Art & science women’s health

Managing menopausal symptoms: hot flushes and night sweats Brockie J (2013) Managing menopausal symptoms: hot flushes and night sweats. Nursing Standard. 28, 12, 48-53. Date of submission: June 13 2013: date of acceptance: September 11 2013.

Abstract Menopausal hot flushes and night sweats are the most common  symptoms of the menopause, and a minority of women find them  distressing and seek treatment. Hormone replacement therapy (HRT)  is the most effective treatment for managing these symptoms. HRT  is also beneficial in the treatment of other symptoms associated with  menopause such as urogenital atrophy and psychological symptoms,  and in protecting against the early metabolic changes associated with  premature ovarian failure (Rees et al 2009). This article discusses  the use of HRT and alternative treatment approaches to manage  menopausal hot flushes and night sweats. 

Author Jan Brockie Advanced nurse practitioner menopause, John Radcliffe Hospital,  Oxford. Correspondence to: [email protected]

Keywords Hormone replacement therapy, menopause, vasomotor symptoms, women’s health

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HOT FLUSHES ARE a common symptom of the hormonal changes associated with menopause and are experienced by many women (Pitken 2010). They are described typically as a sudden sensation of heat beginning in the chest and radiating up through the neck and head, accompanied by a feeling of intense heat. A hot flush may last for a few minutes before the heat gradually subsides, and afterwards the woman may feel cold and shivery. Sometimes women experience palpitations with the hot flushes and others describe an aura, such as a feeling of 48  november 20 :: vol 28 no 12 :: 2013 

dread, before the hot flush starts. During a hot flush some women become red and may also sweat, but in other women a hot flush is barely noticeable. Hot flushes can occur during the day or night, but at night women experience sweating and these are generally called night sweats (Barrett-Connor 2003). Menopausal hot flushes and night sweats, also known as vasomotor symptoms, vary in severity and frequency. In the Western world about 70% of women will experience them (Hope 2005). Some women will have an occasional hot flush and others will have dozens throughout the day. Vasomotor symptoms can start in the peri-menopause, the time when menstruation becomes irregular and menopause symptoms begin, or early post-menopause. Without treatment menopausal hot flushes and night sweats will settle within a few years. However, some women experience them in the longer term, with 15% of women being symptomatic at 66 years old and 9% at 72 years (Rödström et al 2002). The cause of hot flushes is not known but it is thought to be a dysfunction in the thermoregulatory centre in the hypothalamus (Sturdee 2008). This causes inappropriate peripheral vasodilation of superficial blood vessels, which gives the sensation of heat. The increased cutaneous blood flow and perspiration cause rapid heat loss and the body’s core temperature drops. This is why women may feel cold after a flush has subsided and shivering is a normal mechanism to help restore body temperature. Some studies suggest that the thermoneutral zone is narrowed in women with hot flushes (Freedman 2005, Sturdee 2008), which means that this mechanism of heat loss is triggered more readily with much smaller rises in body temperature than normal. In women who do not experience hot flushes, mechanisms to reduce heat are initiated when the core body temperature increases by 0.4°C, but this will be lower in women who experience hot flushes (Freedman 2005). Menopause symptom reporting from around the world varies but vasomotor symptoms and vaginal atrophy are reported in all cultures (Melby et al 2005). The differences in menopause symptom reporting are complex. This is probably


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because of underlying biological and genetic differences, and variations in sociocultural factors such as attitudes towards menopause, which may be related to vasomotor symptom perception and reporting (Melby et al 2005). Language differences may also be a factor (Melby et al 2005). In addition, dietary and diversity of lifestyles may affect vasomotor symptoms, and it is recognised that they can trigger hot flushes and night sweats (Rees et al 2006). With the cessation of menstruation brought on by ovarian failure, women lose their main source of oestrogen production. Oestradiol is produced during the menstrual cycle and is the main premenopausal oestrogen. After the menopause, the oestrogen profile changes so that oestrone is the main oestrogen. This oestrogen is weaker than oestradiol and is produced in adipose tissue from the conversion of androstenedione (this hormone, a precursor of sex hormones, is mainly produced in the adrenal glands after the menopause) (Grodin et al 1973). Although obese women have higher levels of circulating oestrone because of increased peripheral conversion of androstenedione to oestrone (Whiteman et al 2003), women with a high body mass are more likely to experience moderate to severe hot flushes. Women who are putting on weight are also more likely to experience hot flushes (Whiteman et al 2003). In addition, smoking increases the risk of hot flushes as nicotine increases the rate at which oestrogen is metabolised in the liver (Whiteman et al 2003). Other risk factors include reduced physical activity and sociodemographic factors such as lower education and income levels (Gold et al 2000). Factors also commonly associated with an increase in vasomotor symptoms are caffeine and alcohol consumption, intake of hot drinks and spicy foods, hot environment, depression, stress and anxiety (Rees et al 2006, NHS Choices 2013). Severe vasomotor symptoms can have a significant and detrimental effect on quality of life (Hunter and Chilcot 2013). A distressing feature of hot flushes is sleep disturbance and insomnia. Some women will sweat so profusely at night that they have to shower and change, which causes much disrupted sleep. This can have adverse effects on energy levels, mood, memory and concentration.

Management of vasomotor symptoms Vasomotor symptoms may be managed using hormone replacement therapy (HRT), complementary therapies, lifestyle changes and other alternatives. Following consultation and assessment of their symptoms by the GP or practice


nurse, women who experience troublesome hot flushes and night sweats may opt for medical intervention or decide not to.

Hormone replacement therapy Oestrogen replacement therapy remains the most effective treatment in reducing the frequency and severity of menopausal hot flushes and night sweats. A systematic review of trials that included 3,329 participants in 24 studies showed that hormone therapy improved the severity of hot flushes by about 87% compared to placebo (Rödström et al 2002). It has also been shown to improve vaginal dryness and sexual function, sleep quality, joint pain, fracture risk and quality of life in symptomatic women (Sturdee et al 2011). Concerns about the use of HRT were raised in 2002 when the first data from the Women’s Health Initiative (WHI) and the Million Women Study (MWS) were published (Rossouw et al 2002). However, a new consensus statement on recommendations regarding HRT, initiated by the International Menopause Society, supports the use of HRT for the treatment of menopausal vasomotor symptoms, with the proviso that the benefits are more likely to outweigh the risks for symptomatic women before the age of 60 years or within ten years of menopause (de Villiers et al 2013). An individual risk-benefit analysis should be made by each woman with the help of her prescriber, the GP or practice nurse, including the potential benefits of symptom management on quality of life and the risks of the therapy. This analysis should be based on the woman’s personal and family history, and while there is no consensus of absolute contraindications to HRT (Hickey et al 2012), for some women HRT should be avoided or used with caution (Table 1). A woman’s preferences should be taken into consideration because HRT may not be a desired treatment option. Systemic HRT for the treatment of vasomotor symptoms can be administered via oral or transdermal (a patch or skin gel) routes. For most women first-line treatment choices can be made on personal preference. Oral therapies tend to be cheaper and easier to use. However, some women, such as those with a history of migraine or if there is concern about thrombosis, will be advised to consider a transdermal therapy because these have a different safety profile (NHS Choices 2013, Panay et al 2013) (Box 1). All oestrogen used in HRT is natural and is derived from soy or yams or is equine in origin. The administration regimen will vary depending on whether the woman is peri-menopausal or november 20 :: vol 28 no 12 :: 2013  49  

