Chai, coffee and caffeine

Caffeine is the stimulant in tea, coffee, cola and many energy drinks. In Pakistan much of it arrives as chai, which brings its own twist: a drink that is caffeinated and hot at the same time, and usually sweet.

This topic is about that cup. Not giving it up, just knowing what the guidance says about it.

The Pakistan Menopause Society's recommendations describe hot flushes as the body's temperature control going off balance as estrogen changes. Some things seem to tip it over more easily. The British Menopause Society's tool for clinicians lists caffeine and spices among the things that may make hot flushes worse. The PMS lists excessive caffeine as something that may break up sleep (Table 7).

Heat counts as well. The NHS website lists hot drinks as a trigger in their own right, separate from caffeine. A steaming cup of chai is both at once.

Then there is sleep. The PMS sleep hygiene advice includes limiting caffeine in the evening (section 4.2.3). If the last cup of the day comes after Isha, that line is worth a second look.

• Moderation, not cutting out. The PMS Table 7 advises moderation for excessive caffeine and asks doctors to talk through both timing and quantity, because chai drinking is high in Pakistan.
• The NHS website suggests avoiding or cutting down on possible triggers, caffeine and hot drinks among them, and lists a cold drink as one way to ease a flush.
• The NHS water and drinks page says to drink caffeine in moderation, and that some people are more sensitive to it than others. Tea and coffee still count towards your daily fluids.

None of these give a number of cups, and Roshara will not either. Your own pattern is the useful thing to know. Trigger tracking means noting your flushes and what came before them, and over time it can show whether chai is one of yours.

If hot flushes or broken sleep are wearing you down, that is reason enough to book an appointment, and caffeine is a fair thing to bring up there. The PMS asks doctors to discuss it with you, so you will not be the one raising something odd.

If your heart races or thumps, mention it even if you think it is just the tea. The Pakistan Menopause Society lists palpitations alongside hot flushes among the early symptoms of the menopause transition (Table 1), and a doctor should hear about them either way.

Saying no to chai at someone's house can feel like refusing the welcome. Women ask how to cut down without offending a mother-in-law or a host who has already put the pan on. A smaller cup, a weaker one or something cold are all polite ways out. You do not owe anyone an explanation of your hot flushes in order to decline another cup.

In Ramadan, chai often lands at sehri and again after iftar, which puts caffeine and heat at either end of a long, dry day. The blog's piece on fasting and temperature goes into that day, and questions about medicine timing during the fast belong with whoever prescribes it.