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There's Hot —&Then There's Hot-Flash Hot

Online Health Chat with Lynn Pattimakiel, MD

November 12, 2012

Introduction

Like pregnancy and delivery, menopause is a normal female life event. ‘The Change’ marks the end of a woman's reproductive years and usually occurs between the ages of 45 and 55. Menopause is defined as the cessation of normal menstruation for one year, and is experienced by all women as they age. The term menopause is commonly used to describe any of the changes a woman experiences either just before or after she stops menstruating, marking the end of her reproductive period. Menopause can mean hot flashes, vaginal dryness, mood swings, low libido and bone thinning, as natural estrogen levels wane. For some women, menopausal symptoms are a minor inconvenience. For others, continual hot flashes and night sweats lead to sleep deprivation and disrupted lives.

There are a variety of treatment options available for women, and successful treatment will depend on a customized plan. Women should know about their healthcare options during menopause, including hormone replacement therapy, bone density testing, and screening guidelines for mammography and gynecology pelvic examinations. As unique as each woman is, the treatment of menopause can be very different for each person.

Going through menopause does not mean you have to just ‘deal’ with all of the symptoms. The best way to come up with a plan that will minimize your symptoms is to discuss all of them with your physician, and come up with a plan together to treat them until you are satisfied. With proper care and management, you can minimize the impact of menopause. Some women even find a new freedom during this time in their life and are able to really enjoy it!

For More Information

On Cleveland Clinic
At the Center for Specialized Women’s Health at Cleveland Clinic, patients are seen in a caring environment that emphasizes technological excellence as well as emotional well-being. The Center offers a full range of state-of-the-art services for testing the unique and changing medical needs of women. We use an interdisciplinary approach to evaluate your problem and arrive at the best treatment for you.

In addition to wellness exams, professionals within the Center for Specialized Women's Health offer a variety of services, including evaluation and/or treatment of:

  • Menopause
  • Peri- and post- menopausal concerns
  • Hormonal concerns and menopausal hormone therapy including “bio-identical” hormones
  • Osteoporosis including bone density and treatments which include yearly infusion therapy
  • Uterine Fibroids and hysterectomy alternatives including UFE and endometrial ablations
  • Urinary incontinence/urine leakage
  • Urinary tract infections/bladder symptoms
  • Sexually transmitted infections and vaginitis
  • Female Sexual dysfunction
  • Breast cancer risk assessment and breast concerns
  • Cervical disease including HPV, colposcopy and LEEP

Women can access routine cancer screenings and information on cardiovascular disease prevention.

Several Cleveland Clinic staff members have participated in the North American Menopause Society (NAMS) Certified Menopause Practitioner Program (NCMP), a competency examination program to set the standards for menopause practices, and to assist women in locating clinicians who could provide optimal menopause-related health care.

Cleveland Clinic's gynecology program is ranked No.3 in the nation by U.S.News & World Report and top-ranked in Ohio.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Dr. Lynn Pattimakiel or any of the other specialists in our Center for Specialized Women’s Health at Cleveland Clinic, please call 216.444.4HER or call toll-free at 800.223.2273, ext. 44437.


About the Speakers

Lynn Pattimakiel, MD, is a staff physician at Cleveland Clinic, and sees patients in the Center for Specialized Women's Health at Cleveland Clinic. Dr. Pattimakiel is board-certified in internal medicine, and is a women's health specialist. She provides clinical care for osteoporosis, menopause and menstrual disorders at Cleveland Clinic's main campus.

Dr. Pattimakiel completed her fellowship in women's health at Cleveland Clinic. Her residency was at St. Vincent Charity Hospital in Cleveland. She earned her medical degree from Medical University of Debrecen, in Hungary.


Let’s Chat About Menopause and Hot Flashes

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Lynn Pattimakiel. We are thrilled to have her here today for this chat on Menopause.


Pelvic Screening Guidelines After Menopause

patch_it_up: How often do I need to get PAP smears once you hit menopause, after getting normal results year-after-year?
Dr_Pattimakiel: The guidelines for PAP tests have recently been changed. If you have always had normal PAP tests and tested negative for HPV (human papillomavirus), then you may go every three to five years before your next PAP test.

Women may stop their routine PAP tests at age 65 and older, if the previous tests have all been normal. It is important to remember that you should continue to have annual pelvic exams, even though you may not need a PAP test.


Menopause Diagnosis

top_knot: Can you please explain FSH and LH numbers as they relate to peri-menopause, menopause and post-menopause? Do the numbers determine where a patient is in terms of menopause?
Dr_Pattimakiel: The hormone levels of FSH and LH may sometimes be checked during the different stages of menopause. Unfortunately, it is not used as a diagnostic tool because these levels are not constant, and may fluctuate depending on when they are checked.

