Confessions of a Hot Flush Queen

I am a Hot Flush Queen. I've earned the title after four years of chronic hot flushes intermittently relieved by various treatments. I'm not proud of the title; in fact I'm actively looking for a way to give it up!

My first hot flush started with a chill, followed by a roaming band of heat that crawled up my legs to my back, all the way to my scalp. Soon I was drenched in sweat. Within the next few months the pattern took hold, repeating every half-hour to 45 minutes, interrupting every daytime activity and, worse, sleep.

Hot flushes, or flashes, are the most commonly reported menopausal symptom. But if you've canvassed your friends, you've probably discovered how varied women's experiences of them are.

During perimenopause, as hormones fluctuate and ovulation becomes erratic, symptoms also change. A treatment for hot flushes that was effective in year two of perimenopause may be useless in year five or during menopause when your periods have stopped. Finding a solution is a bit like trying to thread a moving needle.

What's Wrong With Women Today?

A Canadian study shows that many women are having difficulty: 75 percent of 9,928 women between the ages of 39 and 52 reported having hot flushes, 68 percent reported sleep disturbances, and 64 percent experienced night sweats. Health concerns such as depression, irritability, and anxiety are common.

The Women's Health Initiative in 2002 was the most publicized of a series of studies that showed that women were at increased risk of heart attack, stroke, and breast cancer if they treated their hot flushes with synthetic estrogen and progesterone (hormone replacement therapy or HRT) for more than five years. These results scared women. Those taking HRT faced a return of symptoms when they quit HRT; to seek relief, 24 percent returned to the same drugs.

There are alternatives, but they are not well publicized. Instead, media commentary about the issue often asks, or implies, Why can't these women just cope?

I put this question to Dr. Jerilynn Prior, a professor of endocrinology and scientific director of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia. "A hot flush is a dog's breakfast of central stress hormones," she responds. "These hormones make you sweat, make your blood pressure go up, increase your heart rate, make you feel panicky. Cortisol, norepinephrine, adrenocorticotropic hormone (ACTH)–we know for sure these are in play." This is why hot flushes are often surrounded by a distressing aura of anxiety, anger, dizziness, and nausea.

I also asked Dr. Prior about the often-quoted fact in menopausal literature that women in some cultures do not have hot flushes at all. "Is there a reason why some women in the west are having a hard time?"

"A woman in a Third World country who has never been exposed to birth control pills, high levels of estrogen, or who is thin may not experience hot flushes," Dr. Prior says. "A genetic sensitivity to estrogen may be another reason why some women are more at risk for hot flushes than others."

Stress is another factor. Dr. Prior mentions a study from the University of Western Ontario that showed a worsening of hot flush symptoms (measured by finger temperature) when women were placed in a chaotic, noisy room. We need to de-stress, says Prior. "In a sense we need to make a quiet room for ourselves."

A Calming Hormone

For women having severe hot flushes that interfere with sleep, Dr. Prior, who is also a family doctor, prescribes natural-source progesterone. In a few specific circumstances, she also prescribes natural-source estrogen therapy via a patch or gel for a limited time. But in general she challenges the current medical wisdom regarding estrogen therapy.

"In medicine it was commonly taught that a drop in estrogen produced the hot flush," she explains, "so the gold standard was to treat women with estrogen therapy. Estrogen levels do fluctuate during perimenopause, but on average they're 30 percent higher than usual.

"When there's a swing down from super-high to high or even normal levels of estrogen, then we're like an addict going through withdrawal. Our brains get addicted to these super-high levels and we have hot flushes and other reactions." After menopause, low levels of both estrogen and progesterone are the norm, and within two to five years hot flushes will wane for most women.

Dr. Prior is conducting a clinical study on the effect of progesterone on hot flushes and heart health in menopausal women. I asked her how progesterone works. "It may be through thermoregulatory centres in the brain," she replies, "or because it's a calming agent, or it may have direct antagonistic effects to estrogen in the brain. We do know it helps with sleep and it's effective for hot flushes."

Give the Body What it Knows

Many women are understandably wary of hormone therapy; I certainly was. Dr. Alvin Pettle, past chief of obstetrics and gynecology at Etobicoke Hospital and director of an integrative medicine centre in Toronto, makes a strong case for the safety of bio-identical hormone therapy as opposed to synthetic hormone therapy. It is synthetic hormones, altered from their source so manufacturers could obtain patents, which have been associated with health problems.

Dr. Pettle tells me, "My patients didn't appear to do well with synthetic hormones. Synthetic estrogen is far too potent. Synthetic hormones may look like natural hormones, but they don't behave like them in a woman's body. For example, synthetic progesterone has a 30-hour half-life in the body; natural progesterone has a 12-hour half-life. And studies indicate that synthetic progesterone doesn't offer the same protection to a woman's breasts and heart."

How can we be sure bio-identical hormones are safe? "They've always been safe," he says. "We know that because they've been around a long time, in our own bodies. Your body knows how to handle bio-identical hormones, how to recognize them."

To treat perimenopausal symptoms, Dr. Pettle prescribes bio-identical progesterone creme from a plant source that is molecularly identical to the progesterone made by our own bodies. "For patients who do not receive adequate relief with progesterone," he says, "I feel very comfortable adding natural bio-identical estrogen in a creme."

Again, Dr. Pettle looks to the body to determine the estrogen formulation. "Women naturally have three different estrogens in a ratio of 80 percent estriol, and estrone and estradiol at 10 percent each," he explains. "The key issue here is that we're beginning to learn that estrone is the most cancer permissive of all three. If a patient takes estradiol, 50 percent will become estrone in the body. I don't prescribe 100 percent estradiol to my patients."

Instead, the low-dose, bio-identical estrogen Dr. Pettle prescribes follows the natural ratio, either in a formulation that combines estriol and estradiol and omits estrone, or one that contains all three estrogens. When estrogen is being used, he always prescribes bio-identical progesterone creme, too. (For more information on bio-identical hormones, see drpettle.com.)

Why the emphasis on cremes rather than pills? "Estrogen should never be taken as pills," he says emphatically. "When it goes through the liver, it lowers the sex drive and increases the chance of blood clotting." It is safe to take oral, bio-identical progesterone, he says. It doesn't produce problematic metabolites (waste products) via the liver. Cremes give the advantage of not passing through the liver at all. A compounding pharmacist (see sidebar) can make bio-identical hormonal cremes.

Cool Down a Hot Flush

1. Try yoga breathing, relaxation exercises, or acupuncture. "These all decrease the activation of the regulating centres in the brain that are triggered during a hot flush," says Dr. Prior.
2. Exercise regularly: in particular, cardiovascular fitness helps hot flushes.
3. Avoid alcohol: even a sip of alcohol, particularly at the start of perimenopause, can make symptoms worse.
4. Keep a daily diary of hot flushes. "This gives a sense of coping and helps reduce severity of symptoms," says Dr. Prior.
   A sample diary is available from cemcor.ubc.ca/tools/download.shtml#diaries.
5. Ask your doctor about natural-source progesterone therapy.

Compounding Pharmacies

Compounding pharmacies customize prescription medication to meet individual needs.

"We can offer very low doses of medication for women going off hormone therapy," says Maike Lorenzen, a compounding pharmacist in Vancouver. "We can help women and doctors determine dosages and methods of delivery for bio-identical hormones. Nutrition also has a major impact on perimenopause and menopause."

To locate a compounding pharmacy in your area, call the Professional Compounding Centers of America at 1-800-331-2498.