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Art & science women’s health post-menopausal and whether she has had a hysterectomy. For women who have not had a hysterectomy, oestrogen alone will increase the risk of endometrial cancer and therefore HRT is given in combination with a progestogen to protect the endometrium in these women (NHS Choices 2013). Combined HRT products combining oestrogen and progestogen are available as either a tablet or patch for ease of taking. In peri-menopausal women, the progestogen is given cyclically (usually 12-14 days in each 28-day cycle), resulting in a regular withdrawal bleed. In post-menopausal women, both oestrogen and progestogen can be given together continuously, resulting in a cycle-free HRT without a withdrawal bleed because this treatment renders the endometrium atrophic (NHS Choices 2013). Alternatively, progestogen can be given via an intrauterine system (Mirena) and the oestrogen of choice prescribed separately. However, it is important to remember that Mirena is licensed for four years only for HRT, instead of five years for contraception and bleeding control (British National Formulary (BNF) 2012). As well as the choice of route, different dosages of HRT are also available. The optimum dosage and duration of treatment should be decided according to the severity of a woman’s symptoms and her response to therapy. Generally, HRT is given at the lowest effective dosage for symptom management but young women, particularly those with severe symptoms following a surgical menopause, initially may require higher dosages of HRT to alleviate vasomotor symptoms (Rees et al 2009). Conversely, older women usually require lower dosages to manage their symptoms. Generally, an improvement in vasomotor symptoms is noted within four weeks, with maximum response usually achieved within three months. If hot flushes continue after this time, a higher dosage, an alternative route of administration or other causes of hot flushes should be considered. The effectiveness of HRT is usually

monitored by symptom management rather than any investigations such as blood tests. Patients should be reviewed annually to evaluate their indications for use of HRT. It should include assessing the benefits and risks of HRT and include promotion of a healthy diet and lifestyle to reduce the long-term risk of chronic disease (Hickey et al 2012). There has been interest in bio-identical hormones for the treatment of menopausal symptoms. These are hormones derived from plant sources and are molecularly similar to hormones produced naturally by the body. In spite of claims that they are superior to traditional HRT, this is not supported by evidence, they remain unlicensed and their purity and risks are not known (Huntley 2011). Most women who commence HRT to relieve vasomotor symptoms will take it for five years or less, but women who experience hot flushes over a prolonged period sometimes continue with the hormone therapy because they still meet the criteria for HRT. They should continue to be reviewed annually to discuss the continuing benefit/risk ratio (Hickey et al 2012). Women with a premature menopause are encouraged to take HRT until the average age of the natural menopause (51/52 years) and at that point reassess

BOX 1 Reasons to avoid oral hormone replacement therapy and consider obtaining expert advice Women with a history of: Liver disease. Gallstones. Personal or family history of venous  thromboembolism. Migraine. Smoking. High triglycerides. Gastrointestinal absorption problems. (Hickey et al 2012)

TABLE 1 Contraindications and cautions to hormone replacement therapy (HRT) Avoid HRT

Use HRT with caution

History of oestrogen-dependent cancer

Undiagnosed breast lump

Un-investigated abnormal vaginal bleeding

Active liver disease

Uncontrolled hypertension

Personal or first degree relative with a history of  venous thromboembolism


History of migraine Previous cardiovascular disease event Gall bladder disease

(Hickey et al 2012)

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the HRT regimen depending on symptoms and quality of life (Panay et al 2013).

Alternative treatments Alternative approaches to manage vasomotor symptoms include other prescribed medication, complementary therapies, psycho-educational approaches, and diet and lifestyle advice. Women who choose these treatment options will either not want or should not take HRT. Some women who avoid HRT will have had breast or endometrial cancer, and it is important for all menopause healthcare practitioners to be aware of the ‘Do Not Do’ recommendations for women with a history of breast cancer (National Institute for Health and Care Excellence (NICE) 2009).

