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The Heat is On: Hot Flash Help, Everything you want to know about Menopause

Online Health Chat with Dr. Lynn Pattimakiel

November 4, 2011

Introduction

Cleveland_Clinic_Host: Confused about hormone replacement therapy? Wondering if you really need a yearly mammogram? What health changes can you expect after menopause?

Many women have questions about their health care. Dr. Lynn Pattimakiel, women’s health specialist, gently reminds women that midlife is not only a time of change but also a time of great freedom. Now is the time to ask questions about hot flashes and how to get a good night's sleep; the facts about vitamins, supplements, and antidepressants; using diet and exercise to boost energy; the basics of good bone health; preventing cancer and heart disease; and how to recharge your sex life.

Dr. Lynn Pattimakiel is an internal medicine physician and has an appointment in the interdisciplinary Cleveland Clinic Center for Specialized Women’s Health. Join Dr. Pattimakiel for answers to your questions about general health, the effects of aging, menopause, and current understanding of the role of menopausal hormone therapy.

Cleveland_Clinic_Host: To make an appointment with Dr. Lynn Pattimakiel or any of the specialists in the Center for Specialized Women’s Health at Cleveland Clinic, please call 216.444.4HER or call toll-free at 800.223.2273, ext. 44437. You can also visit us online at www.clevelandclinic.org/womenshealth. Check out Speaking of Women’s Health at www.speakingofwomenshealth.com.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic Women's Health specialist, Dr. Lynn Pattimakiel. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.


Hot Flashes

Toasty: What foods or drinks trigger hot flashes?

Dr__Lynn_Pattimakiel: Common foods that trigger hot flashes are spicy food, caffeine, and warm beverages.

Toasty: When will the hot flashes end?

Dr__Lynn_Pattimakiel: Unfortunately, there is no set time as to how long menopausal hot flashes will last. Every woman experiences menopausal symptoms uniquely. Many women have the worst symptoms even before menopause occurs, during perimenopause. There is really no reason to suffer and tough it out. There are many safe treatment options available that may be right for you.

dixzeland: I have been going through menopause since my early 40s. I have bad osteoporosis and recently, last month, had a subtotal parathyroidectomy for removal of overactive glands. When having a "hot flash," why does my heart rate and blood pressure get high? Is this normal? Thank you.

Dr__Lynn_Pattimakiel: Small fluctuations in blood pressure and heart rate may occur when someone is under increased stress, which is how you may feel during a "hot flash"! But if your blood pressure and heart rate are becoming very elevated, this is not normal, and you should follow-up with your primary care doctor to investigate other causes.

dsquared: Is there any way to cool down without being obvious to those around you?

Dr__Lynn_Pattimakiel: The most important thing is to dress in light layers because it is the fluctuation of ambient temperature that really triggers hot flashes. Also, practice paced abdominal breathing (six to eight slow breaths/minute). Do this for 15 minutes, three times a day, and try this during a hot flash.

Pennie: How long do hot flashes persist without treatment? Is it usually just the first few years?

Dr__Lynn_Pattimakiel: Unfortunately, there is no magic formula to answer this question. People's symptoms vary, even between family members. I hear all the time that their mother breezed through hot flashes but they are really suffering, or vice versa. Many women have the worst symptoms during perimenopause -- five to seven years before menopause actually occurs.

dqsquared: I had cancer and had to have a hysterectomy (TAH) at the age of 41. I was given hormone replacement for the next 10 years. Once I was off the hormones, I went into menopause, and for the last 10 years, I have been having the hot flashes and night sweats. The intensity varies from time to time, but never goes away. What can I do to lessen this? I have not worn a sweater in 10 years and that is depressing.

Dr__Lynn_Pattimakiel: There are many lifestyle modifications that may help relieve symptoms of hot flashes, including identifying and avoiding your triggers. These may include stress, caffeine, alcohol, spicy food, tight clothing, and cigarette smoking. Other tips include:

  • At night, make sure to keep the room cool. Wear light layers of clothing during the day. Exercise daily.
  • Practice slow abdominal breathing (six to eight breaths per minute) for 15 minutes, three times daily.
  • Consider adding soy protein in your diet (40 to 60 mg) daily. We recommend doing this through food rather than supplements.

