Hot flashes (sometimes called "hot flushes")
Hot flashes are a common symptom of the menopause and they are commonly made worse by taking tamoxifen. Hormones released from the pituitary gland cause them by inducing dilatation of blood vessels in the skin of the face and upper body. This warms the surface of the skin sending signals to the brain that the body is overheating. In fact, body temperature is normal and hot flashes should not be confused with a fever, when the body temperature can be measured by thermometer to be above the normal upper limit of 37.4 degrees centigrade. Skin warming is accompanied by a hot prickly sensation that may begin as a tightness or warmth over the face and scalp, and that quickly migrates to involve the whole upper torso. At it’s peak the flash is accompanied by sweating which is sometimes profuse as the body attempts to cool itself. There is an overwhelming desire to stand in front of an air conditioner, or remove clothing! They are more common at night when they might disturb sleep. In some women they are severe enough to disturb the ability to work and they severely inhibit quality of life, particularly as they are unpredictable and may occur at the most inconvenient moments socially and professionally. Each flash may last up to 5 or 10 minutes and some women experience them up to ten times daily, although the majority have only one or two episodes daily. Flashes can occur independent of outside air temperature, but seem more difficult to manage in the summer months, for obvious reasons. They can last for months to years, but the severity generally decreases rather than increases with time.
Simple measures may help to ease hot flushes, including the wearing of several layers of light clothing which can be removed if necessary, and sleeping in an air-conditioned room, or one with a ceiling fan.
Health food stores and pharmacies heavily promote natural products containing plant oestrogens as being of benefit in easing hot flushes. These products include Promensil and Remifem (black cohosh). Remifemin is the only product which has shown any benefit in properly conducted clinical trials, but the benefit is slight, and is less than that shown with Efexor. These products are also quite expensive. Furthermore, none of the "natural" estrogens are of proven safety in women who have had breast cancer, and recently they have been shown to stimulate breast cancer growth in the laboratory, which is a concern to me.
Two drugs that have been shown to reduce the severity of hot flushes are venlafaxine and medroxyprogesterone acetate ("Provera"), in a dose of between 10 and 50 mg daily, and venlafaxine ("Efexor"), in a dose of between 37.5 and 75 mg in the morning. These drugs must only be used under the advice of your doctor. Whilst there is some evidence that the blood pressure table Clonidene may reduce hot flushes, I have never seen it work, and most of my colleagues are skeptical about its efficacy.
NOTE: Antidepressant medication like venlafaxine can interfere with the activation of tamoxifen in the liver. Patients on tamoxifen should avoid the "selective serotonin reuptake inhibitor " (SSRI) antidepressants like venlafaxine unless under specific medical advice.
Vaginal irritation, dryness and discharge.
Vaginal irritation and dryness may be relieved by the use of local estrogen-containing pessaries. The best of these is probably oestriol ("Ovestin"). This should be used twice weekly at first, then weekly, under strict medical supervision.
Headaches
Mood disturbance
Unexplained and quite dramatic mood disturbance is one of the most unpleasant aspects of early menopause. Typically mood may swing from day to day unpredictably and uncontrollably. One day may be "flat", the next characterized by intense impatience and irritation by routine events and the behaviour of close associates and colleagues. You may "lose it" for no apparent reason and your customary levels of sweet-natured tolerance are suddenly stripped from you and most people around you are intensely irritating and unspeakably boring. You yell at your secretary for not removing stick-on notes from your files. She looks astonished.
The next day you may feel full of remorse, tearful for no reason. You may weep inconsolably over the thought of your cat being out in the rain all day while you are at work, or over your recollection of a trivial domestic dispute with your daughter over her late arrival home. "I’m such a dragon to that poor girl, she must hate me!" your brain says. Consolatory and reassuring words from your partner are only annoying and seem patronizing, which, in turn, makes him feel impotent and useless and compounds the tension. The next day you are overcome with the desire to completely reorganize the house, moving furniture and throwing out vast amounts of junk. You have to climb over the family to do so. They are completely unimpressed with the urgency you alone seem to be able to see in the project and tensions arise because of their seeming lack of cooperation and apparently passive resistance to your innovative domestic transformations.
The next day you are overwhelmed by the desire for reassurance. Your partner is puzzled and confused by your desire to be reaffirmed in his love for you. "You’re not going out with another bird are you?" you ask. You need to be hugged and nurtured.
Sometimes these mood variations extend into true depression and may require professional assistance and perhaps antidepressant medication. Tell-tale signs of serious depression include: