February 26, 2011
Hot flashes and night sweats are common symptoms of menopause. Interestingly, in a study of 60,000 post-menopausal women, those that suffered the worst night sweats and hot flashes at the start of menopause had a 17% lower chance of stroke and 11% lower chance of heart disease when followed for 10 years, compared with those who had no symptoms. Heart attack deaths were 24% lower. The authors could not give a clear explanation for their findings. Here’s my explanation:
I’ve written before that I often see hot flashes and night sweats in young men. They also have irritability, mood swings and insomnia. These symptoms are neurologic events that occur due to a relative change in the status of the involuntary nervous system. These young men are typically gaining weight quickly. This causes a rapid relative change in their sleep-breathing status, due to more frequent breathing pauses at night. Rapid weight gain is known to contribute to obstructive sleep apnea.
In menopausal women, not only do most gain some amount of weight, their progesterone levels begin to drop in their early 40s. Progesterone is a known upper airway muscle dilator, increasing muscle tone to the tongue. As progesterone slowly drops, the tongue relaxes more, especially when in deep sleep. This causes more frequent micro-obstructions and arousals, leading to the typical neurologic (vasomotor) symptoms commonly seen in perimenopausal women. It’s this relative change in the sleep-breathing status that irritates the involuntary nervous system (which regulates temperature, sweating, heart rate, blood pressure, digestion, and various other body functions).
Dr. Guilleminault of Stanford University states that people with obstructive sleep apnea have diminished nervous systems in the throat. Vibrations from snoring or reflux from obstructive events can damage the protective pressure and chemical sensors in the throat. If you already have some degree of obstructive sleep apnea as you approach menopause, it’s plausible that as progesterone levels drop, the additional breathing pauses don’t have as much of an effect on the involuntary nervous system, since it’s been happening already for years or decades. If your nervous system is intact, then the sudden increases in breathing pauses can lead to more severe vasomotor symptoms.
What this study suggests is that the more you’re susceptible to obstructive sleep apnea, the less likely you’ll suffer hot flashes and night sweats early in menopause. This can explain the higher rate of cardiovascular disease in post-menopausal women.
This is another example of interpreting scientific studies based on my sleep-breathing paradigm. If you’re not familiar with this concept, you can read my articles, or for a more in-depth explanation, take a look at my book, Sleep, Interrupted.
What do you think about my line of reasoning? Please enter your feedback below in the comments box.
January 18, 2011
Can taking an antidepressant diminish menopause symptoms such as hot flashes and night sweats? A study just published in JAMA showed that menopausal women who were given Lexapro had small, but significantly less number of hot flashes per day compared to women given placebos.
Many antidepressants can diminish REM sleep, which is when you’re dreaming, and also when your muscles are most relaxed. Mirtazapine, another antidepressant, was shown to lower the AHI in sleep apnea patients by about 50%.
Women who are going through menopause are also going to have more frequent breathing pauses, due to a gradual lowering of progesterone levels. Progesterone is a powerful upper airway muscle dilator or stimulant. So if you lower this hormone, you’ll have more frequent breathing pauses, which will cause you to wake up all of a sudden, which can be a surprise to your nervous system.
It’s also been shown that many of the symptoms of menopause, including hot flashes and night sweats, are autonomic nervous system reactions (vasomotor symptoms) that can occur whenever your nervous system is shocked or in a state of major imbalance. I described young men having hot flashes and night sweats, mainly due to slowly progressing obstructive sleep apnea during rapid weight gain. These nervous system reactions can also occur during the daytime. Whenever your nervous system is en garde or edgy, it’s going to over-react to any form of stimulus. I vaguely remember reading another study what showed that women don’t wake up from hot flashes themsleves, but rather from breathing pauses. This is similar to why people get up to urinate at night (from breathing pauses).
Since even Lexapro can lower REM sleep qualtity, it’s not surprising that taking this drug can also lower the rate of hot flashes. If you have obstructive sleep apnea, do you suffer from hot flashes or night sweats?
August 2, 2010
You wake up one morning with a sore, scratchy throat, feeling a little run down. The next night, your throat pain gets even worse, and you experience mild fever, with sweats and chills. Your nose is a little stuffy and runny. Your muscles ache. You're feeling even more tired. After a few days, your symptoms slowly improve, and in retrospect, you conclude that it was a passing cold.
This is a description of the classic cold, where once you catch a cold virus, it invades your body, releasing toxins and chemicals which causes fever, aches, and general fatigue. But what if I told you that the same symptoms can happen due to an allergy attack, or whenever the weather changes, or even during menopause?
About once or twice every month, I see young men who complain of hot flashes, night sweats, chills, and fever. This occurs for weeks to months. But this history isn't consistent with a typical cold. What's going on?
Whenever your involuntary nervous system is upset or imbalanced, it reacts with what are called vasomotor symptoms. This particular part of your nervous system is what normally controls sweating, temperature, blood flow, digestion, and other automatic body functions. So technically, you can have fever, chills, and even sweats from this reaction.
What then can cause this type of reaction? Let me answer by giving you the story of someone I saw this past week. He was a young man who noticed a mild sore throat 4 days prior to seeing me, and by the next morning, had a horrible sore throat. That night, he felt hot, had some sweats and shaking chills. He felt much more tired than usual, and also had some muscle aches. He saw his medical doctor that same say and was given a strong antibiotic, but didn't feel any better over the next few days.
When I saw him, I was expecting to see the typical tonsillitis with pusses out tonsils, but was surprised to find only mild inflammation and swelling. An endoscopic exam revealed severe narrowing of the space behind the tongue, made much worse when on his back.
