Not Every Hot Flash Means Menopause

In Part 1, More Than Just Feeling Hot: Understanding Hot Flashes, we talked about what a hot flash actually is, why it happens, and what is going on with your body's internal thermostat during perimenopause and menopause. Yet, not every episode of feeling hot, flushed, sweaty, or waking up drenched at night is necessarily menopause.

If you're in your 40s or 50s, it's pretty easy to blame hormones and very often hormones are the reason. However, what if you're years past menopause and your hot flashes suddenly come back? What if you've been doing well on hormone therapy and suddenly start having them again? What if what you're experiencing just doesn't quite fit the typical pattern?

That's when I think we need to look a little deeper rather than automatically assuming it's menopause or that you simply need more estrogen. As with so many things in medicine, we need to look at the whole picture and think about what else could be going on.

This isn't about overreacting or assuming the worst. It's really about not having tunnel vision and assuming that every episode of flushing, sweating, or night sweats has to be related to menopause.

Before we get into some of the other possible causes, I also want to point out that some of them may sound a little scary, and many are very uncommon or even rare. But I believe the more we understand about our health and the different things that can affect it, the better we are able to ask questions, understand our options, and make informed decisions about our care.

Hot Flashes Can Continue Into Postmenopause

I do not want every woman thinking something is wrong with their bodies if they have hot flashes after menopause. Some women continue to have occasional hot flashes well into postmenopause. What we need to give attention to is when your usual pattern changes or there are associated symptoms that were not present before.

If you've continued to have an occasional hot flash over the years, that's one thing. If you haven't had one in five years and suddenly you're waking up drenched every night, that's different. The same is true if you've been doing well on hormone therapy and suddenly your symptoms return. 

Sometimes It Really Is Something You're Eating or Drinking

It's important to look at some of the simple things first. Alcohol is a big one. Alcohol causes blood vessels to widen and can affect the parts of the brain and nervous system involved in temperature regulation. It can also cause flushing, sweating, a faster heartbeat, and headaches which are symptoms that can feel very similar to a hot flash.

Sometimes the timing makes the connection easy to miss. If you have wine with dinner and wake up sweaty several hours later, you may not think the two are related.

Caffeine and spicy foods can also trigger or worsen hot flashes in some women. This doesn't mean everyone needs to stop drinking coffee, eating spicy food, or having an occasional glass of wine. I usually recommend paying attention to your own pattern. Like everything else, what bothers some women does not affect others. I recommend trying to remove one thing for a week or two and seeing what happens.

What About Histamine?

Histamine has gotten a lot of attention lately in the menopause space, especially online.

Histamine is a chemical naturally produced by the body and is also present in certain foods.

In some people, foods that are higher in histamine  including aged cheeses, cured meats, fermented foods, and alcohol may be associated with flushing, headaches, a racing heart, or gastrointestinal symptoms.

The challenging part is that histamine intolerance isn't always straightforward to diagnose, and there isn't one simple blood test that confirms it. I wouldn't recommend jumping immediately into a very restrictive diet. But if you consistently notice symptoms after certain foods, keeping a food and symptom diary can help you identify a pattern.

Could it Be One Of Your Medications?

A surprising number of medications can cause sweating, flushing, or symptoms that feel very similar to a hot flash.

These can include:

• Certain antidepressants, including SSRIs and SNRIs

• Some migraine medications

• Opioid pain medications

• Corticosteroids such as prednisone

• Some blood pressure medications

• Thyroid hormone

• Some asthma medications

• Niacin (not used as much anymore)

• SERMs such as raloxifene and ospemifene

• Tamoxifen, aromatase inhibitors, and other medications that affect estrogen

Something that can be confusing is that some of the SSRIs and SNRIs that are used to treat hot flashes can also cause increased sweating in some people. It is important to look at the timing.

Did your symptoms start shortly after you began a new medication? Did they become worse after the dose changed? I do not recommend stopping a prescription medication on your own, but definitely bring it up with your healthcare provider. 

Night Sweats Can Have Other Causes Too

Night sweats can be caused by a number of things. This seems obvious, but sometimes it can be as simple as a warm bedroom, sleeping under a heavy comforter, or wearing thick pajamas.  If you're repeatedly waking up sweaty, particularly if this is new for you, I want to know what else is going on.

One thing I think we sometimes miss in women is sleep apnea. Sleep apnea can cause night sweats, and women often don't have the classic symptoms we typically associate with it, such as loud snoring or witnessed pauses in breathing. Sleep apnea also becomes more common during and after the menopause transition. One reason may be the decline in estrogen. Estrogen plays a role in helping maintain the tone of the muscles that keep the upper airway open. As estrogen declines, these muscles may become more relaxed and the airway more likely to narrow or collapse during sleep.

Could It Be Your Thyroid?

An overactive thyroid, or hyperthyroidism, can look surprisingly similar to menopause. It can cause heat intolerance, increased sweating, a racing or pounding heart, shakiness, anxiety, and sometimes unexplained weight loss. That's one reason to follow your thyroid values. 

Blood Sugar Can Play a Role

Low blood sugar can cause sweating, shakiness, dizziness, anxiety, weakness, and a racing heart, which feels very similar to a hot flash. Pay attention to whether these episodes tend to happen when you haven't eaten for a long time, after exercise, or if you take medications that can lower your blood sugar.

