Two sips of a cool Chardonnay, and suddenly, you feel those prickly sweat droplets forming, just as you sense your face melting off like a Dali painting.

Or you go to bed shivering-a popsicle wrapped in a thermal blanket-only to find yourself awake hours later, skin on fire, longing for the energy to go stand in your freezer.

Most of us know it as the Hot Flash. Deep South matriarchs use the more descriptive: "I'm in my Private Summer."

Hot flashes may be the only effect of menopause for some women, but for serious sufferers, hot flashes can roll one after another and swell to a swooning crescendo. They may last a minute or recur for years.

In light of new findings regarding hormone replacement therapy (HRT), femmes with flashing heat sensors are taking another look at alternatives to HRT, even with its 80 percent success rate.

The day the music died

In early March 2004, the abrupt end of the second phase of the National Institutes of Health (NIH) Women's Health Initiative study indicated additional health problems associated with HRT. The study showed:

• Comparatively higher occurrences of breast cancer in women taking estrogen and progesterone
• An increased incidence of stroke in the estrogen-only phase similar to that discovered in the estrogen and progesterone phase
• No beneficial effects on cardiovascular disease
• A trend toward increased risk of dementia in a subset of the study's population

Burning inside and out

Why hot flashes occur is still a mystery. Estrogen production diminishes as a woman ages. This affects the part of the brain that controls a woman's "thermostat." The hot flash may be due to the brain sensing an increased body temperature.

As her core body temperature rises subtly, leading to skin vasodilation, a light-skinned woman may even appear flushed. The brain releases chemicals that cause blood vessels in the skin to dilate so this heat can be released. The woman's heart rate may speed up as the heat wave starting at her head accelerates through her body.

Sweating, especially through the upper chest, head and back of the neck, is often followed by chills, nausea and even anxiety.

Commonly thought to be the harbinger of menopause, hot flashes are experienced by an estimated 40 to 70 percent of perimenopausal women — those transitioning into menopause.

Pamela D. Berens, MD, associate professor of obstetrics and gynecology at The University of Texas Medical School at Houston, explains that hot flashes are very common in perimenopausal women. "These women may notice them most premenstrually. The peak age group experiencing hot flashes is the early 50s, but there are a number of women on either side of that."

Hot flashes may last from a few months to five years, and rarely, up to 15 years.

When Berens counsels her patients on alternatives to HRT, she considers proven medications. She also investigates for scientific backup when patients report success with herbal products.

Promising prescriptions

SSRIs, selective serotonin re-uptake inhibitors, perform effectively as symptom-relieving substitutes for HRT. SSRIs, originally developed for depression, seem to perform a support task in the brain so that serotonin, a major neurotransmitter in the synapses of the brain, works properly.

"A decent amount of research, most being smaller studies done with breast cancer patients, has found SSRIs help with hot flashes," Berens says. "For instance, a 75 mg dose of Effexor was found effective in 61 percent of patients." Both Effexor (vanlafaxine) and Paxil (paroxetine) are prescribed for hot flashes as effective alternatives to HRT for controlling menopausal symptoms.

Berens says that in recent studies the effectiveness of the seizure medicine Gabapentin is similar to the SSRI medications in controlling hot flashes. The blood pressure medication Clonidine is another alternative, though studies suggest it may be helpful in a smaller percentage of women. She suggests that women who also are experiencing high blood pressure may find this medication helpful on two fronts.

But more research has been conducted on SSRIs. "Given that we have more information on the SSRIs, I'm probably going to start out with Effexor or Paxil if I'm not prescribing hormones," Berens says.

Skin Deep: Topicals

Seems like a good idea-bypass the bloodstream altogether and use a cream version of HRT. Women have been trying it in hopes of changing waning libidos, relieving excessive vaginal dryness because they believe it is a safer delivery method of HRT. The problem is, no one really knows how much HRT is or is not absorbed.

Berens says that because absorption can vary, estrogen and progesterone creams are unreliable. As with oral estrogen, if the woman still has a uterus, she needs progesterone along with estrogen to prevent cancer. "With estrogen cream, if she doesn't absorb much, it's probably not going to hurt her. But if she absorbs the estrogen, she's going to have the same side effects that she'd have with other forms of estrogen.

" With progesterone cream, I can't predict the absorption is going to be enough to protect her from endometrial cancer or cancer of the uterus."

A Sizzle from Herbals

Of products that contain isoflavones such as soy and red clover, "The data are not very optimistic," Berens says.

Proponents of isoflavones say they promote estrogen balance and remedy menopausal symptoms from hot flashes and night sweats to hair loss and thinning of vaginal tissue. Berens says that in trials, they performed only slightly better than placebos.

Placebos perform in the 20 to 30 percent range in most studies. "In small studies, when a substance performs only slightly better than placebo, you can't really say it is more effective," she explains.

When tested against the placebo group, Berens recalled that black cohosh performed a little better than soy and red clover.

Another product from which Berens' patients have said they benefited is evening primrose oil. "There's really no data to suggest that's effective." She mentions that while products like vitamin E, soy, red clover, and evening primrose oil are not particularly dangerous, "I just don't know that they are worth the money."

Berens did point out other herbal products that may be dangerous and should be avoided: dong quai and ginseng. "They don't seem to work. There are complications and a potential for drug interaction, especially in women using blood thinners. Just because a product is herbal doesn't mean it's safe."

Woman wanting to check on the alternatives can click on the North American Menopause Society (www.menopause.org).

Is it something else?

Berens says women who have taken medications without improvement of hot flashes should ask their physicians to look for other causes, including thyroid disease or, rarely, cancer.

Last Updated: 4-15-2004

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