The real reason researchers cannot find more effective drugs and supplements for hot flashes is due to the placebo effect, which has run as high as 33 to 50 percent in many clinical trials! This means a pill has to really kick gluteus maximus to get FDA approved or sold as an effective supplement, and this just isn’t going to happen anytime soon. The placebo response in men with hot flashes (yes, men can also get them in rare cases, such as during prostate cancer treatment when testosterone drops) is just as high.
Hot flashes are the second most common complaint among women going through menopause, and as many as 75 percent experience them. There are two theories about the cause of hot flashes. One is that they’re due to roller-coaster levels of estrogen and an increase in norepinephrine, a stress hormone; high levels of a metabolite of norepinephrine known as 3-MHPG are found in the brain after a hot flash. Another theory is that during menopause the body’s internal thermostat no longer functions normally, so very small changes cause hot flashes.
When the famous US Women’s Health Initiative study, which was published in 2002, showed that hormone replacement therapy using estrogen and progesterone or estrogen alone had serious potential side effects—including an increased risk of breast cancer and other problems like cardiovascular issues— there was an almost 50 percent drop in estrogen use and a 30 percent drop in progesterone use within 6 months. And a huge increase in the incidence of hot flashes, was seen! I believe lifestyle changes work best for mild to moderate hot flashes, and medication, such as hormone replacement therapy or venlafaxine, works better for severe to very severe hot flashes.
Home Remedies For Hot Flashes
1. St. John’s wort (potentially with black cohosh) 500 to 1,200 milligrams a day in divided doses
In studies, taking 500 to 1,200 milligrams of St. John’s wort per day (in divided doses) over 4 to 12 weeks has shown some efficacy for reducing hot flashes. Look for an extract that’s standardized to contain 0.25 to 0.3 percent hypericin, the active ingredient in St. John’s wort. (In the Depression section of this book, I recommended 0.3 percent hypericin based on those clinical studies, but most of the studies of St. John’s wort in combination with black cohosh to reduce hot flashes or overall menopause symptoms used 0.25 to 0.3 percent hypericin.)
St. John’s wort is an extract of the plant Hypericum perforatum. Researchers haven’t yet been able to determine the exact mechanism of action, but it seems to block serotonin uptake and alter levels of multiple brain neurotransmitters, including dopamine, norepinephrine, and gamma-aminobutyric acid (GABA). Many prescription antidepressants can also reduce hot flashes based on this same mechanism, so this helps build a case for St. John’s wort’s ability to reduce them.
Critics of St. John’s wort often do not mention that side effects—including insomnia, vivid dreams, anxiety, dizziness, and skin sensitivity—have been very low in clinical trials. But they have mentioned St. John’s wort’s potential to interact with or reduce the effectiveness of almost half of all prescription drugs, including oral contraceptives. This is true, but prescription antidepressants also have significant side effects. Regardless, do not combine St. John’s wort with prescription antidepressants, including SSRIs (selective serotonin reuptake inhibitors), tricyclic antidepressants, or monoamine oxidase (MAO) inhibitors; immunosuppressants; antiretrovirals (anti-HIV drugs); blood thinners, like warfarin; and certain chemotherapy and other cancer drugs. Talk with your doctor about the possibility of using St. John’s wort; it has been inappropriately tagged as the poster child of why supplements cannot be combined with prescription drugs, and this is not entirely fair in my opinion.
Now, if St. John’s wort doesn’t work for your hot flashes, combining it with black cohosh (Cimicifuga racemosa or Actaea racemosa) might help, according to numerous clinical trials. It’s one of the most tested dietary supplements for hot flashes; the research has always been mixed and controversial. Black cohosh has been tested with dosages ranging from 8 to 160 milligrams per day for anywhere from 4 weeks to a year. The most common amount is 40 milligrams for an average of almost 6 months, which has turned out to be as safe and effective as a placebo or slightly more effective than a placebo overall. There’s some research to suggest black cohosh works by reducing pain and impacting neurotransmitters (like serotonin), but this needs more investigation. There’s just not enough evidence to recommend taking it by itself, only with St. John’s wort.
There has been some concern that black cohosh might increase the risk of liver problems, and while the number of reports has been small, this is still something to be aware of.
Magnesium is a viable option. In a study with breast cancer patients having hot flashes, subjects took 400 milligrams daily of magnesium oxide for 4 weeks (escalating to 800 milligrams if needed). Hot flashes, fatigue, sweating, and distress were all reduced. A larger clinical trial against a placebo was conducted, and it appeared that magnesium supplements worked similar to the placebo. But the benefit outweighs the risk right now for most individuals because it costs a couple of pennies a day and it’s safe. Diarrhea is the most common side effect.
What Supplements Are Useless For Treating Hot Flashes?
