Help! I’m in Hot Flash Hell!

Disclaimer:  This information is not a substitute for medical care.  Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your provider before starting new treatments, therapies, or health routines.

There’s nothing like the frustration that comes with an untimely hot flash, whether you’re in the frozen section of the grocery store stripping off your sweatshirt and sticking your head in a freezer, or you’re in the middle of trying to get frisky with your cutie and suddenly announcing “Stop touching me!  I’m too hot!”

And what about that gross feeling of waking up in the middle of the night in the soup of your own clammy sweat? Augh.

Hot flashes and night sweats are common side effects of cancer treatment (5).  Although hot flashes themselves are not unsafe or unhealthy, they can be extremely disruptive and distressing.  The good news is that there are options available to help you find relief.

 

Why am I suddenly experiencing these symptoms?

During the natural menopause transition, hot flashes are a sign of decreasing levels of estrogen.  But for young survivors, a menopausal hormonal state (read: low estrogen levels) can be artificially induced by cancer treatments.  Most of our estrogen is made by our ovaries, and this estrogen production can slow or stop in response to certain types of chemotherapy or radiation, or if both ovaries are surgically removed.  Also, endocrine treatments (such as tamoxifen, aromatase inhibitors, and ovarian suppression) either reduce the amount of circulating estrogen or disrupt its effects.

No matter which treatment is the culprit, the impact is the same – menopausal symptoms, including hot flashes.  And unlike the gradual decline of hormone levels during natural menopause, the sudden and drastic drop in estrogen from these treatments can mean worse symptoms (3,5).

 

What does estrogen have to do with how hot I’m feeling?

Honestly, the exact mechanism of hot flashes is still somewhat unknown (6).  However, we do know that estrogen impacts the hypothalamus, a part of the brain responsible for temperature regulation (6).  Fluctuating levels of estrogen seem to confuse this regulation process, with lower levels narrowing the tolerance our bodies have for temperature changes.  This causes an exaggerated cooling response to occur even with only small increases in body temperature (7).  Blood flow and vasodilation (expansion of small blood vessels) leads to visibly flushed skin and an increase in skin temperature (3), which can be accompanied by sweating.

The sensation often starts in the chest and neck and radiates out.  Some people also report a racing heart or palpitations, as well as transient feelings of anxiety or uneasiness (6,7).  Episodes can last several minutes, and may be followed by an immediate sensation of feeling cold or chilled.  This makes sense, because these physiological changes really do successfully decrease your core body temperature (3,7)!

 

I’m so miserable!  What can I do?  

Depending on their severity and frequency, hot flashes and night sweats can really impact your quality of life.  The suddenness and unpredictability of episodes can lead to embarrassment and discomfort.  They may disrupt your sleep and contribute to daytime fatigue, which can have a snowball effect on your energy level, mood, and even your libido. Your relationship might be affected, if the warmth from cuddling and touch is a trigger. Not to mention that it’s hard to feel sexy when you’re experiencing a symptom associated with a life change that isn’t supposed to happen for another couple of decades (although, plenty of women are sporting their sexy selves after menopause, trust me!).

Management options can be distilled into a few different categories: behavioral and lifestyle modifications, prescription treatments, and complementary and alternative therapies.  Some interventions are better supported by evidence than others.  Most available studies have looked at women without cancer who are going through natural menopause, and there is less known about how to manage hot flashes in cancer and AYA populations.

Guidelines are available from several trusted organizations (2,5,8), but there is still not complete agreement among experts on which interventions are considered appropriate and worthwhile options for survivors. This makes it extra important that you talk with your provider about what is right for you.

 

Behavioral and Lifestyle Management

Avoid your personal triggers.  Some people have identifiable patterns to their hot flashes.  Keeping a hot flash diary can help you identify your personal triggers (6).  For example, you may find that alcohol, spicy foods, hot beverages, or caffeine significantly worsen your hot flashes.  If so, you can feel better by steering clear of them.

Stop smoking.  Studies show that women who smoke have more severe hot flashes (5,6,7).

Find ways to manage stress. Studies have found that stress and anxiety can impact hot flashes (6,7).  Engaging in relaxation techniques like yoga, massage, meditation, and guided imagery may minimize these emotional triggers.

Aim for a healthy weight.  Research shows that being overweight is associated with hot flashes, and that weight loss can reduce them (5,6,7).

Exercise.  While physical activity may not directly decrease hot flashes (and vigorous exercise might actually trigger them by increasing your core body temperature (6)), exercise may provide relief indirectly by improving sleep, promoting a healthy weight, and reducing stress (2,5).

