More Than Just Feeling Hot: Understanding Hot Flashes

We have all heard about hot flashes and have always associated them with menopause. They’re one of those symptoms we’ve joked about, laughed about and almost come to expect as just part of going through menopause. If you've had a hot flash yourself, you don't need anyone to describe one to you.

Up to 80% of women have hot flashes at some point during perimenopause or menopause. For some, they're just slightly annoying. For others, they show up throughout the day and night and disrupt sleep, work, and daily life. Since there was a good amount to discuss, I have made this into a two part series. In part 1, I discuss what a hot flash actually is, why it happens, and what treatments actually have evidence behind them. In Part 2, I will discuss other conditions and habits that can cause the exact same symptoms, even when menopause isn't the reason.

What Is a Hot Flash?

If you've had a hot flash yourself, you don't need anyone to describe one to you. What is often described is that one minute you’re going about your day and feeling completely fine, and the next, a sudden wave of extremely intense heat rushes up through your chest, neck, and face. Your heart may start beating faster, you may feel flushed or start sweating, and then, once it passes, you may actually feel cold or chilled afterward. If you wake up hot or drenched in sweat at night, that's a hot flash too. That is just called the nighttime version and called a night sweat.

Hot flashes are part of a group of symptoms called vasomotor symptoms, or VMS. That is the medical term we use for hot flashes and night sweats that happen when hormonal changes affect the way your brain regulates your body temperature.

During a hot flash, the blood vessels near your skin open up (dilate) to release heat, and then narrow again (constrict) as your body cools down. During a hot flash, it's mostly your skin that heats up, the temperature at your skin can jump by about 5 degrees Fahrenheit.

But your core body temperature usually stays right around its normal 98.6 °F. In fact, the whole point of a hot flash, the flushing and sweating is your body dumping heat to keep that core temperature steady. So even though you feel like you're burning up, your internal thermostat is actually working hard to keep your core temperature normal.

Why Do Hot Flashes Happen?

A hot flash does not mean that your body isn’t working right. Hot flashes start in a part of the brain called the hypothalamus. I like to think of the hypothalamus as your body's internal thermostat. It's constantly adjusting and working to keep your core temperature steady.

During perimenopause, estrogen is shifting and declining. Estrogen normally helps keep your internal thermostat working regularly. As it shifts and declines, the hypothalamus becomes more sensitive to tiny changes in body temperature. It can mistakenly sense that you're overheating, even when you're not. To try and bring your temperature back down, your blood vessels dilate, you start to sweat, and your heart rate climbs.

Your body is trying to function well with a sensitive thermostat.

How Long Do They Last, and How Long Do They Stick Around?

Hot flashes can start during perimenopause, years before your final period, and for some women they keep going well into the years after menopause. On average, they last about 7 to 10 years. But for some women, they can stick around much longer, a decade or even close to 20 years. A single hot flash typically lasts anywhere from 30 seconds to a few minutes, though some women feel warm for a while afterward.

Every woman is different, and there is no single timeline. Some women get a hot flash every few days. Others get several an hour. Research also shows differences by race: Black women tend to experience hot flashes more often and more severely than Asian and white women.

Why Night Sweats Can Feel Worse

Night sweats are hot flashes that happen while you sleep, and they can feel more intense. Your body temperature naturally dips in the evening as part of your circadian rhythm, and a more sensitive internal thermostat can react strongly to that small shift. A surge of heat can jolt you awake from a deep stage of sleep, and getting back to sleep afterward isn't always easy.

Are Hot Flashes Telling Us Something About Heart Health?

Hot flashes may be more than just an uncomfortable symptom. Research has found that women with persistent, moderate to severe hot flashes may have a higher risk of cardiovascular disease. During a hot flash, the blood vessels near your skin open up (dilate) to release heat, and then narrow again (constrict) as your body cools down. This can cause brief changes in your blood pressure. Researchers think that, over many years, these repeated swings , along with the other changes of menopause may add stress to your blood vessels.

A recent analysis of the SWAN study, (Study of Woman’s Health Across the Nation), followed more than 2,700 women with hot flashes over 20 years. Women who started hormone therapy during perimenopause or early postmenopause had fewer cardiovascular events than women who did not use hormone therapy. This was an observational study, so it cannot prove that hormone therapy was the reason for the lower risk. Women who use hormone therapy may also be more likely to exercise, eat well, receive regular medical care, and have other habits that lower their heart disease risk.

It's important to know this is a link, not proof that hot flashes cause heart disease, and this study does not mean that every woman with hot flashes should take hormone therapy to prevent heart disease. Overall, it adds to what we're learning about the connection between hot flashes, menopause, and cardiovascular health.

Do Lifestyle Changes Make Hot Flashes Better?

Lifestyle habits are less likely to change how often hot flashes happen, but they're still worth prioritizing. Regular exercise, good sleep, nourishing meals, and limiting alcohol support your bone health, heart health, and mood, all of which help you feel better overall during this transition.

Although they are not the root cause, there are a few things that can make hot flashes feel more frequent or more intense, including caffeine, alcohol, spicy food, tight clothing, and poor sleep.

