implants release estrogen gradually over time and can stay in place for several months before needing to be replaced.

This may be a convenient option if you don’t want to worry about taking your treatment every day or every few days. But if you still have your womb, you’ll need to take progestogen separately too.

If you’re taking a different form of estrogen and need to take progestogen alongside it, another implant option is the intrauterine system (IUS). An IUS releases a progestogen hormone into the womb. It can remain in place for a few years and also acts as a contraceptive.

Vaginal estrogen

Estrogen is also available in the form of a cream, pessary or ring that is placed inside your vagina.

This can help relieve vaginal dryness, but won’t help with other symptoms such as hot flushes.

It doesn’t carry the usual risks of hormone replacement therapy and can be used without taking progestogen even if you still have a womb.

Hormone replacement therapy treatment regimens

Different treatment courses of hormone replacement therapy are also available, depending on whether you’re still in the early stages of the menopause or have had menopausal symptoms for some time.

The two types are cyclical (or sequential) hormone replacement therapy and continuous hormone replacement therapy.

Cyclical hormone replacement therapy

Cyclical hormone replacement therapy, also known as sequential hormone replacement therapy, is often recommended for women taking combined hormone replacement therapy who have menopausal symptoms but still have their periods.

There are two types of cyclical hormone replacement therapy:

• monthly hormone replacement therapy – you take estrogen every day, and take progestogen alongside it for the last 14 days of your menstrual cycle
• three-monthly hormone replacement therapy – you take estrogen every day, and take progestogen alongside it for around 14 days every three months

Monthly hormone replacement therapy is usually recommended for women having regular periods.

Three-monthly hormone replacement therapy is usually recommended for women experiencing irregular periods. You should have a period every three months.

It’s useful to maintain regular periods so you know when your periods naturally stop and when you’re likely to progress to the last stage of the menopause.

Continuous combined hormone replacement therapy

Continuous combined hormone replacement therapy is usually recommended for women who are post-menopausal. A woman is usually said to be post-menopausal if she has not had a period for a year.

As the name suggests, continuous hormone replacement therapy involves taking estrogen and progestogen every day without a break.

Estrogen-only hormone replacement therapy is also usually taken continuously.

Side effects of hormone replacement therapy

Like any medication, the hormones used in hormone replacement therapy (hormone replacement therapy) can sometimes have side effects.

Any side effects usually improve over time, so it’s a good idea to persevere with treatment for at least three months if possible.

Speak to your doctor if you experience severe side effects or they continue for longer than three months.

Side effects of estrogen

The main side effects associated with taking estrogen include:

• bloating
• breast tenderness or swelling
• swelling in other parts of the body
• nausea
• leg cramps
• headaches
• indigestion
• vaginal bleeding

These side effects will often pass in a few weeks, but the following measures may help relieve some of them in the meantime:

• taking your estrogen dose with food may help to reduce nausea and indigestion
• eating a low-fat, high-carbohydrate diet may reduce breast tenderness
• regular exercise and stretching may help reduce leg cramps

If side effects persist, your doctor may recommend switching to a different way of taking estrogen (for example, changing from a tablet to a patch), changing the specific medication you’re taking, or lowering your dose.

Side effects of progestogen

The main side effects associated with taking progestogen include:

• breast tenderness
• swelling
• headaches or migraines
• mood swings
• depression
• acne
• tummy (abdominal) pain
• back pain
• vaginal bleeding

As with side effects of estrogen, these will usually pass in a few weeks.

If they persist, your doctor may recommend switching to a different way of taking progestogen, changing the specific medication you’re taking, or lowering your dose.

Weight gain and hormone replacement therapy

Many women believe that taking hormone replacement therapy will make them put on weight, but there’s no evidence to support this claim.

You may gain some weight during the menopause, but this often happens regardless of whether you take hormone replacement therapy.

Exercising regularly and eating a healthy diet should help you to lose any unwanted weight.

More serious risks of HRT

Hormone replacement therapy has also been associated with some more serious risks, such as an increased risk of blood clots and certain types of cancer.

Breast cancer

The National Institute for Health and Care Excellence ⁸⁾ says:

• taking combined hormone replacement therapy (estrogen and progestogen) is associated with a small increased risk of breast cancer – some studies have suggested that for every 1,000 women taking combined hormone replacement therapy, there will be around five extra cases of breast cancer (from a normal risk of 22 cases of breast cancer per 1,000 menopausal women to 27)
• the risk of breast cancer decreases when you stop taking hormone replacement therapy – estimates suggest the level of risk returns to normal after about five years
• estrogen-only hormone replacement therapy is associated with little or no change in the risk of breast cancer

Because of the risk of breast cancer, it’s especially important to attend all your breast cancer screening appointments if you’re taking combined hormone replacement therapy.

Ovarian cancer

Studies looking at whether hormone replacement therapy can increase your risk of ovarian cancer have so far had conflicting results.

It’s thought that if there is any increase in cases of ovarian cancer in women taking hormone replacement therapy, the risk is very small.

A recent study found that for every 1,000 women taking hormone replacement therapy for five years, there will be one extra case of ovarian cancer.

Any risk of ovarian cancer is thought to decrease once you stop taking hormone replacement therapy.

Womb cancer (uterine cancer)

Estrogen-only hormone replacement therapy can increase the risk of womb cancer (also called endometrial cancer), which is why it’s only used in women who don’t have a womb (for example, because they’ve had a hysterectomy).