Omega-3 fatty acids
These have shown minimal effects for hot flashes. I really wanted to believe that fish oil (EPA and DHA) could help, thinking that if it can lower blood pressure and heart rate, it might be able to reduce the intensity of a hot flash. But in a randomized trial of more than 350 women published in the journal Menopause, 1,800 milligrams of omega-3 fatty acids (including 1,275 milligrams EPA and 300 milligrams DHA) worked no better than a placebo. (There was no improvement in sleep or mood either.)
As I said earlier, this supplement by itself is a big “no!”
Okay, I’m on the fence with these supplements. Red clover at daily doses of 40 to 82 milligrams of red clover isoflavones have shown a minimal benefit in reducing hot flashes, which some experts would regard as clinically meaningless. However, later studies with higher doses (80 to 160 milligrams of isoflavones and more) are showing more promise, so I don’t want to say they’re completely worthless just yet.
This supplement has clinical evidence for premenstrual syndrome or issues related to menstruation, but in the area of menopause it’s begging for clinical studies. Chasteberry has been preliminarily tested with St. John’s wort (1,000 milligrams of chasteberry plus 900 milligrams of St. John’s wort) for hot flashes, and it did not help.
The pills (not soy protein powder or the soy in food) just have too many human studies showing they didn’t work or barely worked better than a placebo for hot flashes. In addition, recent research continues to suggest that soy protein and isoflavones from traditional soy sources (protein powder, tofu, milk, tempeh, edamame, etc.) might slightly reduce hot flashes, cholesterol, and breast cancer risk. Many traditional food sources of soy are low in calories and very high in protein and have omega-3s and fiber, so they are heart healthy (see the “Lifestyle Changes” section). I would rather have people try to reduce hot flashes with 20 to 40 grams of soy protein daily than with an expensive soy supplement that doesn’t have any data against hot flashes.
L-isoleucine, L-valine, and L-methionine have done nothing for reducing hot flashes in studies. Plus, you would have to take so many pills (up to 10).
Regardless of the dosage (even up to 800 IU per day), E has failed to reduce hot flashes more than a placebo!
Another supplement I’ve been asked about recently is DIM, an antioxidant from cruciferous veggies. Despite all the hype, no one has completed a study that can get me excited enough to recommend it over something less expensive and safer. Some folks claim this supplement reduces the risk of breast cancer based on a few metabolism studies. Come on! It is now known that in menopause, losing weight and exercising definitely reduces the risk of breast cancer and helps put the kibosh on hot flashes, too. So put your hard-earned money toward that instead!
Maca and Panax ginseng have some positive research suggesting they may reduce some menopausal issues (sexual dysfunction, for example), but not hot flashes. Evening primrose oil and dong quai haven’t been impressive for hot flashes either.
What Lifestyle Changes Can Help With Hot Flashes?
Improve your heart health
Several heart unhealthy changes, such as excessive weight gain, can exacerbate hot flashes. Plus, more women than men are now dying from cardiovascular disease, and these deaths occur mostly after menopause. As you improve your heart health, many menopausal symptoms and issues, like osteoporosis, can be significantly reduced. In addition, recent research suggests heart-friendly dietary changes may be associated with reduced frequency and severity of hot flashes (for example, eating 2 to 3 tablespoons of flaxseed or sesame seeds on foods or in beverages and 20 to 40 grams of soy products—not soy supplements!—or protein daily).
Avoid hot beverages, spicy foods, and excess alcohol and caffeine
Drinking colder liquids can be helpful. Use your diary (see “Log Your Hot Flashes” above) to identify foods and drinks that trigger or exacerbate flashes.
Do not smoke or inhale secondhand smoke
It’s simply unhealthy and makes hot flashes worse due to circula-tory and temperature changes. Not to mention, smoking can cause early onset of menopause.
Exercise and lose or maintain weight (it matters!)
Excess weight acts as an insulator, keeping heat in instead of letting it dissipate (it’s like having a hot flash with a sweater on versus a T-shirt). Women with higher body mass indexes (BMIs) report more frequent and severe hot flashes compared to those with a lower BMI. In addition to helping with weight loss, exercise (even low impact) can reduce stress, improve mood, and may even reduce hot flashes.
Practice stress-reduction techniques
Meditation, yoga, exercise (again), and other stress-busting activities can reduce the severity of hot flashes and help minimize the negative impact menopause has on other areas of life, such as on sleep. Breathing exercises can help, too: Practice controlled, deep, slow abdominal breathing (six to eight breaths per minute) for at least 15 minutes twice daily (morning, midday, or evening) or at the beginning of a hot flash. Also known as paced respiration, this can decrease blood pressure (temporarily), the number of hot flashes, and their severity. It takes some practice, but you’ll get it.
Drink sage tea (lukewarm or cold, not hot)
Based on a few studies, it might provide a benefit due to the unusually high amount of plant estrogens in sage.
Wear slightly loose clothing
This helps keep the body’s core temperature lower and won’t feel as constricting or intense when a hot flash occurs.
Get acupuncture (once or twice every week or two)
There is fairly good research showing it may help with hot flashes.