Tagged Menopause

Exercise May Ease Hot Flashes, Provided It’s Vigorous


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Hot flashes are a lamentable part of reaching middle age for many women. While drug treatments may provide relief, two new studies suggest that the right type of exercise might lessen both the frequency and discomfiting severity of hot flashes by changing how the body regulates its internal temperature.

As estrogen levels drop with the onset of menopause, many women become less adept, physiologically, at dealing with changes to internal and external temperatures. The result, famously, is the hot flash (also known as a hot flush), during which women can feel sudden, overwhelming heat and experience copious sweating, a problem that in some cases can linger for years.

Hormone replacement therapy can effectively combat hot flashes, and antidepressants may also help, though drug treatments have well-established side effects. Weight loss also may lessen hot flashes, but losing weight after menopause is difficult.

So researchers at Liverpool John Moores University in England and other institutions recently began to consider whether exercise might help.

Endurance exercise, after all, improves the body’s ability to regulate temperature, the scientists knew. Athletes, especially those in strenuous sports like distance running and cycling, start to sweat at a lower body temperature than out-of-shape people. Athletes’ blood vessels also carry more blood to the skin surface to release unwanted heat, even when they aren’t exercising.

If exercise had a similar effect on older, out-of-shape women’s internal thermostats, the scientists speculated, it might also lessen the number or the intensity of their hot flashes.

Previous studies examining exercise as a treatment for hot flashes had shown mixed results, the scientists knew. However, many of those experiments had been short term and involved walking or similarly light exercise, which might be too gentle to cause the physiological changes needed to reduce hot flashes.

So for the two new studies, one of which was published in the Journal of Physiology and the other in Menopause (using the same data to examine different aspects of exercise and hot flashes), the researchers decided to look at the effects of slightly more strenuous workouts.

They first recruited 21 menopausal women who did not currently exercise but did experience hot flashes. According to diaries each woman kept for a week at the start of the study, some women were having 100 or more of them each week.

The scientists also measured each woman’s general health, fitness, blood flow to the brain (which affects heat responses) and, most elaborately, ability to respond to heat stress. For that test, researchers fitted the women with suits that almost completely covered their bodies. The suits contained tubes that could be filled with water. By raising the temperature of the water, the scientists could induce hot flashes — which typically occur if an affected woman’s skin grows hot — and also track her body’s general ability to deal with heat stress.

Fourteen of the women then began an exercise program, while seven, who served as controls, did not. (This was a small pilot study, and the researchers allowed the women to choose whether to exercise or not.)

The sessions, all of them supervised by trainers, at first consisted of 30 minutes of moderate jogging or bicycling three times a week. Gradually, the workouts became longer and more intense, until by the end of four months the women were jogging or pedaling four or five times per week for 45 minutes at a pace that definitely caused them to pant and sweat.

They also, in the last of those 16 weeks, kept another diary of their hot flashes.

Then they returned to the lab to repeat the original tests.

The results showed that the exercisers, unsurprisingly, were considerably more aerobically fit now, while the control group’s fitness was unchanged.

More striking, the women who had exercised showed much better ability to regulate their body heat. When they wore the suit filled with warm water, they began to sweat a little earlier and more heavily than they had before, showing that their bodies could generally dissipate heat better.

But at the same time, during an actual hot flash induced by the hot suit, the exercisers perspired less and showed a lower rise in skin temperature than the control group. Their hot flashes were less intense than those of the women who had not worked out.

Probably best of all from the standpoint of the volunteers who had exercised, they turned out to have experienced far fewer hot flashes near the end of the experiment, according to their diaries, with the average frequency declining by more than 60 percent.

These findings strongly suggest that “improvements in fitness with a regular exercise program will have potential benefits on hot flushes,” said Helen Jones, a professor of exercise science at Liverpool John Moores University, who oversaw the new studies.

Precisely how exercise might change a women’s susceptibility to hot flashes is still not completely clear, although the researchers noted that the women who exercised developed better blood flow to the surface of their skin and to their brains during heat stress. That heightened blood flow most likely aided the operations of portions of the brain that regulate body temperature, Dr. Jones said.

The cautionary subtext of this study, though, is that to be effective against hot flashes, exercise probably needs to be sustained and somewhat strenuous, she said. “A leisurely walk for 30 minutes once a week is not going to have the required impact.”

Meet the Super Flasher: Some Menopausal Women Suffer Years of Hot Flashes


Credit Kim Murton

What kind of hot flasher are you?

