Hot Flashes: How to Deal With Them

Colette Dowling, LMSW

Estrogen levels begin dropping in the mid-thirties, gradually making pregnancy less likely. In the early forties, menstrual cycles become shorter and FSH (follicle stimulating hormone) may be elevated. When this is the case, in the words of one gynecological researcher,"the ability to get these women pregnant, even with heroic intervention, is discouraging at best." By then, the perimenopause has begun, and while pregnancy isn't out of the question, it's unlikely. By the late forties, cycles become irregular and periods often produce heavy bleeding. Irregularity is a clear sign that you're soon leaving perimenopause and entering menopause. Some women miss a period or two, and it's all over. For others, the irregularity goes on for a year or longer.

It isn't only estrogen that acts on us as we approach midlife. Who gets hit with hot flashes, insomnia, and mood changes--and when, how severely, and for how long--has to do in part with brain neuerotransmitters like serotonin. A chemical that requires the presence of estrogen for its metabolism in the brain, serotonin regulates sleep, energy, mood, and libido and is central to our wellbeing.

Women(like men)vary in the amount of serotonin their brains process. Many researchers have suggested that women with low serotonin (largely a genetic matter) may become more symptomatic when their estrogen levels drop off than those whose serotonin levels are closer to normal. The rate at which hormone changes occur, before menopause, is also relevant when it comes to the severity of hot flashes. The relative speed with which our sex hormone levels change could be THE determining factor in how symptomatic we become during perimenopause (and during menstrual cycles too, for that matter). In those whose drop-off is gradual, and who have sufficient serotonin flowing through their brains to begin with, there may be NO overt symptoms. In those whose drop-off is sudden--say, for example, a woman whose ovaries have been removed--symptoms are likely to be pronounced and dramatic.

Between the two extremes lies the middle ground of the menopausal spectrum, where everyone else falls. Some in this group may find their symptoms mildy discomfiting. Others may be quite symptomatic. The drop in estrogen that begins in perimenopause can disturb sleep, affect sex, alter memory and cognition, and create anxiety and difficulty in concentrating. It can also, as we said above, create hot flashes.

Hot flashes are the notorious outward sign of estrogen drop-off and perimenopause. Some women never have a hot flash, some may be only moderately inconvenienced by the symptoms, and some may find cataclysms of temperature change wrecking their sleep and embarassing them as they try to negotiate corporate buyouts.

Researchers at the University of California in Los Angeles found that most hot flashes in a group of women they studied occurred at night, often causing waking. The perimenopausal women awoke three times as often as the premenopausal women and experienced far less REM sleep--the type necessary for genuine rest. As a result, the UCLA team concluded, perimenopausal women are more likely to be sleep-deprived.

Any woman experiencing hot flashes has one big question: How long is this going to last? For the majority of women (65 percent) hot flashes occur over a period of one to five years. Another 25 percent have them for six to ten years. Ten cent have hot flashes for ten years or more.

During a hot flash the heart rate can increase as much as 25 beats a minute. The body temperature actually falls because the body is getting rid of heat. The hypothalamus of the brain controls heart rate, dilation of blood vessels and capillaries and breathing--so-called vasomotor symptoms. A hot flash occurs when the hypothalamus gets its signals mixed. Mistakenly perceiving body temperature as too high, it abruptly triggers cool-down mechanisms. Thus, at the beginning of a hot flash the skin becomes cold and clammy.

The cause of this sudden downward "resetting" of the body's thermostat is unknown. It's assumed that estrogen plays a major role, since hot flashes begin during perimenopause, when estrogen levels drop. The abrupt onset of flashes when ovaries are removed surgically, as well as the relief from hot flashes when estrogen supplements are administered, appear to support the argument. However, the exact role of estrogen in this peculiar experience of temperature dysregulation isn't understood.

(More on the science of hot flashes can be found at The North American Menopause Society.) Women in droves used to take estrogen supplements for perimenopausal symptoms such as hot flashes. Far fewer do today because some breast cancers are estrogen-responsive. Drug companies sell non-estrogenic medications for the treatment of hot flashes and other perimenopausal symptoms. As well, there are many non-pharmaceutical possibilities for improving hot flashes and other symptoms during perimenopause. Those experiencing significant mood shifts, however, should definitely have a medical evaluation. Women whose serotonin levels are lower than normal to begin with can suffer seriously due to the further lower of this neurotransmitter that occurs when estrogen levels plummet. There's no need to suffer from even moderate mood changes during perimenopause. Such mood changes can affect everything,from relationships to a woman's ability to make a living.

There are enough changes--physical, social, emotional--occurring during a woman's perimenopausal years that she sometimes can benefit from psychotherapy. This is not because menopause turns women "crazy", as was thought for centuries, but because therapy can be helpful at any time in a person's life when many changes converge at once, causing a kind of blow to the psyche. It takes years for the changes of perimenopause to resolve themselves, and some of these changes, on occasion, won't resolve without outside help. This is nothing to be ashamed of. Get the help you need so that you can pick yourself up and move on. A long, productive life lies ahead, and you deserve to enjoy it.

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To hear Colette speaking on what it's like to begin therapy with someone new, click on the auddio button, below.

Colette is best known for uncovering women's psychological conflicts with independence in her best-selling The Cinderella Complex: Women's Hidden Fear of Independence. She has also written on the unique mental health issues of midlife women in her book, Red Hot Mamas: Coming Into Our Own at Fifty. You can find excerpts from her books at http://www.colettedowling.com.

For information on Colette Dowling's therapy practice click here.

For articles on women's mental health see Colette's website.