This article was originally published in the March 2024 issue of UltraRunning Magazine. Subscribe today for similar features on ultra training, racing and more.
So much of life is about what we choose to see. We can see aging and menopause as a bad thing, or we can learn the facts and develop strategies that reduce or eliminate energy loss and disrupted sleep, and enhance our performance. We can run from the slower times and the difficulties, or we can learn to embrace this stage of our lives just the way we embrace a tough workout or race: with compassion, understanding and curiosity.
Starting, of course, with hot flashes.
We posted about the topic on social media and received the following comment from ultrarunner Sheri Bentley: “I feel that one of the hardest things about being a female ultrarunner is dealing with perimenopause. Not only do we have to deal with the hormonal fluctuations causing mood swings, bloating and a slowing metabolism, but we also have the extra burden of hot flashes.”
WHAT IS A HOT FLASH?
Those who’ve had them know the feeling: sudden bursts of heat. Red faced and sweating, we throw off layers and reach for a towel. At night, they drench pajamas and disrupt sleep. By day, they leave us tired and irritable. Whether you call them hot flashes, hot flushes, blooms, power surges or something that includes expletives, 75% of women will experience them during menopause.
Prior to perimenopause, our body’s thermostat maintains a core temperature of 98.6 degrees, plus or minus half a degree. Called the thermoregulatory or the vasomotor system, our internal thermostat is in a region of the brain called the hypothalamus.
Temperature is monitored with nerve cells on the skin and within the body’s core. As things warm up, these cells stimulate the hypothalamus, which tells blood vessels to shunt blood to the skin, allowing heat to radiate away from the body and into the environment. This is the flush of heat and redness you feel when exercising on a hot day. The hypothalamus turns sweat glands on, soaking the skin and allowing heat to evaporate. It also signals behavior changes, which is why you take off layers (or at least want to) before even thinking about it.1
During menopause, the thermostat becomes hypersensitive. Minor alterations in body temperature generate a large heat reduction response. Fluctuating estrogen levels play some role, but the exact mechanisms are unclear. This haziness generates a lot of confusion about how to respond to hot flashes.
WHO EXPERIENCES HOT FLASHES AND FOR HOW LONG?
The Study of Women’s Health Across the Nation (SWAN) followed 16,065 women over a period of years and found four distinct hot flash patterns.2 Approximately 25% of women experience hot flashes in perimenopause, which gradually taper after the final menstrual period; 25% experience hot flashes around the final menstrual period, then decline over an average of four years; 25% of women have few or no hot flashes; and 25% of women experience flashes early in the menopause transition, which continue 10-11 years or more.
HOW DOES RUNNING IMPACT HOT FLASHES?
Most recent studies find that exercise increases both the frequency and intensity of hot flashes.3 Please don’t interpret that as a reason to stop running. Exercise is important for mental and physical health, even if it increases hot flashes. Let’s look at strategies for managing them.
MANAGING HOT FLASHES
Thinking back to the thermostat, approach management the way you do any situation that triggers your heat response. Ensure you are hydrated before working out. There is an association between drinking hot liquids and hot flashes, so consider avoiding them before a workout, and add ice to your water bottle. Use external cooling sources like fans, ice wraps and water misters to reduce the chance of becoming overheated. Dress in layers and remove them as you warm up.
Weather and time of day influence the frequency of hot flashes. Consider adjusting your workout time by targeting earlier, cooler periods of the day, especially in summer.
NON-MEDICAL THERAPIES
If hot flashes are disrupting your sleep, non-hormonal therapies may be helpful. Studies of cognitive behavior therapy showed a “significant reduction…over a 4-week period that persisted 26 weeks.”4 The evidence supporting other therapies is less robust, but hypnosis, yoga and acupuncture may reduce hot flash frequency.
Controlled studies do not find significant reduction in hot flashes with mindfulness/relaxation, weight loss (if overweight) or paced breathing. These do have health benefits, but don’t expect to reduce hot flash symptoms when using them.
NON-HORMONAL THERAPIES
Research studies showed four non-hormonal medications reduce hot flash frequency with minimal side effects. The newest is Fezolinetant, the first drug specifically designed to inhibit hot flashes. It blocks neurokinin B, an enzyme from the hypothalamus that signals heat. Approved by the FDA in 2023, clinical trials show a 58% reduction in hot flash severity. Reported side effects include headaches, gastrointestinal distress and elevated liver enzymes relative to the placebo group.5
Selective serotonin reuptake inhibitors (SSRIs) are anti-depressants. The chemicals causing hot flashes use some of the same neurotransmitters and SSRIs effectively reduce symptoms. Side effects include reduced libido.
Gabapentin may help with hot flash-associated sleep loss. Higher doses may cause dizziness and sleepiness.
Clonidine is a blood pressure medication that has reduced symptoms for some women but is not as effective as other therapies.
HORMONAL THERAPY
Menopause hormone therapy (MHT) is still the gold standard of treatment for hot flashes. MHT includes topical and oral estrogens and progesterone. Oral estrogens have a low but increased risk of stroke and blood clots. Those risks have not been associated with topical estrogens. Progesterone offsets the effect of estrogen on the uterus by preventing uterine thickening that can develop into uterine cancer and is included as part of MHT for women with a uterus. Women unable to take estrogen may find oral progesterone reduces hot flash frequency.
WHAT’S BEST FOR ME?
Just like an ultra, each of us will develop slightly different strategies for managing hot flashes, and the solutions that worked yesterday may need tweaking tomorrow. We look forward to connecting with our community as we answer your questions and share the latest training strategies. If you have a question or a training hack that worked (or didn’t), we’d love to hear about it.
References
- Osilla EV, Marsidi JL, Shumway KR, et al. Physiology, Temperature Regulation. [Updated 2023 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507838/
- Tepper PG, Brooks MM, Randolph JF Jr, Crawford SL, El Khoudary SR, Gold EB, Lasley BL, Jones B, Joffe H, Hess R, Avis NE, Harlow S, McConnell DS, Bromberger JT, Zheng H, Ruppert K, Thurston RC. Characterizing the trajectories of vasomotor symptoms across the menopausal transition. Menopause. 2016 Oct;23(10):1067-74. doi: 10.1097/GME.0000000000000676. PMID: 27404029; PMCID: PMC5028150.
- Romani WA, Gallicchio L, Flaws JA. The association between physical activity and hot flash severity, frequency, and duration in mid-life women. Am J Hum Biol. 2009 Jan-Feb;21(1):127-9. doi: 10.1002/ajhb.20834. PMID: 18942715; PMCID: PMC2753173.
- McCormick CA, Brennan A, Hickey M. Managing vasomotor symptoms effectively without hormones. Climacteric. 2020 Dec;23(6):532-538. doi: 10.1080/13697137.2020.1789093. Epub 2020 Jul 22. PMID: 32696683.
- Onge ES, Phillips B, Miller L. Fezolinetant: A New Nonhormonal Treatment for Vasomotor Symptoms. J Pharm Technol. 2023 Dec;39(6):291-297. doi: 10.1177/87551225231198700. Epub 2023 Sep 16. PMID: 37974591; PMCID: PMC10640863.