Keeping a simple symptom journal can help you notice your own personal triggers, whether that's a glass of wine, a spicy meal, or a warm bedroom. Cooling your space down, dressing in breathable layers, and using a fan may make a hot flash more comfortable once it starts, even if they don't change how often they occur.

What Can Help

You don't have to just white-knuckle your way through hot flashes. There are several treatments that have good evidence behind them. And if you can't take hormones, or you'd simply rather not, there are other options. Some have stronger evidence than others, and your health history, symptoms, and personal preferences all matter when deciding what makes sense for you.

Menopausal hormone therapy. This is considered the most effective treatment available, and it's endorsed as the first-line option by The Menopause Society. Estrogen, alone or combined with a progestin, works directly on the hormone shifts that drive the problem, and it can reduce how often hot flashes happen and how intense they feel. Hormone therapy also has important benefits for bone health, and we're continuing to learn more about its relationship with cardiovascular health. Hormone therapy comes in different forms, including gels, patches, rings, and pills. The right choice depends on your age, your health history, and your personal preference. You need a provider that can give you all of these choices.

Neurokinin receptor antagonists. These are newer nonhormonal medications that work differently from many of the older medications we use for hot flashes. These medications were designed to target the brain pathway involved in hot flashes. Neurokinin receptor antagonists block some of those signals that make the hypothalamus more sensitive, helping calm the temperature-control system down. Fezolinetant (Veozah) and elinzanetant (Lynkuet) are FDA-approved options for moderate to severe hot flashes and can be especially helpful for women who can't take hormones or prefer a nonhormonal treatment.

SSRIs. Certain antidepressants can also ease hot flashes. The exact way that they work on treating hot flashes isn't fully known but it is felt that these medicines seem to help steady the hypothalamus. They can be a good option for women who can't or don't want to use hormones. Some examples include lower doses of Paxil, Lexapro, and Effexor.

Gabapentin. This medication also acts on the hypothalamus and has shown it can reduce hot flashes. It's a good option if hot flashes are disrupting your sleep and hormone therapy isn't the right fit for you.

Cognitive behavioral therapy (CBT). CBT may not actually decrease the number of hot flashes you have, but it can help change how you respond to them, making them feel less bothersome and easier to manage.

Clinical hypnosis. Clinical hypnosis uses guided relaxation and imagery to help change how your body responds to a hot flash. The Menopause Society recommends it as a nonhormonal option. It can be done with a trained provider or through self-guided audio programs, making it something you can even try at home.

Acupuncture. The research on acupuncture is mixed. Some women absolutely feel that it helps, but when acupuncture has been compared with sham, or "fake," acupuncture in studies, much of the additional benefit disappears. Because of this, The Menopause Society does not currently recommend acupuncture specifically for treating hot flashes. That doesn't mean you can't try it if it's something you're interested in. I just think it's important to be honest about what the research does and doesn't show.

Herbal supplements and OTC remedies. You've probably seen plenty of teas, tinctures, and supplements marketed for hot flash relief. The research on most of them is mixed or simply isn't strong enough to show that they work. "Natural" also doesn't always mean harmless. Supplements can have side effects and interact with medications, so if there's something you're interested in trying, talk with your clinician first.

Staying Open to Your Choices

There are treatments that have strong evidence behind them, treatments where the evidence is more mixed, and plenty of things we are still learning about. We can be evidence-based and we can also be open-minded.

It's also important to recognize that not everything has been studied equally. Large clinical trials are expensive, and prescription medications generally have much more funding behind them because companies are required to do extensive research to bring a new drug to market and there is a financial incentive to invest in that research. Supplements don't always have that same funding or incentive, especially when an ingredient can't easily be patented.

So sometimes when we say there isn't strong evidence for a supplement, medication, or treatment modality, it may partly be because we simply don't have enough good research yet.

At the same time, lack of research doesn't prove that something works. That's where I think we have to find a balance. We can be honest about the evidence we have while staying open to options that haven't been studied as much.

If you're interested in acupuncture, a supplement, meditation, yoga, hypnosis, or another approach you've heard about, I want you to feel comfortable bringing it up. We can talk about what we know, what we don't know, whether there are any risks or interactions with your medications, and whether it makes sense for you to try it.

I usually like to start with treatments that have the strongest evidence as well as the safety data behind them, but that doesn't mean those are your only choices. Some women want to avoid medications altogether. Others are comfortable combining medical treatment with mind-body or complementary approaches. Some simply want to start with the least invasive option and see how they feel.

Most importantly, there isn't one treatment plan that's right for every woman. Your symptoms, health history, comfort level, values, and goals all matter. Find a provider you feel comfortable bringing your questions to and who will really listen. Tell them what you've read about, what you're interested in trying, and even what you're hesitant about. You should feel like you can have an open conversation and work together to come up with a plan that feels right for you.

Putting It All Together

Hot flashes are one of the most common signs of the menopause transition, and they have a biological explanation: hormone shifts making your brain's temperature control center more sensitive than it used to be. The good news is that you have various options for treatment.

However, not every hot flash is caused by hormone shifts and menopause. In Part 2 of this series, we'll cover the other conditions, medications, and habits that can cause the exact same symptoms, and how to tell the difference.