Hot flashes – Help!

Those pesky waves of sudden sweating and heat have you pulling off layers of clothing. You know it is your declining hormones but what to do about them? You may have heard that hormone replacement therapy (HRT) is dangerous for you, but you know others that swear by them. It turns out that the type of hormones that you replace are the key between whether they are safe or not.

Hormones start to wane typically in our mid to late 40s and is called perimenopause. The average age of perimenopause is 48. The average age of menopause is 52, which when periods stop completely for 12 months. Perimenopause is that transition time of declining hormones that are accompanied by all kinds of wonderful symptoms – irregular periods, heavy bleeding, spotting, worsening cramps, worsening PMS, hot flashes, anxiety and lack of sleep to name a few. As hormones continue to decline, women often experience more vaginal dryness, memory and cognitive changes and weight gain.

Hormones in Perimenopause

Let’s focus what is happening to your hormones. Estrogen and progesterone slowly decrease because ovaries are declining in function. Most often, the progesterone declines first, followed by a wobbly decline in estrogen. Because progesterone often declines first, and initially there is adequate estrogen, it is most often effective in early perimenopause to find the most symptom relief with progesterone alone. Progesterone supplementation often relieves hot flashes, poor sleep, and irritability most effectively in early perimenopause.

There are simple ways to test for progesterone. You can either do a blood draw, which often shows progesterone at very low levels when symptomatic. More detailed information can be seen with a urinary spot collection called the DUTCH test. This test can help show where your progesterone levels lie in relation to normal reference ranges, and can be compared to estrogen and where your estrogen levels are relative to normal reference ranges.

If you can see in the above example, this persons estrogen, or Estradiol (E2), is well above reference range for normal levels of urinary estadiol. However, their progesterone is well below reference range and almost at postmenopausal ranges. This is someone who has declining hormones, but progesterone has fallen well before estrogen has declined. This means their hormones are not in balance and can actually set them up for conditions linked with estrogen dominance such as fibroids, heavy bleeding, endometrial cancer, as well as experiencing symptoms of low progesterone.

Safety of Hormone Replacement

Progesterones, however, are not all created equal. There is synthetic progestin and there is bioidentical progesterone. Synthetic progestins are molecules that look very similar to human progesterone, but with minor changes. Bioidentical progesterone is synthetically made but the molecule is identical to a normal human female’s progesterone. Why does this matter? It turns out, the safety profile of the two are very different. Synthetic progestins has been linked with elevated rates of breast cancer, while bioidentical progesterone does not increase breast cancer risk and some show it is breast protective (1,2,3,4). Bioidentical progesterone does not increase risks of strokes or clots and is generally very safe (5).

I’d like to take a moment to discuss the difference between medical risks and side effects. Medical risks are increased risks to diseases, such as synthetic progestins increase risks of breast cancer. That doesn’t meant that bioidentical progesterone doesn’t have any side effects. These can happen and can include irregular bleeding, bloating, water retention, digestive issues and mood changes. These can happen, but by and large, bioiodentical progesterone is my favorite most effective way to improve hot flashes in perimenopause, and also improves sleep and anxiety in a fairly predictable way.

If for whatever reason, progesterone does not work for you, other natural supplements for hot flashes include high doses of vitamin B6, and herbal medicine such as Black Cohosh, Rehmannia and and a product on the market derived from Rhaponic Rhubarb called ERr731. Regular exercise and sleeping regularly and avoiding triggers, such as alcohol, are also helpful.

Contact us to learn more about support for your hot flashes.


1. Writing Group for the Womenʼs Health Initiative Investigators . Risks and benefits of estrogen and progestin in healthy postmenopausal women. Principal results from the Womenʼs Health Initiative Randomized Controlled Trial. JAMA. 2002;288:321–333
2. Million Women Study Collaborators . Breast cancer and hormone replacement in the Million Women Study. Lancet. 2003;362:419–427
3. Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study [published correction appears in Breast Cancer Res Treat. 2008 Jan;107(2):307-8]. Breast Cancer Res Treat. 2008;107(1):103–111. doi:10.1007/s10549-007-9523-x
4. Baber R. Breast Cancer in Postmenopausal Women After Hormone Therapy. JAMA 2011;305(5):466-467
5. Regidor PA. Progesterone in Peri- and Postmenopause: A Review. Geburtshilfe Frauenheilkd. 2014; 74(11):995-1002. doi:10,1055/2-0034-1383297