In the middle of a meeting a flush of heat creeps into the face and it’s clear it’s the start of a hot flash. For some, hot flashes, also called vasomotor symptoms, are mild annoyances, while for others hot flashes cause them to break out in a sweat and then experience terrible chills. Most women, 80%, will experience hot flashes as they reach perimenopause, and they can last anywhere from seven to 10 years.
Often women suffer with hot flashes and do not seek help. But there are several treatment options available that work to reduce hot flashes, including a newly FDA approved treatment Veozah (fezolinetant). While many might think that hot flashes are simply part of being a woman, they are linked to serious health conditions.
Why women get hot flashes
Estrogen helps regulate body temperature and when those levels dip, changes occur.
“Our temperature control happens in the thermal regulatory zone in the brain and essentially there’s a number of mechanisms that keep the thermal regulatory zone functioning and one of them are these neurons, KNDy neurons, NK 3 neurons,” Dr. Lauren Streicher, a professor at Northwestern University, and host of “Dr. Streicher’s Inside Information: The Menopause Podcast,” tells TODAY.com. “One of the pathways that controls the KNDy neurons is estrogen. So, when you lose your estrogen, you lost that control factor.”
When estrogen drops, the KNDy neurons “become hypertrophic” and “go into overdrive.” They stop working as well and fail to regulate body temperature correctly. Though there are multiple pathways that contribute to body temperature, which could explain why some do not experience hot flashes, Streicher says.
3 treatments for hot flashes
“Hot flashes are associated with cardiovascular disease, with Alzheimer’s, with bone lost,” Streicher says. “It’s not just that lack of estrogen but it’s the hot flashes themselves (that contribute).”
Treating hot flashes might make women more comfortable and less likely to experience other health issues. Streicher shares data-backed therapies that work for easing hot flashes:
Estrogen
“Estrogen is the first line drug. It has been around a long time. We know it’s safe. We know it’s effective,” Streicher says. “We know it has benefits beyond just reducing hot flashes.”
When people start taking estrogen to treat hot flashes — or other menopause symptoms — it’s something they likely need to take for life, she adds. With hot flashes, estrogen works by binding to the KNDy neurons “and gets them regulated again.”
Estrogen also offers loads of other benefits, including stronger bones, potentially less cognitive decline, bolstered cardiovascular function and better vaginal health, she says.
However, many people are afraid to take estrogen because they believe it increases the risk of breast cancer. 20 years ago, a study published by the NIH Women's Health Initiative (WHI) looked at the role hormone replacement therapy (HRT) plays in preventing disease in postmenopausal women 60 and older. The research showed the treatment increased some health problems, including breast cancer. These results scared women away from taking hormones. Studies following WHI participants over time have found HRT is safe for many. TODAY's Maria Shriver spoke to Dr. Janine Austin Clayton, director of the NIH Office of Research on Women's Health in a segment that aired on May 17.
“There’s a lot of new evidence... Discussions like we’re having are the right way for us to get as many women as possible,” she told Shriver. “I understand that this led to fears about menopausal hormone therapy... We now know for women close to the menopausal transition that hormone therapy can be safe and effective for relieving menopausal symptoms. The benefits can outweigh the risks.”
Streicher agrees that most people can take estrogen without harming their health.
“We know that it not only doesn’t increase the risk of breast cancer, but it appears to decrease the risk of breast cancer about 18% and decrease all causes of mortality by 30%,” Streicher says. “But the message isn’t getting out there.”
She adds that she’s not surprised that women fear taking estrogen because they’re receiving “misinformation.”
“The majority of the people if you ask them … ‘Is estrogen safe or is estrogen going to increase the risk of breast cancer?’ They’re going to say it increases your risk of breast cancer,” she says. “That message is still prevalent even though it’s misinformation.”
According to the FDA, there are people who cannot take estrogen to manage their menopause symptoms and they include people who have:
- Certain cancers, such as breast cancer
- A history of blood clots
- Heart attack or stroke
- Vaginal bleeding
- Liver disease
Fezolinetant
Fezolinetant also works on the KNDy neurons, much like estrogen.
“It tricks the KNDy neurons into thinking that there’s estrogen binding to these KNDy receptors,” Streicher says.
Right now, doctors only have 52 months of data on this new treatment. Yet, it seems to be almost as effective as taking estrogen.
“They may have up to an 80% reduction in hot flashes, which is essentially as good as taking estrogen,” Streicher says. “It is a welcome option for women who either truly can’t take estrogen or have chosen not to.”
She adds that it doesn’t seem to have any intolerable side effects either.
“The side effect profile was really very minimal,” Streicher says.
According to the FDA, the side effects include:
- Stomach pain
- Diarrhea
- Insomnia
- Back pain
- Hot flashes
- Liver injury
"If you have someone who has liver disease you probably don't want to go with fezolinetant," Streicher says.
S-equol
S-equol is an over-the-counter supplement that uses a metabolite of soy to manage hot flashes. According to a paper in the journal Current Developments in Nutrition, only 20-30% of the U.S. population produce equol so it’s not a benefit that occurs naturally for most people.
“Not everybody is generally able to metabolize soy, which is why (eating) soy doesn’t work for everyone,” Streicher says. “S-equol would be the over-the-counter supplement or botanical, which is worth giving a try for women — especially if they’re having mild hot flashes.”
Streicher says, for many, S-equol just doesn't work as well in tampering the hot flashes. People with moderate to severe hot flashes — hot flashes that range from taking layers of clothes off to sweating profusely then becoming “freezing cold”— might not notice a change from taking S-equol.
“If someone’s having moderate to severe (hot flashes) it might cut it a little bit but it’s not going to eliminate them in the same way as estrogen or fezolinetant,” Streicher says.
CORRECTION (May 19, 2023 at 8:58 p.m. ET): An earlier version of this article misstated the goal of the NIH Women's Health Initiative study. It studied the role hormone replacement therapy plays in disease prevention in women, not the symptoms or effects of menopause.