Could It Be Anxiety or a Panic Attack?

Sometimes it can be hard to tell. Both a hot flash and a panic attack can cause sweating and a pounding heart. A hot flash is usually relatively brief and tends to center around that sudden change in temperature, particularly through the face, neck, and chest.

Although it doesn’t always fit into this clinical picture, a panic attack is more likely to include intense fear or a sense that something bad is happening. You may also experience shortness of breath, chest tightness, trembling, dizziness, or tingling in your hands or feet. A hot flash can make you anxious, and anxiety can make a hot flash feel much worse.

What About Infections?

This isn't where my mind goes first when a woman in midlife tells me she's having hot flashes. But persistent night sweats can sometimes be associated with an infection, particularly when there are other symptoms such as fever, a persistent cough, unexplained weight loss, fatigue, or just generally feeling unwell.

Travel history can also be important because infections such as malaria may need to be considered after travel to certain parts of the world. Sometimes even less obvious infections can cause increased sweating or night sweats.

A Few Less Common Possibilities

There are also medical conditions that can cause flushing or sweating that are much less common. Pheochromocytoma, for example, can cause episodes of sweating along with severe headaches, a pounding heart, and high blood pressure.

Carcinoid syndrome can cause flushing along with symptoms such as diarrhea or wheezing. Certain cancers, including lymphoma, can cause drenching night sweats, typically along with other concerning symptoms such as unexplained fever, weight loss, swollen lymph nodes, or significant fatigue.

I don't mention these because I want women worrying that every night sweat means something serious. These conditions are extremely uncommon. I also don't think we should automatically label every new episode of flushing or sweating in a woman over 40 as menopause.

What If You're Already on Hormone Therapy and Still Having Hot Flashes?

Hormone therapy is the most effective treatment we have for menopause-related hot flashes. But having hot flashes while you're using hormone therapy doesn't automatically mean you need more estrogen. First, I want to know what changed. Are you using your medication consistently? Are you using it correctly? Could there be an absorption issue? Is the dose appropriate? Did hormone therapy ever control your hot flashes?

And most importantly, were you doing well and then suddenly your symptoms came back? If you've been on the same hormone therapy for years, your hot flashes were well controlled, and now you're suddenly waking up drenched at night, I wouldn't automatically increase your estrogen without asking why.

Maybe your hormone therapy does need to be adjusted, but maybe you started a new medication. Maybe your alcohol intake changed. Maybe you're developing thyroid disease or sleep apnea. Maybe you have a viral or bacterial infection. Maybe something else in your health has changed. That's why I think it's important to look at the whole picture rather than simply treating the symptom.

When Should You Get Checked?

I would want to take a closer look if:

• Your hot flashes disappeared for years and suddenly returned

• You develop new, drenching night sweats that are very different from what you've experienced before

• Your symptoms suddenly change despite previously doing well on hormone therapy

• You have a fever or persistent cough

• You're losing weight without trying

• You notice swollen lymph nodes

• You're having persistent diarrhea or wheezing along with flushing

• You're having severe headaches with a pounding heart or very high blood pressure

• You've recently traveled somewhere where certain infections are more common

• Your symptoms began after starting a new medication or changing a dose

Having one of these symptoms doesn't automatically mean something serious is wrong. We just need to rule out other causes besides them being hormonally driven.

So What Does the Workup Look Like?

Usually, we don't need to order every possible test. Your history is often the most helpful place to start. I want to know when the symptoms started, whether anything changed around that time, what medications and supplements you're taking, how you're sleeping, how much alcohol you're drinking, whether you've traveled recently, and whether you're having any other symptoms.

Depending on what we find, it is important to see what recent labs you have had and if none done recently I will likely check your thyroid, blood count, blood sugar, or other targeted labs. If sleep apnea seems possible, a sleep study may be appropriate. If there are symptoms suggesting infection, then the evaluation would be directed toward that.

A simple symptom journal can be surprisingly helpful. When did it happen? What had you eaten or had to drink? Did you take medication beforehand? Were you asleep? Have you exercised? Were you anxious? Did anything else happen at the same time? Sometimes a week or two of paying attention to the pattern tells us a lot.

What If It Really Is Menopause?

Sometimes we look at all of this and end up right back where we started: the hot flashes really are related to menopause. As we talked about in Part 1, there are very effective treatments for menopausal hot flashes.

Hormone therapy remains our most effective treatment when it's appropriate for the individual woman. We also have effective nonhormonal options, including neurokinin receptor antagonists such as fezolinetant and elinzanetant, certain SSRIs and SNRIs, and gabapentin.

Cognitive behavioral therapy and clinical hypnosis are also evidence-based nonhormonal options. The important part is figuring out what we're actually treating.

The Bottom Line

Hot flashes are incredibly common during perimenopause and menopause, and they can continue for years after menopause. I don't want women worrying that every hot flash means something is wrong. I also don't want us to assume that every episode of feeling hot, flushed, sweaty, or waking up drenched at night is automatically menopause.

What matters is your pattern. You need to look at the whole picture. Most of the time, there isn't something scary hiding behind a hot flash. The important thing is to pay attention to what is normal for you. When that changes, it’s important to figure out why.