Non-hormonal Management of Hot Flashes

Is It Hot In Here?
by Dr. Kumi Swart

As the weather cools down in North Georgia, one might think the change in temperature brings welcome relief to those who suffer from hot flashes, but that is not the case.  The unfortunate fact is that an estimated 70 to 80 percent of women, and 20 percent of men, experience hot flashes.  One in five women will continue to suffer so badly through the winter that they cannot tolerate it and seek treatment.  The average woman suffers up to six a night!

We have a fairly good understanding of what causes these flashes, also called vasomotor symptoms, to occur and an even better understanding of what helps them go away.  Where conventional medicine struggles is with non-hormonal therapeutic recommendations for those who cannot, or will not, take hormone supplements.  The good news is that research is ongoing and novel natural therapies are being discovered.  Some of these newer therapies combine impressive safety profiles with surprising efficacy.

We do understand the mechanisms responsible for all the flushing, sweating and misery.  It begins up to ten years before a woman enters menopause (the mechanism is different in men), when a woman’s ovaries begin producing less of the hormones progesterone and estrogen.  This change affects other hormonal messengers down the line, causing them to fluctuate. The fluctuations affect an area in the brain called the hypothalamus where body temperature is regulated.  When hormonal signals are not correctly transmitted, they can be misinterpreted by the brain.  The misinterpretation narrows what is known as the thermoneutral zone (the range of body temperature your body considers to be normal).  The brain starts to think that the normal range in the body’s core temperature is so narrow that it overreacts to slight deviations outside of this range.  In other words, tiny changes in temperature (i.e. warming up under light blankets on a cool night) result in sweating and flushing (and throwing off those cozy blankets) when the body should not be reacting to the change in temperature at all.

The most effective treatment for vasomotor symptoms has been hormone replacement therapy in the form of estrogen and progesterone.  There are pros and cons to hormone therapy and it is still a hotly debated, controversial subject.  According to the North American Menopause Society, the Academy of Women’s Health, American Association of Clinical Endocrinologists, American Society for Reproductive Medicine, and most other related professional medical associations, if a patient cannot or will not take hormone therapy, they should be counselled on lifestyle modification techniques such as exercise, cognitive behavioral therapy, paced respiration and mindfulness-based stress reduction.  When mindfulness fails, prescription medications that affect the levels of a neurotransmitter (a chemical in the brain) called serotonin may be helpful.  These medications, called SSRIs (serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) have been shown to decrease symptoms from 25 percent to 60 percent.  Still, the side effect profiles of these medications often make them a less than perfect solution.  There are other medications, including gabapentin and clonidine, which work well for both men and women for vasomotor symptoms, but the dosages necessary to have an impact come with the unfortunate side effects of dizziness, disorientation, and changes in blood pressure so severe they are soon eliminated as viable options for many patients.

What about herbs?  In training, primary care providers and gynecologists are taught to suggest the herb Black cohosh (Actaea racemosa) for hot flashes.  It has been used in traditional folk medicine for generations and is safe enough that it can be found easily on the shelves of your local grocery store, though you should consult your physician before taking it if you have liver disease.  Does it work???  To answer that question, I turned to a database that collects scientific research on natural therapies and what I found was disappointing.  Black cohosh, dong quai root, evening primrose oil, ginseng, red clover extract and soy all showed the same conclusion: “No benefit over placebo for hot flashes.”

Motivated by personal interest, my search over the past several years led me to discover what has been developing in the realm of natural remedies in other countries.  The most promising is a substance that has been on the market in Germany since 1993 called ERr 731.  It is an extract derived from the roots of a particular rhubarb plant called Rheum rhaponticum.  Commercial preparations based on this science have also referred to it as Siberian rhubarb, but I have found no evidence linking its origins to Siberia and many of those supplements lack the key ingredient ERr 731.  Multiple international studies demonstrate that approximately 82 percent of women taking this extract had a reduction in their menopause rating scale of 10 points (compared to a drop of 2 points on a placebo).  That is a reduction from an average score of 18, considered severe, to a score of 8, which is considered mild.  Other studies show a reduction in the number of hot flashes from a baseline of 11 per day to 4 per day after twelve weeks.   There has been post-marketing surveillance data published for commercially available extracts of ERr 731 to assess safety.  From January 2009 to June 2014, approximately 13 million tablets were sold in North America and there were only 79 complaints from consumers recorded.  The main complaints were gastrointestinal symptoms (23 total complaints) and complaints that the extract failed to work as suggested (22 total complaints).

Currently, I could find only one company marketing the extract ERr 731 in the United States.  Metagenics has developed a product called Estrovera which features the ERr 731 extract in the treatment dosage which was found to be most effective in clinical studies and has been available in Europe for twenty five years.

If you or someone you know is suffering from hot flashes and cannot or will not take hormones, you should talk to your Prestige Primary Care provider about your other options.

Happy Thanksgiving!


Dr. Kumi
Dr. Kumi Swart

Interests: Women’s health, family care, functional medicine and weight loss.