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Hot Flashes in Palliative Care – Part 1

  • Carolyn Lefkowits MD
  • Robert Arnold MD

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Background     Hot flashes (or ‘flushes’) are a common symptom which can negatively impact quality of life.  Failure to assess and offer treatment for hot flashes is common.  This Fast Fact is the first in a three part series reviewing hot flash assessment and treatment.

Symptoms     A hot flash is a “subjective sensation of heat that is associated with objective signs of cutaneous vasodilation and subsequent drop in core temperature” (1). It usually starts with a sudden sensation of heat on the face and upper chest that becomes generalized, often associated with perspiration followed by chills and shivering.  Other symptoms can include dizziness, palpitations and headaches. Psychological symptoms include irritability, depression, panic, and social embarrassment. Hot flashes can lead to sleep disturbance, likely due to frequent waking and autonomic arousal. Hot flash duration, frequency, and severity are variable, both from person to person and day to day; average duration is 3-5 minutes.  Nocturnal hot flashes are most common during the first four hours of sleep.  

Physiology    The physiology of hot flashes is not completely understood, but has been attributed to changes in sex hormones leading to thermoregulatory dysfunction.  In healthy women, hot flashes occur as part of the normal menopausal transition.  In a longitudinal study of 3300 women (2), risk factors for hot flashes were found to include

  • smoking
  • lower socioeconomic status
  • obesity
  • anxiety
  • history of childhood abuse or neglect
  • African-American race.

Hot Flashes and Cancer    Cancer therapies leading to hormonal changes and hot flashes include oophrectomy, chemotherapy and endocrine therapies (tamoxifen and aromatase inhibitors for breast cancer and androgen deprivation therapy for prostate cancer). Women who are already postmenopausal do not generally experience treatment-related hot flashes unless they were on hormone replacement therapy that is stopped at the time of the cancer diagnosis. Cancer treatment-related hot flashes may be more abrupt in onset and more severe than those experienced as part of normal menopause. Greater than 90% of women with surgically-induced menopause will experience hot flashes; up to 80% of women on tamoxifen report hot flashes, 30% rate them as severe.  34-80% of men treated with androgen-deprivation therapy for prostate cancer report hot flashes.  In breast cancer patients, severity of hot flashes has been correlated with decreased quality of life and overall sense of well being.  Men with hot flashes from androgen-deprivation report more persistent cancer-related distress than those without hot flashes. 

Assessment

  • Physical and emotional symptoms accompanying hot flashes
  • Impact on daily life including sleep
  • Hot flash triggers or patterns of occurrence (e.g. stress, alcohol, caffeine, spicy food, hot showers, hot weather, smoking and overheated bedrooms).
  • Maintain a one-week diary of hot flash frequency, duration, triggers and severity (usually measured as mild, moderate, severe or very severe).  Examples of validated hot flash symptom diaries are available in reference number 5.
  • Note: objective measurement devices have been developed, but prospective diaries remain the gold standard.

Summary:  A thorough assessment is important to determine a treatment plan.

References

  1. Boekhout AH, Beijnen JH, Schellens JH. Symptoms and treatment in cancer therapy-induced early menopause. Oncologist, 2006;11(6): 641-654.
  2. Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women’s Health across the Nation. Obstet Gynecol Clin North Am. 2001; 38(3): 489-501.
  3. Gupta P, Sturdee DW, Palin SL et al. Menopausal symptoms in women treated for breast cancer: the prevalence and severity of symptoms and their perceived effects on quality of life. Climacteric. 2006; 9(1):49-58.
  4. Loprinzi CL & Barton DL. Gadgets for measuring hot flashes: have they become the gold standard? J Support Oncol. 2009; 7(4):136-7.
  5. Guttuso T, Digrazio WJ, Reddy SY.  Review of hot flash diaries.  Maturitas. 2012; 71: 213-216.

Authors’ Affiliations:  University of Pittsburgh Medical Center, Pittsburgh, PA.

Version History:  First published February 2013. Copy-edited by Sean Marks in September 2015.