The hot flash — that sudden feeling of warmth that can leave a woman flushed and drenched in sweat — has long been considered the defining symptom of menopause. But new research shows that the timing and duration of hot flashes can vary significantly from woman to woman, and that women appear to fall evenly into four hot-flash categories.

Some women, called “early onset” hot flashers, begin to experience hot flashes long before menopause. Symptoms can begin five to 10 years before a woman’s last period, but the symptoms stop with the end of the menstrual cycle.

Then there are women who don’t experience their first hot flash until after menopause, the “late onset” hot flasher. And some women fall into a group the researchers called the “lucky few.” Some of these women never experience a single hot flash, whereas others briefly suffer only a few flashes when they stop menstruating.

And then there are the “super flashers.” This unlucky group includes one in four midlife women. The super flasher begins to experience hot flashes relatively early in life, similar to the early onset group. But her unpleasant symptoms continue well past menopause, like those in the late onset group. Her symptoms can last 20 years or more.

The findings come from the Study of Women’s Health Across the Nation, or SWAN, a 22-year-old study that has been tracking the physical, biological and psychological health of 3,302 women from a variety of racial and ethnic backgrounds. The study is being conducted at seven research centers around the country and is paid for by the National Institutes of Health.

“It explodes our typical myth around hot flashes, that they just last for a few years and everyone follows the same pattern,” said Rebecca Thurston, the senior author and a professor of psychiatry and epidemiologist at the University of Pittsburgh. “We may be able to better help women once we know in what category they are more likely to fall.”

That includes women like Lynn Moran, a 70-year-old retired financial planning assistant who lives near Pittsburgh and falls into the “super flasher” category. She remembers having her first hot flash around the age of 47. While the symptoms were subtle at first, soon the hot flashes became more bothersome. “It was enough to wake me up out of a sound sleep,” she said. “I wasn’t sleeping well because they were coming all night long and during the day. I was just miserable.”

Ms. Moran began hormone therapy, which helped but did not eliminate the symptoms. But when medical studies began to show health risks associated with the treatment, her doctor advised her to stop using hormones. She waited another 18 months until she retired, then stopped taking hormones in 2005.

The hot flashes “came back with a vengeance” and haven’t stopped since.

“I still have them. I still laugh about them,” she said, noting that she may experience several hot flashes a day. “I’ll be trying to get ready to go somewhere, curling my hair and have to redo everything and dry my hair again because I’ll be drenched. My makeup will literally run down my face. Here I am, 70 years old, complaining of hot flashes.”

Dr. Thurston notes that understanding variations on hot flashes is important to understanding women’s health in midlife. A 2012 study, published in the journal Obstetrics and Gynecology, suggested that the timing and duration of hot flashes may be an indicator of a woman’s cardiovascular health. The study found that frequent hot flashes were associated with higher cholesterol markers, particularly in thin women.

The latest findings from the SWAN study identified some patterns around the four subsets of women who experienced varying degrees of hot flashes. Women were distributed about equally among the groups, meaning 75 percent of women experienced some degree of hot flashes, while only 25 percent escaped the symptom.

Women in the early onset group were more likely to be white and obese. Women in the late onset group tended to be smokers. The lucky few women who had no hot flashes or only a few were more often Asian women and women in better health. The super flashers were more likely to be African-American, to be in poorer health and to consume alcohol. But the researchers cautioned that while they identified some statistical trends in each group, it’s important to note that each subset of hot flashers included a variety of women representing all races, ethnicities, body weights and health categories. No one factor appeared to determine a woman’s risk for any hot flash category.

For instance, while African-American women were three times as likely to be in the super flashers group, they represented only 40 percent of that group. The remaining 60 percent were white women, some Asian women and other groups.

Dr. Thurston said it is important that doctors understand that 75 percent of women have hot flashes in midlife and that they persist in at least one in four..

“It flies in the face of the traditional wisdom that women have these symptoms for three to five years around the final menstrual period,” she said. “We now know that is patently wrong.”

Think Like a Doctor: Packing on the Pounds

The Challenge: Can you figure out why a 59-year-old woman keeps gaining weight?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a woman who has been gaining weight despite years of work to lose it. Was this, as the patient worried, a result of menopause, or was there something else going on? She was frustrated and aggravated, but should she be worried?

Below I provide much of the information available to the doctor who made the diagnosis. Regular readers may assume that this, like so many of my cases, is the zebra. But is it? The first reader to offer the correct diagnosis, along with the missing piece of data that helped the doctor get there, will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real life case.