We base diagnosis more on symptoms of menopause and the criteria of not having a menstrual period for over one year. We sometimes use these levels to help confirm menopause rather than to diagnose it.

mehamman: How is menopause diagnosed? Just by symptoms or by blood work?
Dr_Pattimakiel: It is diagnosed by symptoms and going one year without a menstrual period. If a woman has had a hysterectomy, this can be more difficult to diagnose. Therefore, we go by symptoms and may order blood work to check for hormone levels.
Hormone levels alone are not diagnostic for menopause.


Signs and Symptoms of Menopause and After Hysterectomy

maravillosa99: What are some things I can do to improve the quality of my sleep? I have stopped all caffeine intake after about 3:00 p.m., and I try to keep the same bedtime hours even on weekends. The main problem is waking up very hot (with my covers on), and then I get very cold (with my covers off). This pattern repeats all night long.
Dr_Pattimakiel: Getting quality sleep is very important for you to feel energized and for your general well being.

If the difficulty with sleeping is related to night sweats, there are many tips you can try.
Make sure not to sleep with a down comforter. Keep your room cool at night, and you could try sleeping with a fan on. Dress in loose cotton clothing. You can also try using a chill pillow at night. (You can find more information about chill pillows online through Google.) Another tip might be trying to sleep with your socks on because it helps keep your core body temperature down.

monday_monday: What are the most common signs and symptoms of menopause?
Dr_Pattimakiel: The most common symptoms of menopause are hot flashes and night sweats. Women experience these very differently. Some women may feel mild symptoms like a flushing in the face, while others may feel severe symptoms of embarrassing sweats and a deep, ‘inferno’-intense type of heat.

Night sweats can be particularly bothersome, when women wake up soaked and needing to change their sheets. This interferes greatly with the quality of their sleep.

Other things we need to monitor for are vaginal dryness, which can manifest as painful sexual intercourse and low bone density, such as osteopenia or osteoporosis.

Due to the lack of sleep, many women may feel very fatigued and may experience mood symptoms as well.

cold_feet: How do I know when I'm fully done with menopause?
Dr_Pattimakiel: We can say that you have gone through menopause when it has been one full year without a menstrual period. The average age of menopause is 51 years old, but women may experience this much earlier or later.

Once this happens, we categorize women as postmenopausal, because the ovaries are no longer producing estrogen from this point on. Symptoms may continue to persist long after this happens.

havenot: I can't seem to lose any weight now that I'm in menopause. Do you have any suggestions?
Dr_Pattimakiel: After menopause, it is known that metabolism slows down greatly. We tend to store more fat around the abdominal area.

The most important thing to do is to increase your activity level. It is recommended that you get at least 10,000 steps per day.

Due to the decrease in metabolism, it is also important that you watch your meal portion size, and avoid eating late at night. Isolation exercises and yoga have been very helpful in improving muscle tone, and keeping the weight down.

kkpt: What's the best way to deal with the emotional roller coaster I have been going through? If my husband doesn't divorce or kill me, I would be surprised!
Dr_Pattimakiel: Menopause is a huge change in life that can bring on many different emotional changes, and should not be underestimated. Hot flashes and night sweats can severely interfere with your quality of sleep, making you feel fatigued, more irritable and even affect your memory.

Seeking treatment for your symptoms is going to be the most helpful suggestion. If there is an underlying mood disorder, depression or anxiety issue, there are also medications in the category of SSRI/SNRI which may be useful in treating both hot flashes and mood.

Having other women to talk to would also be very helpful, so you know that you are not the only one going through these changes.

it_is_it_is: What are the symptoms of perimenopause? How do you then know that you've entered menopause?
Dr_Pattimakiel: Some women experience the most bothersome symptoms of perimenopause, even before menopause occurs.

They can have irregular, more infrequent menstrual periods and skip cycles. Some women may have heavier bleeding, but this should always be further evaluated. Many women start to feel the hot flashes and night sweats as well.

We say that you have gone through menopause when it has been one full year without a menstrual period.

Lynn: I am experiencing hair loss. Is this common when going through menopause?
Dr_Pattimakiel: Hormonal fluctuations during menopause may trigger more hair loss.

This may also be due to nutritional deficiencies and other underlying medical conditions which should be further investigated. We recommend vitamin D3 2000 IU daily, and biotin to help with hair loss as well.

mclaypool: What is the best treatment for low libido after a total hysterectomy?
Dr_Pattimakiel: There can be many reasons women may feel low libido. It may be due to avoidance as a result of pain, if you are experiencing vaginal dryness or spasming during intercourse. There could be factors in the relationship and stress which interfere with a woman's desire.