It turns out that on the night previous to the onset of his sore throat, he had been out eating and drinking later than usual. He also normally prefers to sleep on his stomach, but felt that his sore throat might improve is he slept on his back, as he's heard about the health benefits of sleeping on his back.
What happened to this patient was that by eating and drinking late, more of his stomach juices were forced up into his throat over the first night. Then, as more swelling arose in the throat, more frequent obstructions and arousals occurred, leading to more reflux of gastric contents into the throat, adding to the swelling in the throat, along with much less efficient sleep.
Lack of deep, efficient sleep causes a physiologic stress response that makes your involuntary system overly sensitive. Hypersensitivity of your involuntary nervous system can lead to vasomotor symptoms, such as fever, hot flashes or sweats. This is why as women go through this process (since progesterone, which stiffens tongue muscle tone, relaxes), symptoms can occur. The same thing can happen when young men are slowly gaining weight.
All I recommended for him to do was to go back to sleeping on his back, and avoid eating or drinking within 3-4 hours of bedtime.
Do you get sore throats in the morning, or have fever, chills or sweats at night?
July 22, 2010
Here's another menopause-related study that may have an alternative explanation. Researchers found that in overweight and obese menopausal women, weight loss significantly improved symptoms of hot flushes. They didn't give any conclusive or plausible explanation for the reason why.
It's clear that if you're overweight or obese, a significantly higher number of women will have undiagnosed obstructive sleep apnea. Losing weight will improved symptoms of obstructive sleep apnea, which include hot flushes, night sweats, mood swings, insomnia, and irritability. We know that even young men can have these same symptoms. These symptoms are not directly caused by hormonal changes per sé—it's the relative change in the person's sleep-breathing status that can cause these vasomotor neurologic symptoms.
For the men out there with obstructive sleep apnea, do you suffer from hot flushes and night sweats?
June 21, 2010
In my last post I described a typical person that sees me for a few day history of throat pain. She has cold-like symptoms, but her exam is essentially normal. Her voice box does show mild swelling and inflammation, consistent with laryngopharyngeal reflux disease.
Upon further questioning, she remembers that she did have a late dinner with alcohol the night before she woke up with her throat pain. This confirms her laryngopharyngeal reflux disease diagnosis. But why does eating late cause throat pain the next morning, accompanied by cold symptoms? As I describe with my sleep-breathing paradigm, most modern humans stop breathing to various degrees at night while sleeping. If you're susceptible to this condition (due to having smaller jaw structures), having any additional stomach juices when you go to sleep will allow it to be suctioned up into the throat every time you stop breathing.
Not only does this cause throat pain and additional swelling and inflammation, it also aggravates more frequent obstructions and arousals, which suctions up more stomach juices.
Well, that explains throat pain, but why would you have fever, chills, and sweats? Isn't this classic for cold symptoms?
Whether inflammation begins with a cold or from reflux, they both cause additional swelling in the throat, aggravating more tongue collapse. When the tongue falls back more and more frequently, this process upsets the balance with your involuntary nervous system. This causes vasomotor symptoms such as fever, night sweats, flashes, and chills. So what may seem like a cold can actually be a nervous system overreaction, with no sign of infection whatsoever.
In this example patients, I just had her stop eating close to bedtime (along with alcohol), as well as to optimize her nasal breathing, by using nasal saline and nasal dilator strips. Usually, most of these problems go away within a few days.
What can you do if it doesn't go away? Find out my answer in a future blog.
October 28, 2008
It’s commonly known that women going through menopause experience hot flashes, night sweats, moods swings, irritability, insomnia and weight gain, but these same symptoms are known to occur in men as well. They generally occur in men in their 40s to 50s, thought to be due to slowly decreasing testosterone levels, along with other symptoms such as loss of sexual desire or functioning, depression, memory loss, or chronic fatigue.
But what if I told you that I see young men in their 20s coming in to see me with the same exact problems? What I’ve discovered is that it’s really not mainly a hormonal issue, but a problem with their breathing. Let me explain.
What I’ve noticed in all these young men is that they all have in common a relatively narrow upper airway. When examined with a thin flexible camera, the space behind their tongues is very narrow, about 2-3 mm wide. This is mainly due to smaller jaw structures and dental crowding. Whenever someone with this anatomy starts to fall asleep, his tongue muscle starts to relax, and in deeper levels of sleep, it relaxes almost completely, leading to partial obstruction, and awakening. Once awakened, the man turns over. In most cases, they usually don’t like to sleep on their backs for this reason.
Most people compensate very well by sleeping only on their sides or stomachs. However, if there’s anything that narrows the upper airway, either due to inflammation (allergies or a cold), or structurally (fat), the tongue collapses much easier and the person gets less efficient sleep due to multiple arousals.
Inefficient sleep leads to an imbalance of the involuntary nervous system, leading to what are called "vasomotor" conditions, such as sweating, heart palpitations, and temperature fluctuations. So is a young man with a predisposed anatomy is slowly gaining weight, he may experience all the above "male menopause" symptoms. If these obstructions last for more than 10 seconds, they are called apneas.
If you have more than 10 to 15 apneas every hour, then you may be diagnosed with obstructive sleep apnea. Untreated obstructive sleep apnea can lead to depression, anxiety, weight gain, erectile dysfunction, memory problems, hypertension, glucose intolerance, going to the bathroom often, heart disease, heart attack and stroke. The physiologic stress state that’s created also can lower one’s thyroid and testosterone levels, making it seem like he may have either hypothyroidism or low testosterone.
So in a sense, the "male menopause" phenomenon does happen, but not for the reasons that you may think. The word menopause literally means cessation of menses. Since men don’t have periods, this is not an appropriate word. Instead, it should be renamed something alluding to the progression of a sleep-breathing disorder. Do you have any of these symptoms or know anyone who’s going through "male menopause"?