The Patient’s Story

“I just can’t seem to lose weight,” the 59-year-old woman said quietly. She’d done everything, she told the young doctor. Weight Watchers. Exercise. She drank more water. She ate more vegetables. She tried eating less fat, then only “good” fat. She kept food diaries, downloaded calorie counters. She’d done it all.

And not only was she not losing weight, these past few years she just kept on gaining. Despite all of her hard work, she’d put on maybe 50 pounds in the past year.

More Than Skin Deep?

She decided to go to Dr. Donald Smith, an endocrinologist at Mount Sinai Hospital in New York. She’d seen the doctor years earlier in a documentary on weight loss surgery on TV. The fact that he was an endocrinologist made him a doubly good choice for her because she worried that the real cause of her weight gain was hormonal.

She first met with the doctor in training who was working with Dr. Smith as part of her endocrinology fellowship. She’d never been skinny, she told the young doctor. But she’d never been heavy like this before, either. She was 5-foot-4, and throughout her 20s and 30s she’d weighed 170 to 180 pounds. It was a comfortable weight for her, easy to maintain. Then, in her mid-40s, weight maintenance was no longer easy and the pounds started to accumulate, slowly at first, then rapidly.

She was considering bariatric surgery, but first she wanted to know, was this just a consequence of menopause? She had thyroid disease and had been on the same dose of medication for years. Could something have happened to her body so that the drug was no longer working for her?

The Patient’s History

Did she have any of the symptoms associated with a low thyroid hormone level, the young doctor queried? Fatigue? Oh yes, these days she always seemed to be tired. Had she seen any changes in her hair or skin? No. Any constipation? No. Do you get cold more easily these days? Never. Indeed, these days she usually felt hot and sweaty.

Any other medical problems, the doctor asked?

Oh sure, she replied promptly. She had high blood pressure and high cholesterol — both well controlled with medications. She also had obstructive sleep apnea, a disorder in which the trachea, the breathing tube connecting the lungs with the nose and mouth, collapses during sleep, causing the sufferer to stop breathing and awaken many times throughout the night. But she had a machine that helped keep her trachea open and used it every night.

In addition, she had low back pain from a place where her spine had become narrow. She had knee pain and carpal tunnel syndrome. She didn’t smoke or drink and had worked as a nurse until the pain in her back, legs and hands forced her to retire early.

Big, Bigger, Biggest

After a quick examination, the young doctor stepped out of the exam room. She returned a few minutes later with Dr. Smith. He looked to be in his mid-60s and had a kind face and friendly smile, just as the patient recalled from the TV show she’d seen him on. The young doctor briefly summarized what she and the patient had talked about. When she finished, Dr. Smith turned to the patient and asked if there was anything she’d like to add.

She thought for a moment. All she could say, really, was that she didn’t understand why she was getting so much bigger. She was gaining weight, but it wasn’t just that. Her legs and feet were huge. She used to have nice ankles, but now you could hardly see them. Her regular doctor, a cardiologist, gave her a diuretic, but it really hadn’t done a thing, she told him.

Not Just the Legs

Dr. Smith leaned over to look at her lower legs a little more closely. They were quite swollen. And yet when he pressed his thumb against the skin there was none of the give he would have expected in such bloated-looking limbs. Usually with swelling from edema, which occurs when extra fluid leaks from the blood vessels into the soft tissues, any firm pressure will leave a deep impression.

The presence of apparent engorgement that doesn’t compress suggested that the patient may have a condition called lymphedema, an accumulation of fluid rich in white blood cells that is normally collected from the tissues and then drained through the tiny vessels of the lymph system. If these vessels somehow become blocked, the fluid backs up and the skin around them becomes thick, inflamed and eventually scarred.

It’s not just my legs, the woman added. It was everything. Maybe this sounded crazy, she told him, but she didn’t feel like she was living in her own body. She’d explained this to many doctors. They’d just encouraged her to lose weight.

Over the years, the patient had been to many doctors. You can review some of the lab results her various doctors had ordered in the two years before she’d come to see Dr. Smith.

Review the patient’s lab results from 2013 here.

2013 Labs

The patient’s labs.

Review the patient’s lab results from 2015 here.

2015 Labs

The patient’s labs.

You can also review the note from her last visit to her regular doctor, a cardiologist, here.

Cardiology Note

The patient’s visit with a cardiologist.

Solving the Mystery

There was one more piece of data that led Dr. Smith — eventually — to the answer. Can you figure out what that missing piece of information might be? And the diagnosis it led to?

Post your answers in the comments section. The first reader to figure out both parts of the puzzle will get a signed copy of my book and that special satisfaction of solving a mystery that my readers know so well.

I’ll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.