Other prescribed medication

Clonidine was developed originally as an antihypertensive and has been used to manage vasomotor symptoms with varying success. The dose is 50-75mcg twice daily. It is the only non-oestrogen preparation licensed for the treatment of hot flushes and the evidence is conflicting, but it may be helpful in women who have hot flushes induced by tamoxifen. Side effects include postural hypotension, sleeping difficulties, dry mouth, dizziness and nausea (Pitken 2012). Selective serotonin re-uptake inhibitors (SSRIs) such as fluoxetine, paroxetine and citalopram have been found to be effective, but most studies show a short-term benefit only (NICE 2013). SSRIs should not be prescribed at the same time as tamoxifen because they affect liver enzymes, altering the effectiveness of tamoxifen. Side effects include low libido. Venlafaxine, a serotonin and noradrenaline re-uptake inhibitor, has been shown to be effective in reducing the frequency of hot flushes, mainly in breast cancer patients unable to take HRT. The drug is generally commenced at a dose of 37.5mg daily and can be increased to 75.0mg (Pitken 2012). Venlafaxine is less likely to interfere with tamoxifen metabolism. Side effects include reduced libido and nausea, and caution is necessary with venlafaxine in patients with cardiovascular risks (Pitken 2012). With all antidepressants, treating vasomotor symptoms is an unlicensed use; they remain less effective than HRT but in some women can reduce vasomotor symptomatology by about 50-60% (Sturdee et al 2011). Gabapentin, used for the treatment of epilepsy, migraine and neurogenic pain, has also been used to relieve vasomotor symptoms in women with breast cancer. It is started at a dose of 100mg three times daily and titrated up to a maximum of 900mg daily. It has been shown to reduce both


the frequency and severity of hot flushes by about 50% (Pitken 2012). Side effects include dry mouth, dizziness and drowsiness. Progestogens such as norethisterone and megestrol acetate have been shown to reduce vasomotor symptoms, but the dose required to achieve symptom control increases thromboembolic risk and safety concerns (Rees et al 2009). Over several years, there have been advocates of transdermal progesterone cream but there is little evidence to support claims of efficacy. A high placebo response has been noted in all trials (Rees et al 2009).

Complementary therapies

There is limited evidence from randomised controlled trials that complementary therapies improve menopausal symptoms including vasomotor symptoms. A few well-designed studies have shown some improvement of symptoms from baseline (Drug and Therapeutics Bulletin 2009). Many women have chosen to use complementary therapies in the belief that they may be safer following the publication of the WMS and WHI (Rees et al 2009). Therapies used include osteopathy, reflexology, aromatherapy, hypnotherapy, yoga, the Alexander technique, breathing exercises and meditation. Most of these therapies concentrate on stress reduction and relaxation, and by improving mood and wellbeing may have an effect on vasomotor symptoms (Pitken 2012). The results of randomised trials of acupuncture for the treatment of hot flushes have not shown consistent effect (Lee et al 2009, Sturdee et al 2011). Herbal remedies Herbal products that women may take to manage vasomotor symptoms include black cohosh, oil of evening primrose, dong quai, ginkgo biloba, ginseng, agnus castus and St John’s wort. Many herbal preparations can be bought over the counter and few have gained registration with the Medicines and Healthcare products Regulatory Agency. There is no evidence that these products are effective for treating menopausal hot flushes (NICE 2013). Herbal remedies need to be used with caution in women with a contraindication to oestrogen because they may interact with other medications with adverse effects (Rees et al 2009). It is the responsibility of the healthcare professional to ascertain if women are using any over the counter product and record its use in patient notes. Homeopathy Homeopathy is the use of dilute substances that bring about a healing response without the presence of side effects. In some cases the response is greater in lower doses. The mechanism of action is unclear, but the results from case histories and observational studies are encouraging and further studies are required (Rees et al 2009). november 20 :: vol 28 no 12 :: 2013  51  

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Art & science women’s health Magnetic therapy Magnets are available in different forms for various health issues, including menopausal symptoms. However, there is no understanding of how magnetic therapy works and there is no randomised controlled evidence that it offers any benefit for hot flushes. Phytoestrogens: soy and red clover There has been much interest in phytoestrogens, plant-derived chemicals that have oestrogenic action, and particularly isoflavones because there is evidence that their consumption may offer beneficial protection against chronic and degenerative diseases. There is conflicting evidence to demonstrate that phytoestrogens reduce vasomotor symptoms and maintain bone health (Lethaby et al 2007, Pitken 2012). More research is required to establish whether phytoestrogens are safe for women with a history of breast or endometrial cancer.

