Vasomotor Symptoms
Hot Flushes, Night Sweats and Palpitations
These symptoms collectively are referred to as vasomotor symptoms, and they are well-recognised during the menopause transition, with approximately 75% of women experiencing them to varying degrees. However, these symptoms can differ significantly in terms of their frequency, duration, and intensity from one woman to another.
A hot flush is described as a sudden sensation of intense heat in the upper body, including the arms and face. Some women also experience visible reddening of the skin and profuse sweating during hot flushes, which can be particularly distressing when they occur in public spaces and may be accompanied by palpitations.
The exact mechanism behind hot flushes is not fully understood. It is believed that fluctuating oestrogen levels during the perimenopause cause a resetting of the area of the brain responsible for regulating body temperature, known as the hypothalamus. This resetting narrows the normal temperature range, causing women to sweat more readily in response to even minor increases in body temperature, which is the body’s natural way of cooling down. However, this process leads to a subsequent decrease in body temperature, falling below what the brain perceives as normal, resulting in shivering. This on-off cycle is familiar to women who have experienced hot flushes and night sweats.
Hot flushes can affect any woman, but they are often more common in women who smoke.
These symptoms can begin before menstruation ceases but are most frequent in the first year following the final menstrual period. On average, if left untreated, hot flushes can persist for 7-8 years, although many women continue to experience them for decades.
Studies have indicated that women who experience hot flushes face an increased risk of future heart attacks or strokes. Severity of hot flushes appears to be more critical than their frequency or duration in terms of this risk.
Moreover, women who suffer from hot flushes may also experience memory impairment. Several factors contribute to this, including the temporary disruption of blood flow to the brain during a hot flush, sleep disturbances caused by night sweats, and the low mood that can result from these physical symptoms.
What can I do to alleviate symptoms?
Many women find that caffeine, hot drinks, alcohol, and spicy foods can trigger hot flushes.
Smokers tend to experience more severe hot flushes and are at increased risk of heart disease or stroke. For help to quit smoking, visit the NHS website.
Dress in layers and opt for natural, moisture-wicking fabrics such as cotton, linen, silk, wool, and bamboo.
A desk fan at work and a bedside fan at night can help cool your skin. Placing a bottle of frozen water in front of the fan can enhance cooling, especially during the summer months.
Consider using two single duvets or a split-tog duvet, allowing you and your partner to have personalised comfort. Alternatively, switch to sheets and blankets that can be easily added or removed as needed.
Experiencing a hot flush in a public place can increase anxiety, which can exacerbate the symptoms.
Cognitive Behavioural Therapy (CBT), a talking therapy, has been found to benefit women with hot flushes. CBT focuses on the relationship between thoughts, feelings, and behaviour. Remember that each flush is temporary and will pass. If you think CBT might be helpful, you can search for a therapist in your area at https://www.bacp.co.uk/
What treatments are available?
The most effective treatment for symptoms resulting from a lack of oestrogen is oestrogen replacement. NICE guidelines state that for most women, the benefits of HRT outweigh the risks. Oestrogen delivered transdermally through a patch, gel, or spray.
Hormone Replacement Therapy (HRT) is recommended as the first-line treatment for vasomotor symptoms by the National Institute for Health and Care Excellence (NICE) in women with no contraindications to HRT.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are not the first-choice treatment and should not be used to alleviate low mood associated with menopause in women without a depression diagnosis. They are sometimes used in women who cannot use HRT due to contraindications. Studies have shown a reduction in symptoms ranging from 20-50% reduction in hot flushes, but they may have adverse effects on sexual function.
Clonidine, initially developed as a blood pressure medication, has been used for decades to reduce hot flushes but may be associated with side effects such as sleep disturbance, dry mouth, nausea, and fatigue.
Herbal medicines such as black cohosh, dong quai, St. John’s Wort, and evening primrose have shown insufficient evidence, inconclusive results, or no benefit in alleviating hot flushes.
There has been considerable media coverage surrounding the recent MHRA approval of a new treatment option for vasomotor symptoms, such as hot flushes and night sweats. The British Menopause Society (BMS) aims to provide clarity regarding this upcoming treatment choice.
Fezolinetant received MHRA approval on December 14th, and it is expected to be accessible through private prescriptions starting in mid-January 2024. A NICE Technology Appraisal, with its publication date yet to be confirmed, will assess the clinical and cost-effectiveness of fezolinetant. If it receives a positive recommendation, it may become available on the NHS.
Fezolinetant is a Neurokinin 3 receptor antagonist designed to address vasomotor symptoms, which are the most prevalent menopausal symptoms experienced by women. Medications in this category influence changes in brain neurotransmitters that regulate vasomotor symptoms via the Hypothalamo-Pituitary-Ovarian axis. Women with symptoms tend to be more sensitive to fluctuations in these brain neurotransmitters.
For women who cannot or choose not to undergo hormone replacement therapy, this class of medication holds the potential to revolutionize menopause management. It represents an exciting advancement, offering women more options to manage severe vasomotor symptoms, which can significantly impact their quality of life.
The expected cost of this medication is approximately £45-50 per month, although pharmacies may apply variable dispensing fees.
The UK manufacturer is collaborating with the Society for Endocrinology and the “People With” registry to coordinate patient feedback on this new medication. This “real-world data” will complement the existing data from clinical trials, facilitating the assessment of this drug’s potential inclusion in NHS treatments following NICE evaluation.
