The Wisdom of the Hot Flash
Women approaching midlife should consider hormone replacement therapy
Have you ever wondered how a woman's reproductive cycle keeps to a 28-day clock?
When I was in my first year as a medical student at the University of Pittsburgh, I was honored to learn about women’s reproductive health from a world-renowned scientist, Doctor. Ernst Knobil. His research showed an on-off switch for the cycle in the brain, and the 28-day clock was in the ovaries. His groundbreaking work forms the basis of modern reproductive endocrinology and inspired me to train as a physician and a scientist in women's healthcare and research.
After a 30-year career in the U.S. Public Health Service, I have come to believe we should do away with the term menopause. It’s not a physiological term, and changing the name could help reduce the stigma associated with it. I’m on a mission to rebrand it as hormone imbalance because that’s what it is.
Our bodies constantly communicate with us, often in subtle and not-so-subtle ways. A hot flash is a profound yet underappreciated form of this communication. While it's frequently dismissed as an unpleasant symptom of women in midlife, the hot flash is, in fact, a vitally powerful message from the body. It offers a unique insight into the intricate mechanisms of a woman's endocrine system and the crucial role of hormones in maintaining overall health and staying well.
Women often experience waves of intense heat and sweating due to hormonal fluctuations during their midlife transition.
Image credit: Getty Images
From 1986 to my retirement in 2017, I organized and directed a research program on women’s health at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD. With my team, I developed clinical and laboratory research programs on Primary Ovarian Insufficiency (POI), which some inaccurately called "Premature Menopause." It’s a rare condition, in which the ovaries stop functioning as they should before the age of 40, but it is not to be confused with menopause. The youngest patient we saw with this disorder was only 12 years old. It’s crucial to understand that there are effective treatments for POI and that it’s not a permanent obstacle to pregnancy or quality of life. The most important advice I can give women with POI is to not take no for an answer. You must advocate for yourself. This is a rare disorder that doesn’t get the attention it needs – you must fight for your health.
While POI and menopause can cause similar symptoms, the key difference is that women with POI can have irregular or occasional periods for years and might even get pregnant. But women with menopause stop having periods permanently and never become pregnant. Our endocrine system, a complex network of glands that produce and regulate hormones, is a key player in maintaining balance within the body. Hormones act as messengers and orchestrate numerous bodily functions, including metabolism, growth, and reproduction. Among these hormones, 17-beta estradiol, the primary estrogen naturally produced by a woman's ovaries, stands out. It exerts profound protective effects on cardiovascular health, bone density, and sleep patterns, making it a crucial component of overall health.
How do you know if your estradiol levels are too low?
Sudden waves of intense heat and sweating result from hormonal fluctuations during the average woman's midlife transition and in young women with POI. Hot flashes are an early warning system that indicates 17-beta estradiol deficiency, which heralds an increased risk of cardiovascular diseases and osteoporosis, weakening bones. These are both silent killers, so listening to this early warning system is crucial.
Another indicator of low 17-beta estradiol is a lack of quality sleep. Many women experience disruptions in their sleep patterns during the midlife transition to 17-beta estradiol deficiency. By understanding the significance behind these experiences, women can prioritize strategies that support rejuvenating sleep habits. Keeping a consistent schedule, a relaxing bedtime routine, and limiting blue light exposure before bed can improve sleep. Thus women can empower themselves to take proactive steps toward their health.
The question many women approaching midlife ask is: Would I benefit from hormone replacement therapy?
Even very low doses of 17-beta estradiol can improve hot flashes and might have protective effects on the cardiovascular system and bone health, according to published evidence. The best evidence supports adding 17-beta estradiol through transdermal systems, for instance, gels or patches, as a safer approach than taking estrogens by mouth. Taking estrogens orally could elevate hormone levels in the liver, increase clotting factors, and hence the risk of potentially fatal blood clots. There is much confusion and misinformation about 17-beta estradiol replacement, so be sure to find a clinician with expertise in this area.
Lawrence M. Nelson, a doctor with more than 30 years of experience in women’s health care, led a discussion on women’s hormonal health at a conference in Chiang Mai, Thailand.
Photo courtesy of Lawrence M. Nelson
Another significant symptom of 17-beta estradiol deficiency is painful intercourse and urinary symptoms. These are beyond the scope here, so discuss this with your clinician if this is a problem.
What about the cancer risk? Many women have read that hormone replacement might increase the risk of breast cancer. However, further studies and associated reviews have discredited this theory.
The U.S. National Institutes of Health Women's Health Initiative (WHI) analyzed the medical data of 160,000 women over up to 20 years for the largest randomized, placebo‐controlled trial and evaluated the benefits and risks of hormone therapy. Subsequent analysis and other independent studies have come to the clear conclusion that hormone therapy is a very effective treatment for symptom relief, especially when it is started early at the onset of hot flashes. Replacing very low levels of 17-beta estradiol has numerous benefits, including increased bone density, reducing vaginal dryness and mood swings. There is good evidence that even women who do not have hot flashes or other symptoms experience cardiovascular and bone-protective benefits from low-dose 17-beta estradiol replacement. Talk with your clinician about adding a progestogen to the replacement.
As members of Rotary International, it is essential to advocate for an integrated approach to health that encompasses the wisdom of the body, recognizing the interconnectedness of hormonal balance and overall health. Rather than dismissing hot flashes as a mere inconvenience, women can deepen their understanding of the pivotal role played by the endocrine system in sustaining cardiovascular and bone health and promoting quality sleep. Let us embrace the wisdom of the hot flash as a powerful reminder of the delicate symphony of hormones that shape a woman's vitality and resilience.
Lawrence M. Nelson, MD, MBA, is the President of the Mary Elizabeth Conover Foundation and a member of the Lampang Rotary Club in Lampang, Thailand. He spent 30 years researching Primary Ovarian Insufficiency (POI) at the US National Institutes of Health Intramural Research Program (NIH-IRP). He now directs a digital women's health initiative named My28Days.org.
This story originally appeared in the May 2025 issue of Rotary magazine.