There are also medications that can be used to help treat hot flashes, including hormone therapy, low-dose SSRIs (antidepressants), and gabapentin.


Night Sweats/Sleeping

tammylb: I have been having some bad hot flashes, especially while I am sleeping. I wake up drenched. What can I do to help prevent this on a nightly basis? I feel cold but as soon as I cover up I am sweating.

Dr__Lynn_Pattimakiel: If you are having hot flashes due to menopause, there are many treatment options available to you, both lifestyle and pharmacologic agents. If the hot flashes are bothering you mostly at night, make sure the room is cool. Sleep in light layers. Avoid using down comforters, because you can bake like an oven. You may try wearing socks to bed, because this may bring down your core body temperature. Try sleeping with a chill pillow. The gold standard of treatment for hot flashes due to menopause is hormone therapy. Check with your doctor if this is right for you.

Toasty: What can I do to get a good night’s sleep?

Dr__Lynn_Pattimakiel:

  • Keep the bedroom cool to prevent night sweats.
  • Make sure to exercise regularly.
  • Avoid caffeine and alcohol at night.
  • Reserve the bed for sleep, and avoid watching television in bed or reading.

monterey: What can you do to help with night sweats?

Dr__Lynn_Pattimakiel: The gold standard to treat moderate to severe night sweats that disturb your sleep is hormone therapy, if you do not have any contraindications.

Of course we always recommend lifestyle modifications first, including getting your weight down, keeping the room cool at night, sleeping with a fan, sleeping in light clothing, and avoiding using a thick down comforter. Also, try wearing socks to bed, which may lower your core body temperature, and get a chill pillow.

Dr__Lynn_Pattimakiel: There are also other non-hormonal medications that are used to help treat hot flashes, including low-dose antidepressants (SSRIs) and gabapentin (an anti-seizure medication).


Weight Changes

rac18327: I am a Healthy Steps to Weight Loss coach and speak with many women who are going through menopause or have already gone through it. Many of them state that as they get older or once they go through this change, weight loss becomes a lot more difficult. I was wondering what truth there is to this and if there are tips for weight loss after menopause that would be helpful for me to discuss with them. Thank you!

Dr__Lynn_Pattimakiel: Unfortunately, this is true for many women. Metabolism slows down as we get older and muscle mass also naturally diminishes. This will slow the rate at which we burn calories and will shift our body composition to more fat. The decrease in estrogen after menopause often shifts weight distribution to around the belly in women. Weight gain is also impacted greatly by lifestyle and genetics.

It is very important to step up activity level and modify our calorie intake, because if we continue to eat as we always have, we are bound to gain weight.

A helpful tip is to avoid eating late at night, because we do not have the opportunity to burn these calories off.

runnergal: Once a woman hits menopause and starts to have weight problems and muscle tone problems, which were previously not concerns prior to menopause, would it be good idea to get hormone levels checked? Thyroid is fine and activity level is very good (runs marathons and does weight training.)

Dr__Lynn_Pattimakiel: Hormone levels are not always necessary to confirm menopause. Natural menopause is defined as one year without a period and can be evident with associated menopausal symptoms. Hormone levels can be useful when patients are on bioidentical hormone therapy to monitor therapy.

whitegoldendiamond: Does weight gain play a role in hot flashes? I have gained weight the last few years and am wondering. Thank you.

Dr__Lynn_Pattimakiel: Getting the weight down will definitely help control hot flashes. Unfortunately, after menopause, this may be more difficult because metabolism will slow down. This means you really need to concentrate on increasing your physical activity and watching your calorie count!

ally7463: I have lost a great amount of weight since entering menopause. Have you ever heard of this?

Dr__Lynn_Pattimakiel: Usually we see women gain weight during menopause because of a slowed metabolism. If you have a lot of unintentional weight loss, make sure to have this further investigated by your PCP. You need to make sure you are updated with all of your screening examinations.


Medications/Hormone Replacement

whitegoldendiamond: I am 51 and starting taking Premarin® in March for hot flashes and low libido. I’m also feeling tired. Is it safe for me to take this? I have had my uterus removed, but not my ovaries. That was done about 11 years ago. Also, does it take a while for the Premarin® to work? I take the lowest dosage, 0.64, a day. It seems like it still does not help that much, somewhat, but not a lot. I’m hoping to hear from you. Thanks from hot flash land!!