Psycho-educational approaches

Evidence suggests that women who have negative expectations of the menopause or are highly stressed or distressed are more likely to experience a more negative menopause (Bauld and Brown 2009). Small studies have identified the value of group meetings, combining cognitive behavioural group treatment,

information giving, self-education, relaxation training, group support, lifestyle modification, and psychological coping skills (Yazdkhasti et al 2012, Hunter and Chilcot 2013). These can lead to improved quality of life and a reduction in frequency of vasomotor symptoms (Yazdkhasti et al 2012, Hunter and Chilcot 2013).

Lifestyle approaches

While diet has an effect on health in terms of morbidity and mortality, there is no evidence that any dietary components offer improvement in vasomotor symptoms, other than possibly phytoestrogens. All women should be encouraged to follow current national guidelines for healthy eating. By reducing intakes of caffeine, alcohol, hot drinks and spicy food, reducing smoking, and avoiding stress and hot environments, women may help reduce the frequency and severity of hot flushes (Rees et al 2006, NHS Choices 2013). A systematic review did not find evidence that exercise reduces vasomotor symptoms because of a lack of trial data (Daley et al 2011). However, as exercise has significant psychological and physiological benefits and helps with weight control, it is worth promoting because it is an

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statement on menopausal   hormone therapy. Climacteric.   16, 2, 203-204.

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Hickey M, Elliott J, Davison SL  (2012) Hormone replacement  therapy. British Medical Journal.  344, e763. Hope S (2005) The menopause. In  Rees M, Hope S (Eds) Gynaecology.  Elsevier Mosby, Edinburgh, 174-199. Hunter MS, Chilcot J (2013) Testing  a cognitive model of menopausal hot  flushes and night sweats. Journal of Psychosomatic Research. 74, 4,  307-312. Huntley A (2011) Compounded or 

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intervention with few side effects. Exercise may help improve some of the negative effects of vasomotor symptoms on mood and poor sleep (Sassarini and Lumsden 2010).

Other causes

Further research Limited trials have used stellate-ganglion blocks for the management of menopausal hot flushes in women with a history of breast cancer. The treatment appears effective for the reduction of symptoms but is invasive and costly, requires skilled practitioners and has side effects, although there were no adverse events in a pilot study of 13 women (Lipov et al 2008). Alternative methods of blocking the sympathetic nerve pathways from the stellate-ganglion with radiofrequency are being trialled (Sassarini and Lumsden 2010). The tissue selective estrogen complex is a new combination treatment of a selective oestrogen receptor modulator with one or more oestrogens. Trial results have suggested a future possible effective and safe treatment option for vasomotor symptoms (Kagan 2012). A recent placebo controlled study showed that folic acid supplementation resulted in

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subjective improvement in hot flushes but further evidence is needed to support these findings (Gaweesh et al 2010).

If the management of symptoms in women using HRT is inadequate, other causes of hot flushes and night sweats should be considered. Thyroid function abnormalities can cause several symptoms that can be confused with those of the menopause, and hot flushes are indicative of an over-active thyroid. Other causes of hot flushes include carcinoid syndrome and phaeochromocytoma (Rees et al 2009).

Conclusion HRT remains the most effective treatment for vasomotor symptoms, yet many women with these symptoms at menopause prefer to use alternative therapies. The evidence for the effectiveness of HRT and alternative therapies in the treatment of hot flushes and night sweats have been discussed. More research is required to understand why hot flushes occur in menopausal women and to develop safe, effective treatment options NS

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Managing menopausal symptoms: hot flushes and night sweats.

Menopausal hot flushes and night sweats are the most common symptoms of the menopause, and a minority of women find them distressing and seek treatmen...
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