Be prepared. There are also things you can do that may not prevent hot flashes from occurring, but can help you deal with them when they do (6,7).  Examples include dressing in layers, keeping cold water nearby to drink, strategically placing fans where you spend most of your time (which can include stashing a handheld one in your car or your bag), sleeping with a fan, using layered bedding, and keeping clean sheets by the bedside if you wake up with night sweats.

 

Prescription Medications

The most studied interventions for hot flashes are prescription medications.  These include hormonal and non-hormonal pharmacologic options.  If your hot flashes are harsh enough that they are significantly impacting your life, a prescription medicine may be appropriate for you.

Hormone Therapy

The most effective treatment for menopausal hot flashes in the general population and in cancer survivors is hormone therapy (5,6).  Young women who experience early menopause due to cancer treatment may be recommended to replace their hormone levels by taking hormonal oral contraceptives or hormone therapy until they reach the average age of natural menopause (about 51) (5,6), which typically relieves hot flashes.

However, if you have had a cancer that is hormone-sensitive, these medicines are not recommended (5,7).  Other non-cancer considerations for avoiding hormone therapies include cardiovascular disease, history of blood clots or stroke, and being a smoker (5,6).  Talk with your provider about the risks and benefits of taking hormones for your symptoms.

Non-Hormonal Prescription Medications

For women who do not wish to take hormones or who are recommended to avoid hormone therapy, there are non-hormonal prescription medications that have also been found effective for hot flashes.

Low-dose antidepressants.  Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSRIs/SNRIs) have been studied in both cancer and non-cancer populations for treatment of hot flashes (5).  While paroxetine is the only SSRI/SNRI that is FDA approved for this purpose, it should not be used in women who are also taking tamoxifen (5). Venlafaxine is commonly recommended for survivors (2,5).

Gabapentin.  This neurologic/anti-seizure medicine has also been studied and found to reduce hot flashes in cancer populations (5,7).  It is sometimes prescribed to treat peripheral neuropathies from chemo, so if you are experiencing both bothersome side effects, taking it may kill two birds with one stone!  Because this medication can cause sleepiness or sedation, taking it at night can help mitigate this side effect (5) while also reducing nighttime hot flashes (7).

Clonidine. This high blood pressure medicine has been found to improve hot flashes in breast cancer survivors, including women taking tamoxifen (5,8). Although not as often used as the other prescription medicines (7), it may be an option for you.

All prescription medicines have potential adverse side effects that do not make them right for everyone (7), so talk with your provider about where to start.  Also, if one medicine doesn’t improve your symptoms, changing to a different one could help.

 

Complementary and Alternative Medicines (CAMs)

Many people prefer natural methods of managing hot flashes and look for alternatives to prescription medicines. CAMs encompass a wide variety of interventions, from herbs and supplements to integrative and mind-body therapies.  Unfortunately, a lot of the CAMs used for hot flashes have not been subjected to rigorous scientific studies, making it difficult to draw conclusions regarding safety and efficacy.  A great resource for more in-depth information regarding the role of CAMs in treating menopausal symptoms can be found at the National Center for Complementary and Integrative Health (NCCIH) website (4).

Non-Prescription Vitamins, Supplements, and Herbal Remedies

Examples of over-the-counter (OTC) vitamins, dietary supplements, and herbal treatments sometimes used for hot flashes include: botanicals (such as maca and evening primrose), phytoestrogens (such as soy and isoflavones), vitamin E, flaxseed oil, St. John’s wort, Chinese herbal remedies, and black cohosh (5,6,7).  The general lack of regulation and oversight of these products calls into question their quality, and many have not been studied well enough to understand their true effectiveness or possible harms (especially in people with a history of cancer), which can include unknown interactions or toxicities.  Due to such concerns, experts typically caution against these alternative options (2,5,6,7).

Also, when it comes to weighing risks and benefits, not all of these options are created equal.  Some may have a relatively a low likelihood of harm (like low-dose vitamin E7, for example), while others may have potentially severe toxicities or adverse effects (such as black cohosh (5)).  Before trying any OTC remedies, seek the guidance of your provider.

Integrative Therapies

Several mind-body therapies have shown some promise in small studies and may be beneficial in relieving hot flashes.  These include cognitive-behavioral therapies (CBT), mindfulness-based stress reduction (MBSR), paced breathing exercises, acupuncture, clinical hypnosis, and yoga (5,6,7).

Unlike the safety concerns associated with many supplements and herbal treatments, there appears to be little if any risk related to participating in mind-body integrative therapies (4), which may make them better alternatives to explore.  However, more high-quality research is still needed before many of these options become standard-of-care.