Dr__Lynn_Pattimakiel: Sorry to hear that you suffering so much. If you have no contraindications, Premarin® (conjugated estrogens) is an excellent medication to help treat postmenopausal hot flashes. You may only see its maximum effect after four weeks of use. If you are still having symptoms on this medication, talk with your physician to see if you may need a slightly higher dose; but all medication should be monitored. Since you have had a hysterectomy, you only need to be treated with estrogen. There are many different modes of therapy, including pills, patches, and gels. Find out which one is right for you.

pegob: I had a hysterectomy at 23, so have been on estrogen therapy (Premarin®) for the last 35 years. I'm on the lowest dosage, taken every other day, but have been concerned about long-term side effects. At the time I was put on it, there wasn't much information on it. I don't feel good without it. What can you tell me about this?

Dr__Lynn_Pattimakiel: There is no time limit for how long someone should stay on hormone therapy. Your hormones were taken away at a very early age, which normally would not have happened. Therefore it was definitely a good idea to replace your hormones.

Dr__Lynn_Pattimakiel: The average age of menopause is about 51. After the age of 60, metabolism does slow down; therefore, you may need less of the hormone to obtain the same efficacy. The greatest risk of any hormone therapy, including birth control, is the risk of blood clots. Therefore, make sure that your hormone therapy is being monitored actively by your physician. Finding the right dose and mode to deliver the therapy (ex., pill versus patch versus gel) is important to control your symptoms, help protect your bones, and stop vaginal atrophy.

Pennie: Is the use of vaginal estrogen less risky?

Dr__Lynn_Pattimakiel: The use of local vaginal estrogen does not have systemic effects. There may be minimal absorption initially when using this due to the thinning of the vaginal tissue, but with continued use, this improves.

sdolg: I have osteopenia (-1.9 spine, -1.4 hip, slightly worse than two years ago), hot flashes, sleep disturbance, fibrocystic breasts, fibromyalgia, HIV, LMP 08/24/03, and have never been pregnant. My paternal grandmother had breast cancer as well as my aunt. I have had three lumpectomies that were negative. My OB/GYN prescribed Prempro® (third year of taking this medication). My breasts are tender and painful at times, which my OB/GYN says is because I am on HRT. It never happened when I took the pill (BCP). I take Centrum® Silver® (500 mg calcium, 800 IU vitamin D) as well as Citracal® with Magnesium (500 mg calcium, 250 IU vitamin D) and take D3 1000 IUs with the Citracal®. Recently I forgot to add Prempro® to my medication basket and don't know how long I was without it. I didn't suffer any hot flashes or night sweats. Should I be on HRT? Am I at high risk for breast cancer?

Dr__Lynn_Pattimakiel: When looking at your risk factors for breast cancer -- having multiple breast biopsies, dense breasts, never having a child, and increasing age – you may be at increased risk for developing breast cancer.

Most types of breast cancer are not hereditary. Having a first degree relative (sister or mother) that had breast cancer would also increase your risk. If your second degree relatives developed breast cancer at a young age, this also may be a red flag.

The benefit of hormone therapy is that it will help protect your bones from bone thinning and against vaginal dryness. There are other treatment options available as well to help in these areas.

Continuing hormone therapy needs to be an individual decision that you are comfortable with by weighing the risks and benefits of the therapy. You should have this discussion with your primary care doctor and make sure that you are keeping up with your mammograms and clinical breast exams.

Pennie: If menopause is triggered suddenly by chemotherapy for leukemia what is the risk of HRT?

Dr__Lynn_Pattimakiel: This is a very important question, but would be best answered by your physician, who can look at all of your risk factors and medical conditions in order to make the best decision for you.


Bioidentical Hormone Therapy

Torino1969: I have completely gone through menopause and did so fairly easily. But now, a year later, I have started to put on a lot of belly fat even though I work out regularly. I also have occasional hot flashes. I have had some joint pain as well. I know these are all symptoms of menopause. Someone suggested using a natural prednisone cream for 21 days and then off for 7. Is this safe? Do you have any other recommendations? I do not want to take medications and would like to take care of this naturally if possible.