It also may be due to lower testosterone levels, which can be measured. Testosterone replacement has not been FDA approved for women in the United States to treat low libido, although some providers may use it ‘off label.’

It may be natural that after a woman is no longer reproductive, that the initial desire or libido is no longer as strong. The most important thing is that a woman is still able to enjoy sexual intimacy with her partner, and that they keep open lines of communication between each other.

Here is a link to a previous lost libido transcript we hosted earlier this year: http://my.clevelandclinic.org/multimedia/transcripts/1352_let-s-talk-about-sex-and-intimacy-find-your-lost-libido.aspx

belle: Should there be any vaginal bleeding during or after menopause?
Dr_Pattimakiel: No. Any bleeding after menopause is considered abnormal and requires immediate evaluation, to rule out any uterine cancer or other structural abnormality.

schmooze: With all of these bothersome symptoms, I hope there is a light at the end of the tunnel. What are the positives that I can hope for during and after menopause?
Dr_Pattimakiel: Women should embrace this new chapter in their life. It's often a ‘second honeymoon,’ with no worries about contraception. Often women are ‘empty nesters,’ leaving them the freedom to focus on their health and relationship with their partner. Today's postmenopausal woman is a more youthful and vibrant woman, allowing herself to finally be a priority again.

sankers2: Why do you continue to have occasional hot flashes years after menopause?
Dr_Pattimakiel: This occurs because the ovaries are no longer producing estrogen. Sometimes extra adipose (fat tissue) may produce a small amount of estrogen, which may help alleviate some of the symptoms.

It would also be a good idea to make sure nothing else is contributing to your hot flashes, such as an abnormal thyroid function. It is important that you identify your triggers, and learn to avoid them. Some triggers may include spicy food, alcohol, caffeine and stress.


Hormone Therapy for Hot Flashes and Hysterectomy

sherrie: I'm 46 years old, and had a total hysterectomy three years ago. I do not take any hormones. I have been having hot flashes and some panic attacks. I'm afraid to take hormones because of a history of breast cancer in the family. My mother, aunt and great grandmother all had breast cancer. Is there a safe way for me to take hormones? Dr_Pattimakiel: It sounds like you are having very bothersome hot flashes, which are really interfering with the quality of your life. Although I understand your fears of a strong family history of breast cancer, it may not be hereditary.

Estrogen therapy alone may be still a good option for you. Studies have not shown an increased risk of breast cancer in women who were treated with estrogen therapy alone.
I think you would benefit from seeing a women's health specialist to formulate a plan which would be best for you.

nyst: I have been taking Premarin® 0.625 for over two years after my hysterectomy for uterine cancer (stage 1). How do I determine when to stop taking the medication? For the past two weeks I have been out of the medication. I’m waiting for a mail-order pharmacy to deliver it, but I have not experienced any horrendous hot flashes. Is there a possibility I could discontinue the Premarin®? How long is safe to stay on hormone therapy?
Dr_Pattimakiel: There is no time frame for how long someone should be on hormone therapy. It is really dependent on monitoring your symptoms and other medical conditions.

Some women are able to stop hormone therapy if their symptoms improve. If you do, you may need to worry about vaginal dryness. This can be treated with local therapy.
It will be also very important to monitor the status of your bone density, because without estrogen, women are at increased risk for bone thinning.

It should be a continuing discussion that you have with your physician, to make sure that you are on the best and safest therapy for you.

HELP: Hot flashes—do they ever stop? I hate being on Prempro® and risking cancer.
Dr_Pattimakiel: Unfortunately, every woman experiences menopausal symptoms differently. Some women do not experience any hot flashes, while others suffer tremendously. The same is true for how long they may last.

Some women may have a trial off hormone therapy to see if the symptoms have subsided, but many need to restart because they may come back with a vengeance. Again, there is no time limit to how long someone should stay on hormone therapy.

It is important to continuously monitor your therapy and symptoms, and make sure that you are up to date with all your screening tests. As women get older, they may need a lower dose of hormone therapy as well, which can provide the same effects.

rjfp: I had a total hysterectomy at the age of 40 years. My hot flashes were controlled with Premarin®, but I stopped taking it after the publicity over breast cancer. I am now 62 years old, and still get significant hot flashes primarily at night, which interrupts my sleep. What can you suggest for treatment?
Dr_Pattimakiel: If the night sweats are really interfering with the quality of your sleep, you may benefit from restarting a low-dose estrogen-only therapy, depending on your risk factors.

There are other classes of non-hormonal therapy such as low-dose antidepressant medications (SSRIs) and gabapentin, which may be helpful as well.
Other things you could try are behavioral modifications.

