Are hot flushes (or flashes) from low estrogen?

If periods every month tell a women that her estrogen level is normal, and if hot flushes are caused by low estrogen levels, how come so many perimenopausal women start having hot flushes when periods are perfect? The answer is that the brain has become used to the young normal estrogen levels and when it has been exposed to the high levels during the perimenopause, it rebels when those levels drop, even to what is normal. What happens with a hot flush is like what a drug addict goes through during withdrawal - a major brain discharge of stress and other hormones. It is this hormonal discharge (along with the flush) that causes the anxious feelings, nausea and chest pain as well as the feeling of heat and the sweating that go with them. So if someone tells a women her flushes are in her head just tell them that "darn tootin" they are!.

I first twigged that I was perimenopausal when I woke abruptly one dark November morning in 1990 feeling MAD! I looked for a cause-my dog and my partner were sleeping soundly, all was quiet in the house and the neighborhood. But my heart was pounding, my legs wouldn't lie still and I was ready to do battle. Then I felt a weak and woozy wave of heat and began to sweat. A day later my period started, and I had no more night sweats until the day before my next period. I had learned an important thing - in the early years of perimenopause, night sweats are a clue that your period is coming (Figure 3).

Another new observation is that women who have increased premenstrual symptoms early in the perimenopause are more likely to have a difficult time with hot flushes at the end of the perimenopause and in the early menopause. That information came from the same Australian study we talked about earlier ^[7]. Perimenopausal premenstrual-like symptoms are caused by high estrogen levels. It makes sense that the brain would react when the high levels drop to normal or become normally low in menopause.

What can women do to help themselves through the rough times in the perimenopause?

The first and most important thing is to realize that, ready or not, this is a time of major change - change in body, even change in concept of one's self ^[8]. A number of years ago I was captured on a National Film Board video "Is it hot in here?" saying I was only 22 times 2 and was looking forward to menopause as a normal phase of life! But, when perimenopause hit me, although my mind said I was okay with it, although I have all the children I ever wanted, and despite my fulfilling job and lots to look forward to, I went through times of real sadness. Losing youth, fertility and even predictable periods is a justifiable reason for feeling blue. It will help women deal with this natural sadness if they can talk with friends, family and perhaps even a counselor about these important and often hidden deep feelings. I also suggest reading a book by Vancouver counselor, Lafern Page, Menopause and Emotions: making sense of feelings when feelings make no sense ^[8]. Your library, book store or health unit can tell you how to get your hands on a copy.

The next and most important thing is for women to take time to care for themselves. A friend of mine and important pioneer in the work of bringing perimenopause information to B.C. women, retired public health nurse, Pat Chadwick, says the first two letters of the word menopause are ME! That means women need to take time out for exercise, meditation, a cup of coffee with a friend, and to say no to more overtime, or continuing to make their 12 year old's lunch. I would also urge women to take a multiple vitamin so they have enough vitamin D (especially important because we can't make enough vitamin D through the slanty northern sunshine exposure we get in B.C. from October through March) and to get at least 1500 mg/day of calcium (which has recently been shown to help with PMS and which also helps sleep, restless legs and other nerve irritability signs).

To help women deal with hot flushes, they can take 400 to 800 IU of vitamin E each day, besides regular exercise, relaxation and slow deep breathing. Recent evidence also says that eating foods made from soy such as soy milk or tofu on a regular basis will decrease hot flushes ^[9].

Most important is what can women do about periods, flooding, cramps and the risk for anaemia? If a woman is regularly soaking over 12 pads or tampons during her whole period, I suggest she take one green iron tablet (34 mg of ferrous gluconate) a day. This can be purchased from the drugstore without a prescription (but be sure to tell your doctor what you are doing). For cramps, as well as to decrease heavy flow, ibuprofen (Advil, Motrin or generic) 200 mg, can be used at the first hint of cramps and two or three times a day during flow. This has been shown to decrease the amount of blood loss. If the cramps are really bad, take two tablets initially and take one more each time you start to get the heavy pelvic feeling that cramps are returning.

If taking ibuprofen (and supplementing with iron) doesn't resolve the perimenopausal flow problems and risk for low blood counts and if bleeding lasts longer than a week or occurs at shorter than 3 week intervals, the family doctor should be seen. Physicians can give you a prescription for progesterone whose job is to prevent estrogen's over-stimulation of the lining of the uterus. Progesterone can also control and even stop flow. It should be taken days 14 to 27 after the first day of flow (Figure 4). It may be necessary to take high doses for a number of months. Unless both the woman and her doctor decide that at least six months of full or high dose cyclic progesterone hasn't helped significantly, there is no need for a referral to a gynecologist, an endometrial biopsy, a D & C or a pelvic ultrasound. Like the rest of perimenopause - this will get better!