Dr__Lynn_Pattimakiel: Natural progesterone is used in combination with estrogen to treat symptomatic menopausal women. There are bioidentical FDA-approved hormones that can be used to help treat hot flashes. Compounded natural progesterone cream is not effective in protecting the uterus from estrogen’s stimulation and will not protect against uterine cancer.

dcsstudent_1: Do you think bioidentical hormone therapy is a correct treatment for hysterectomy

Dr__Lynn_Pattimakiel: If you have had a hysterectomy and still have your ovaries, you still may not be in menopause. If you are starting to have menopausal symptoms, and are around the average age of menopause, 51, you can get blood work to help confirm. If you are having moderate to severe symptoms of menopause and do not have contraindications, then bioidentical hormones may be an excellent choice for you.

Tess: Does Cleveland Clinic work with bioidentical hormones at all?

Dr__Lynn_Pattimakiel: Yes Cleveland Clinic does prescribe FDA-approved bioidentical hormones for symptomatic women during menopause. This is available in different modes -- patches/creams/gels.


Breast Health

whitegoldendiamond: I had a mammogram in September and all was well. However, I have some leaking out of both breasts that is clear from the nipples if I squeeze the nipples. Just a couple drops of clear liquid. I told my doctor, but he didn't think I needed to do anything as my mammogram was OK. I breast fed both my children. I am 51. They are 25 and 22 now. I am just wondering if that is OK also.

Dr__Lynn_Pattimakiel: Clear discharge from the nipple may be physiologic, but anything that is new for you or out of the ordinary does deserve an initial work up. Discharge that is milky, bloody, or purulent (like pus) does need immediate investigation.


Low Libido

SANDYMOMMA: I am a 38-year-old woman who had cervical cancer at the age of 28 and had a partial hysterectomy then. Three years ago, I had my ovaries removed as well, and because of breast issues, I have not had any hormone therapy at all. I've adjusted to the hot flashes and had some panic attacks at first, but those have gone away as well. I take no medications at all. My biggest issue is my complete lack of sex drive, and by "lack of" I mean NONE! I'm too young to feel this way, but I've have several lumps in the past two years removed from my breasts and the specialist does not want me taking hormones if this is the only issue I have; but it is weighing on my marriage, and I would like to know if you have any alternative suggestions.

Dr__Lynn_Pattimakiel: Low libido is a difficult situation many women go through, which can be disruptive to relationships. It is also a complex situation that has many different factors that may come into play, including stress, your relationship status, pain during intercourse/dryness, the ability to climax, enjoying sexual intercourse once you do.

Sometimes low libido may be due to low testosterone, but in the U.S., we do not yet have FDA- approved testosterone for women. The medication Wellbutrin® (bupropion) (used for depression) has been used off label to help improve libido.

In order to properly diagnose the reason for your low libido, I would recommend that you see a women's health specialist to go into these questions in depth. There is no reason for you or your relationship to suffer.


Other Symptoms

kenyya: Can a "surgical hysterectomy" cause anxiety and severe acid reflux/digestive system problems (swelling in the throat and constipation)?

Dr__Lynn_Pattimakiel: A surgical hysterectomy alone should not result in all of your symptoms. If your ovaries were also removed, you are now in surgical menopause and no longer have the estrogen that your body used to have. This may contribute to the classic symptoms of hot flashes and vaginal dryness. If these hot flashes are distressing and lead to poor sleep, this can definitely contribute to stress, anxiety, irritability and fatigue.

HappyHappy: Does menopause affect your bowels? I had a TAH/BSO in April 2010, and since then, I have had to increase my Colace® dose to three gelcaps/day. I am also using Metamucil® once a day, and it still is difficult to have a formed BM. My BMs are consistently "bunny bullets" and at best only once a day. Prior to the surgery, I had, on average, one to two well-formed BMs each day. I am a vegetarian and I drink at least one to two liters of water every day. I am 54 years old. I’m just not sure if I need to do anything other than what I am doing now.