Lucille: What are the different types of hormone therapy?
Dr_Pattimakiel: Hormone therapy comes in many different formulations. There are synthetic hormone therapies as well as bio-identical hormone therapies, which are chemically identical to the body's own hormone.

They also come in many different routes of delivery, such as pills, patches, creams, gels, sprays and even a vaginal ring.

It is important that a provider look at your complete medical history and lifestyle to figure out which option would be best for you.

Lynn: What are the common side effects of being on hormone therapy?
Dr_Pattimakiel: People usually tolerate hormone therapy very well. The greatest risk of being on any hormone therapy (including birth control) is the rare risk of developing a blood clot. It is very important that you monitor for any symptoms of pain or swelling in your leg, and notify your physician right away if it occurs. People who are on natural progesterone may feel a little sleepy. Therefore, we recommend taking it at night. Some women may experience some breast tenderness when starting hormone therapy, but this is usually minimal.

mclaypool: I am 45 years old, and had a total hysterectomy one and a half years ago. I am on estradiol patch. In your opinion, is there a preference between the patch and oral hormones? I have issue with the patch coming off during the week.
Dr_Pattimakiel: There are different formulations of the patches that are available, such as the Vivelle-dot® (which may have a stronger adhesive). There are also formulations of gels/creams and sprays. Both oral hormone therapy and transdermal hormone therapy each have a different advantage, depending on your medical history and types of symptoms that you are having. There may be a lower risk of developing DVT (blood clot) on transdermal therapy.

EvansD114: I am 51 years old, and I had a hysterectomy around 25 years ago. I have had hot flashes for the last year or so. I had both ovaries removed one week ago for a large benign cyst. I have had no hot flashes since the surgery, but I have had some nausea since the surgery. Can this nausea be due to the loss of hormones?
Dr_Pattimakiel: Everyone experiences perimenopausal symptoms differently, but nausea is not a typical symptom of perimenopause or due to fluctuation of hormones.
If the symptoms persist, I would recommend further evaluation by your provider.

HOPPERM: I am fibrocystic (active family history) and have been told I cannot go on hormone replacement therapy or use any 'natural' products. What can I do for hot flashes?
Dr_Pattimakiel: You may still be a candidate for different formulations of hormone therapy, depending on your complete medical and family history. You may benefit from further evaluation by a women's health specialist, so that you can be given all of your options in order to make an informed decision for yourself. Please see my previous responses about non-hormonal ways to treat hot flashes.


Compounded Hormone Therapy

nystr: What is your opinion of compounded hormone therapy and can you explain it?
Dr_Pattimakiel: It is very important to distinguish between compounded hormone therapy and FDA approved hormone therapy.

The danger of compounded hormone therapy is even though it is promoted as a more ‘natural’ therapy, it is not regulated. Therefore, there is no safety and consistency in the ingredients used and in the dosing from batch to batch.

There are FDA-approved bio-identical hormone therapies available, which you can discuss with your provider or women's health specialist.


Complementary Therapy and Nutrition

HOPPERM: Does acupuncture help with hot flashes?
Dr_Pattimakiel: Acupuncture has been widely used to help treat many different
Again, the results may vary among women, but I have had many female patients who have experienced good relief of symptoms.

Gert: What are the non-hormonal ways to treat menopause symptoms, and are they as effective?
Dr_Pattimakiel: The non-hormonal and non-pharmacological ways to treat menopausal symptoms include black cohosh (do not take longer than six months), increasing soy in your diet, behavioral techniques, trigger avoidance and even acupuncture.

Women find different levels of relief with these therapies, but some have been found to be effective.

There are also non-hormonal pharmacological treatments, including low-dose antidepressants and a medication called gabapentin, which may be effective in treating symptoms of hot flashes and night sweats.

The ‘gold standard’ of treatment for hot flashes though is hormone therapy.

Msdt21: Would eating too much sugar cause hot flashes/night sweats?
Dr_Pattimakiel: Sugar can be a trigger of hot flashes in some women. I would avoid sugar and see how your symptoms respond.

Msdt21: What foods or vegetables can you eat to curb the hot flashes?
Dr_Pattimakiel: There may be a slight improvement of hot flashes by increasing natural soy products in your diet. Not all women have the enzyme to convert the soy into estrogen. We do not recommend soy supplementation.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Lynn Pattimakiel, MD, is now over. Thank you Dr. Pattimakiel for taking the time to answer our questions today about Menopause ‘There’s Hot — And Then There’s Hot-Flash Hot’.
Dr_Pattimakiel: Thanks for joining us today, and for all the excellent questions that you provided. It was a lot of fun, and I hope that you found it helpful.


Contact Information

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