Blushing & Flushing

Flushing at the menopause
Most women experience flushes around the menopause. They can be the earliest sign, so you can have them while your periods are still quite regular. A survey showed that 41% of women whose periods were still regular, but who were over the age of 39, had flushes. They usually go on for 2 –3 years, but 1 in 4 women has them for 5 years, and an unlucky 1 in 20 has them for the rest of their lives.

A flush is an unpleasant sensation of heat which begins in the face, head or chest. Often, there is sweating, visible redness of the skin, palpitations and a feeling of weakness. It usually passes after 1 –2 minutes, leaving a feeling of coldness. Some women have just the flush without the sweating, while others sweat profusely, but hardly flush. Flushes may occur frequently, even several times an hour, or just occasionally. Some women find that any slightly stressful situation will bring on a flush, or that flushes are more likely to occur when they are warm (e.g. in bed, in an overheated room, on holiday in a warm place). The flushes and sweats disturb sleep – some women wake covered in sweat – and this results in lethargy and irritability during the day.

Common-sense ways to help menopausal flushing. Remember that the flush may not be as noticeable as you think. You may be very aware of sweat on your forehead, but other people may not notice.

Wear suitable clothing . Avoid clothes made from synthetic fibres (acrylic, polyester, nylon) and clothes that will show sweat (such as plain-coloured silk shirts). Instead, choose natural fibres that will absorb and hide sweat (e.g. cotton T-shirts). A cotton bra (such as a sports bra) will absorb sweat better than a nylon one. Wear several layers of light clothing, instead of one thick item, so you can easily peel something off.

Avoid trigger foods and drinks. Alcohol, coffee and spicy foods can provoke flushes.

Keep your bedroom cool. Buy a summer-weight duvet and use it all year, or use sheets and a blanket. Choose pure cotton sheets.

Take exercise. Some research suggests that regular exercise reduces menopausal flushes.

Stop smoking and lose weight. The more you smoke and the heavier you are, the greater the likelihood of troublesome flushes (Obstetrics and Gynecology 2003;101:264 –72).

Increase your intake of plant oestrogens . Some fruits and vegetables contain oestrogen-like substances known as ‘phytoestrogens’.

Foods that contain phytoestrogens
Vegetables Alfalfa Broccoli Carrots French and green beans Peas Fennel Beans and pulses Soy beans Tofu and miso (both made from soya) Lentils Herbs Parsley Sage Garlic	Fresh fruit Apples Cherries Dates Pomegranates Seeds and grains Linseed Sesame seed Oats Rye Wheat Other Breads containing soya and linseed Liquorice

However, not enough research has been done on phytoestrogens, so we do not know exactly what they do, but it is possible that eating these foods could help menopausal symptoms such as flushing. Phytoestrogens are very much weaker than human oestrogens, so it is unlikely that they would deal with really troublesome flushing. You might find they help a bit.

The easiest way to take phytoestrogens is to add a pint of soya milk to your daily diet, or to switch to a soya- and linseed-containing bread (available from supermarkets).

Some women find that taking extra phytoestrogens makes their flushes worse. This could be because menopausal women still have some oestrogen, made from other hormones (androgens); the phytoestrogens might interfere with this conversion process.

Herbal remedies and vitamins are heavily promoted to menopausal women, but there is no good scientific evidence that they are effective.

• Black cohosh, which you can buy as tablets from health food stores, is a plant from the buttercup family, Cimicifuga racemosa, native to North America. A German study in the 1980s suggested that it can help menopausal symptoms such as sweating and flushes (Therapeuticon 1987;1:23 –31), but a more recent study showed no effect (Journal of Clinical Oncology 2001;19:2739 –45). It can cause gut symptoms, headache, dizziness and serious liver damage (UK Committee on Safety of Medicines, October 2004).
• Dong quai is a Chinese plant, Angelica sinensis. A study gave it to some menopausal women, and gave others a dummy tablet. There was no difference in effect between dong quai and the dummy tablet (Fertility and Sterility 1997;68:981 –6). It can act like a blood thinner, so you should avoid it if you are taking anticoagulants, aspirin or similar drugs.
• Evening primrose oil was tested in a study in which some women were given dummy capsules and some were given the primrose oil. There was no difference in flushes and night sweats between the dummy capsules and the evening primrose oil (British Medical Journal 1994;308:501 –3).
• Red clover is claimed to relieve the symptoms of the menopause, but good evidence for any effect is lacking. Some studies have shown no effect at all. Other studies claim to show an effect, but were flawed so cannot be relied on (Menopause 2001:8:333 –7). It can act like a blood thinner, so you should avoid it if you are taking anticoagulants, aspirin or similar drugs.
• Ginseng is a herb from China and Korea. In a study, 384 women who had menopause symptoms were given either ginseng or a dummy tablet for 4 months. There was no difference between the effects of ginseng and the dummy tablet (International Journal of Clinical Pharmacology Research 1999;19:89–99). Ginseng can have serious side effects in some people.
• Vitamin E is a popular ‘natural’ treatment. The only proper scientific study found it reduced the number of flushes by just one per day, which was no better than dummy capsules (Journal of Clinical Oncology 1998;16:495 –500).
• Sage is sometimes recommended, although it has not been assessed scientifically. It is taken by infusing some sage leaves in boiling water.

What your doctor can do
Hormone replacement therapy (HRT) is the most effective treatment for menopausal flushing. It consists of oestrogen and (unless you have had a hysterectomy) a daily dose of progesterone for 14 days of the month. It may be a few weeks before the flushes disappear. However, HRT can increase your risk of breast cancer and stroke, so you should take it only if your flushes (or other menopausal symptoms) are intolerable, and not long term. Unfortunately, when you stop taking HRT, the flushes will probably return.

Tibolone is a hormone drug that is being investigated as a treatment for menopausal flushes. It is not yet clear whether it increases the risk of breast cancer. It does not reduce the number of flushes that you experience, but they are much less severe (British Journal of Obstetrics and Gynaecology 2005;112:228 –33).

Paroxetine and venlafaxine are drugs that can help if you prefer not to take HRT and have really troublesome flushes. They are mainly used to treat depression, because they change the way that cells in the brain handle transmitter chemicals, such as serotonin and noradrenaline. These chemicals may also be involved in hot flushes, so it is not surprising that these drugs reduce flushes by about 60% (Lancet 2000;356:2059 –63, Journal of American Medical Association 2003;289:2827 –34). However, they do not get rid of the flushes entirely and can have side effects.

Gabapentin is a promising treatment that is being investigated. It is normally used for seizures (epilepsy), but it has another effect – it halves the number and severity of hot flushes (Obstetrics and Gynecology 2003;101:337 –45). Sleepiness is the main side effect.

• Why do we blush or flush?
• Flushing caused by anxiety, or drugs, chemicals or foods
• Useful contacts