Dr__Lynn_Pattimakiel: Menopause in itself should not affect your bowel habits. Sometimes after surgery people can develop adhesions/scar tissue, which may contribute to constipation. Other helpful options to keep your bowel movements regular include regular physical exercise and adding a magnesium supplement. You may also try Miralax® which is found over the counter to keep a good bowel regimen.

Flames12: Can menopause be blamed for muscle achiness and stiffness? Can vaginal dryness be reversed after menopause by having more sex? As the years pass after periods cease, do things level off. For instance, brain fogginess, cranky mood swings, etc. Do you recommend over-the-counter sleep aids to get through the sleeplessness and the night sweats?

Dr__Lynn_Pattimakiel: There is that expression that if you don't use it you lose it! So regular sexual intercourse can help with vaginal dryness! But you may also need moisturizers/lubricants. To help improve the vaginal tissue (vaginal atrophy), we recommend local hormone therapy available in cream/tablet or even ring.

Symptoms of menopause may become less severe as time passes, but there is no guarantee. If night sweats improve, this will lead to better, restful sleep and improve the forgetfulness/and brain fog/and mood swings.

Some women do feel better on HT with regard to achiness and stiffness, but hormone therapy is not recommended solely for the treatment of this.

You could try over-the-counter sleep agents, such as melatonin, which may help with your sleep, but there are also non addictive sleeping agents by prescription that may help.


Perimenopause

myera01: A couple of quick questions: 1) I am looking for any tips for dealing with night sweats during perimenopause. 2) I wonder if heavier menstrual flows are normal during perimenopause.

Dr__Lynn_Pattimakiel: During perimenopause, the menstrual cycle may change. It can become irregular (skipped months), lighter, and heavier as well. Depending on how heavy your periods are, for example, if you are overflowing, or are anemic, you may need some other work-up to make sure there is not another reason for heavy periods.

If you are currently sexually active and need birth control, and do not have any contraindications to be on an oral contraceptive pill, this may help with the hot flashes and the heavy menstrual periods. Other tips for night sweats include: keeping the room cool at night, sleeping with a fan on, sleeping in light clothing, avoiding down comforters, trying to sleep with socks on, and sleeping with a chill pillow. If these lifestyle modifications do not work, there are medications that have been used to help treat hot flashes, for example low-dose antidepressants and gabapentin. Talk with your physician to see what is right for you.

smit: What would some of the perimenopause systems (symptoms) be?

Dr__Lynn_Pattimakiel: The symptoms of perimenopause vary between women and include irregular periods (skipped months). They may become lighter/heavier. Some women start to feel hot flashes and night sweats as well. If these disturb sleep and cause stress, sometimes women may feel more emotional/irritable during this transition.


Length

dcsstudent: Does having a hysterectomy prolong menopausal symptoms?

Dr__Lynn_Pattimakiel: Having a hysterectomy should not prolong your menopausal symptoms, but there has been some evidence of going through menopause slightly earlier after a hysterectomy.

frankie: When can you be certain menopause has completed?

Dr__Lynn_Pattimakiel: The definition of menopause is one year without a period. The average age is 51, but can be as early as early 40s to as late as late 50s. After this, you are postmenopausal and this remains life-long. The duration of symptoms of menopause vary, unfortunately, among women.


General Questions

shpachka: I have got a saphena varix. Will it get worse in the future? Do I need treatment? Thank you.

Dr__Lynn_Pattimakiel: This is more a vascular condition and would be best answered by a vascular specialist. Maintaining a low body mass index is imperative to keep your intra-abdominal pressure down and may help with stopping the progression of varices.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Pattimakiel is now over. Thank you again, Dr. Pattimakiel, for taking the time to answer our questions today about the menopause.

Dr__Lynn_Pattimakiel: Thank you very much for your great questions!


More Information

Cleveland_Clinic_Host: To make an appointment with Dr. Lynn Pattimakiel or any of the specialists in the Center for Specialized Women’s Health at Cleveland Clinic, please call 216.444.4HER or call toll-free at 800.223.2273, ext. 44437. You can also visit us online at www.clevelandclinic.org/womenshealth. Check out Speaking of Women’s Health at www.speakingofwomenshealth.com.

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This chat occurred on November 4, 2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.

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