Taking combined hormone replacement therapy, particularly a course of continuous hormone replacement therapy (where you take both medications without a regular break), largely eliminates this risk.

If you still have a womb and you’re taking hormone replacement therapy, it’s important to take both medications as advised by your doctor to avoid increasing your risk of womb cancer.

Blood clots

Blood clots can be serious if they become lodged in a blood vessel and block the flow of blood.

The National Institute for Health and Care Excellence ⁹⁾ says:

• taking hormone replacement therapy tablets can increase your risk of blood clots
• there’s no increased risk of blood clots from hormone replacement therapy patches or gels
• It’s thought the risk of developing a blood clot is about two to four times higher than normal for women taking hormone replacement therapy tablets. But as the risk of menopausal women developing blood clots is normally very low, the overall risk from hormone replacement therapy tablets is still small.

It’s estimated that for every 1,000 women taking hormone replacement therapy tablets for 7.5 years, less than two will develop a blood clot.

Heart disease and strokes

The National Institute for Health and Care Excellence ¹⁰⁾ says:

• hormone replacement therapy doesn’t significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age
• estrogen-only hormone replacement therapy is associated with no, or reduced, risk of heart disease
• combined hormone replacement therapy is associated with little or no increase in the risk of heart disease
• taking estrogen tablets is associated with a small increase in the risk of stroke, although the normal risk of women under 60 having a stroke is very low, so the overall risk is small

Speak to your doctor if you’re taking hormone replacement therapy or are considering taking it and are worried about the risk of stroke or heart disease.

Bioidentical or “natural” hormones

Bioidentical hormones are hormone preparations made from plant sources that are promoted as being similar or identical to human hormones.

Practitioners claim these hormones are a “natural” and safer alternative to standard hormone replacement therapy preparations.

However, bioidentical preparations aren’t recommended because:

• they aren’t regulated and it’s not clear how safe they are – there’s no good evidence to suggest they’re safer than standard HRT
• it’s not known how effective they are in reducing menopausal symptoms
• the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there’s no evidence that these levels are related to your symptoms

Many standard hormone replacement therapy hormones are made from natural sources, but unlike bioidentical hormones they’re closely regulated and have been well researched to ensure they’re as effective and safe as possible.

Unproven, Nonscientific “Treatments” for Hot Flashes

People often assume that “natural” or “herbal” products cause no harm. However, all supplements may have potentially harmful side effects, and supplements can also interact with medications you’re taking for other medical conditions. Always review what you’re taking with your doctor.

You may have heard about black cohosh, DHEA, or soy isoflavones from friends who are using them to try to treat their hot flashes. These products are not proven to be effective and some carry risks like liver damage.

Phytoestrogens are estrogen-like substances found in some cereals, vegetables, and legumes (like soy), and herbs. They might work in the body like a weak form of estrogen, but they have not been consistently shown to be effective in research studies, and their long-term safety is unclear.

At this time, it is unknown whether herbs or other “natural” products are helpful or safe. The benefits and risks are still being studied. Always talk with your doctor before taking any herb or supplement to treat your hot flashes or other menopausal symptoms.

Dietary supplements commonly used for menopause symptoms include:

• Plant estrogens. Asian women, who consume soy regularly, are less likely to report hot flashes and other menopausal symptoms than are women in other parts of the world. One reason might be related to the estrogen-like compounds in soy. However, studies have generally found little or no benefit with soy, although research is ongoing to determine whether specific components of soy, such as genistein, help hot flashes.
• Black cohosh. Black cohosh has been popular among many women with menopausal symptoms. Studies of black cohosh’s effectiveness have had mixed results, and the supplement might be harmful to the liver in rare circumstances.
• Ginseng. While ginseng may help with mood symptoms and insomnia, it doesn’t appear to reduce hot flashes.
• Dong quai. Study results indicate that dong quai isn’t effective for hot flashes. The supplement can increase the effectiveness of blood-thinning medications, which can cause bleeding problems.
• Vitamin E. Taking a vitamin E supplement might offer some relief from mild hot flashes. In high doses, it can increase your risk of bleeding.

Nerve block procedure

A procedure known as stellate ganglian block has shown promise for treating moderate to severe hot flashes, but more research is needed. It involves injecting an anesthetic into a nerve cluster in the neck. The treatment has been used for pain management. Side effects include pain and bruising at the injection site.

Hot flashes in men

Men with locally advanced or metastatic prostate cancer are commonly treated with luteinizing hormone–releasing agonists and antiandrogens (androgen deprivation therapy) ¹¹⁾. Approximately 50% of men with prostate cancer will receive androgen deprivation therapy at some point in their treatment and in this large population, a major debilitating side-effect can be hot flashes ¹²⁾. These hot flashes deteriorate health-related quality of life and significantly alter physical function and general health, compared to men not receiving androgen deprivation therapy ¹³⁾. Androgen deprivation therapy-induced hot flashes are a vasomotor disturbance identical to those in menopausal females, consisting of sweating, an elevated heart rate, a drop in blood pressure (during the attack), and changes in heart rate variability ¹⁴⁾. There are also incapacitating alterations in sleep and daily activity and findings of osteoporosis, decreased libido, erectile dysfunction, fatigue, and irritability or depression ¹⁵⁾.

For treatment – see hot flashes treatment above, they are all applicable to men except for female hormone replacement therapy.