 

The Bottom Line

You are not alone!  Hot flashes are a part of the cancer experience for many AYAs, but you don’t have to accept feeling miserable.  Report your symptoms to your care team and ask for help creating an individualized plan for managing them.  It may take a combination of some of the above options, as well as a few different tries to find interventions that work.

If your ovarian function resumes when you are done with treatment, your hot flashes may resolve.  However, treatment can cause permanent early menopause.  If this is your situation, the guidance of an expert can help you deal with menopausal symptoms.  Ask your provider for a referral to a specialist who is familiar with the needs of young women facing early menopause, or use the “Find a Menopause Practitioner” search on the North American Menopause Society’s website to locate someone in your area.

 

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A Day at the Beach: The Emotional Toll of Hot Flashes

On a personal note, I will say that my years (six and counting) of treatment-induced hot flashes have made my Wisconsin winters much more bearable!  And my supportive husband has been well-trained to react to my cues; the minute I begin the process of de-layering, he holds out his arms to catch my purse and whatever articles of clothing I’m tearing off, ready to fan me with a piece of junk mail or a magazine or whatever happens to be available (I think potato chip bags have been used).

But all joking aside, these constant hot flashes are not only super annoying; they are also a persistent reminder of my cancer, and they have a way of making me feel older than I am.  It’s sort of like I’m watching all my 30-something friends live typical 30-something lives, while I’m on the sideline in my aging body.  Where did my 30-something life go!?  And it doesn’t help when well-meaning older women see me in the middle of a heat wave and exclaim, “Oh honey, you’re too young for that!”

Believe me, I’m aware.

Sometimes when I have a hot flash, I try to imagine myself at the beach, with the sun on my skin.  Those warm golden rays…scalding my face.  I have also heard that we could try to think about hot flashes as power surges (1), instead.  It’s an interesting twist in perspective.  Can I challenge myself to think of that swell of heat rising within me as strength, rather than suffocation?  Can I somehow harness that power for good?  Can I use it as a reminder to recenter myself in the present moment? Can I use it to prove to myself that I am here? Because I am still here.

And I guess, each day that I am here to experience the ragingly intense wrath of a hot flash means that I am also still here to experience and be grateful for all of the good in my life, too.  Like ice cream cake.  And my new, insane tolerance of those frigid winds coming off the beautiful Lake Michigan.  And the blessed human who invented my battery-operated fan necklace.  Because let’s be honest; that’s just genius!

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References:

1. Foley, S., Kope, S., & Sugrue, D. (2012). Sex matters for women: A complete guide to taking care of your sexual self (2nd ed.). Guilford Press.
2. Kaplan, M., Ginex, P. K., Michaud, L. B., Fernández-Ortega, P., Leibelt, J., Mahon, S., Rapoport, B. L., Robinson, V., Maloney, C., Moriarty, K. A., Vrabel, M., & Morgan, R. L. (2020). ONS guidelines™ for cancer treatment-related hot flashes in women with breast cancer and men with prostate cancer. Oncology Nursing Forum, 47(4), 374–399. https://doi.org/10.1188/20.ONF.374-399
3. Kelly, L. (2020). The menopause transition. In D. M. Schadewald, U. A. Pritham, E. Q. Younkin, M. S. Davis, & C. Juve (Eds.), Women’s health: A primary care clinical guide (pp. 410-443). Pearson Education, Inc.
4. National Center for Complementary and Integrative Health. (2017). Menopausal symptoms: In depth. https://www.nccih.nih.gov/health/menopausal-symptoms-in-depth
5. National Comprehensive Cancer Network. (2020, July 14). Survivorship. NCCN Clinical Practice Guidelines in Oncology. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf
6. North American Menopause Society. (2015). The menopause guidebook (8th ed.).
7. Santen, R. J., Loprinzi, C. L., & Casper, R. F. (2020, April 27). Menopausal hot flashes. UpToDate. https://www.uptodate.com/contents/menopausal-hot-flashes?search=vasomotor%20symptoms&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
8. Shifren, J. L., Gass, M. L. S., Kagan, R., Kaunitz, A. M., Liu, J. H., Pinkerton, J. A. V., Schnatz, P. F., Stuenkel, C. A., Allam, S. H., Allen, R. H., Bachmann, G. A., Merz, C. N. B., Bergfeld, W. F., Block, J. A., Clarkson, T. B., Clayton, J. A., Cwiak, C., Davis, S. R., Diab, D., … Schiff, I. (2014). The North American Menopause Society recommendations for clinical care of midlife women. Menopause, 21(10), 1038–1062. https://doi.org/10.1097/gme.0000000000000319