Hot flushes

A wave of heat that comes out of nowhere, usually up through the chest, neck and face.

When one happens in your sleep and leaves you wet through, it has its own name: a night sweat. Doctors call the two together vasomotor symptoms, which is the word you will find in the guidelines.

Heat climbing from your chest while everyone else in the room is comfortable. A face that goes red mid-conversation. Sweat at the hairline under your dupatta. Your heart racing for no reason, or a jolt of panic just before the heat arrives. Then, sometimes, cold and shivery once it passes.

In Urdu most women say garmi lagti hai. Some tell their doctor they keep getting a fever, and the flush goes unrecognised. Even four official Urdu health leaflets translated hot flushes as mild fever.

The Pakistan Menopause Society's recommendations describe hot flushes as coming from the brain's temperature control going off balance as estrogen changes. Think of a thermostat turned oversensitive, switching on all the cooling at once: the flushing, the sweat, the faster heartbeat.

That is why a flush can arrive in a cool room in the middle of winter. The room has not changed. The setting has.

• The NHS website lists lighter clothing, a cooler bedroom at night, a cool shower, a fan or a cold drink, ways to lower stress, regular exercise and a healthy weight. Among the possible triggers it names to avoid or cut down are spicy food, caffeine, hot drinks and smoking.
• The European Menopause and Andropause Society (EMAS) says the evidence on whether exercise eases hot flushes is mixed. It still advises exercise for stronger bones and fewer falls. Just do not count on it to cool the flushes.
• On weight, The Menopause Society says the limited evidence suggests losing weight may ease hot flushes for some women, and may do more earlier in the transition.
• The British Menopause Society also names caffeine among the things that may increase hot flushes. On chai, the Pakistan Menopause Society notes that tea drinking is high in Pakistan and asks doctors to talk it through with you, timing and quantity included (Table 7).

NICE NG23 and the PMS recommendations both list HRT as a first-line option for hot flushes, in women who can take it. Whether you can is your doctor's call. The NHS website says HRT may not suit women with a history of breast, ovarian or womb cancer, untreated high blood pressure or liver disease, and NICE NG23 tells doctors to consider specialist advice for a woman with a condition HRT may affect (1.8.2).

NICE NG23 sets out three more lines a woman should know about:

• On CBT: "Consider menopause-specific cognitive behavioural therapy (CBT) as an option for vasomotor symptoms associated with menopause" (1.5.2). The PMS recommendations also recommend CBT for hot flushes and mood, in person, in a group or remotely (4.2.4.1).
• On a newer non-hormonal medicine: "Fezolinetant is recommended as an option for treating moderate to severe vasomotor symptoms associated with menopause when HRT is unsuitable." (1.5.3)
• On antidepressants: "Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone." (1.5.4)

That last line matters here. An audit of 250 women aged 45 to 55 diagnosed with depression at Benazir Bhutto Hospital in Rawalpindi, presented at a conference in 2024, found that 78% had significant perimenopausal symptoms that had been missed (Gul, 2024). If an antidepressant is offered for hot flushes alone, asking what it is for is a fair question.

EMAS adds that the non-hormonal medicines, fezolinetant and some antidepressants among them, tend to work less well than HRT.

If the flushes are new, or they are wrecking your sleep or your work, that is reason enough to book an appointment.

See a doctor sooner if the heat comes with a very high temperature, or feeling hot, cold and shivery, a cough or diarrhoea, or if you are losing weight without trying. The NHS website lists those alongside night sweats as signs a GP should check, because they can point to something other than the menopause.

A flush on a fasting day hits differently. No water until Maghrib, a warm kitchen at iftar, a packed row at taraweeh. Women ask whether the heat changes anything about how they fast, and it is a question they rarely get a straight answer to. Questions about the fast itself belong with a qualified scholar. Questions about medicine timing in Ramadan belong with whoever prescribes it.

At home, the hard part is often explaining a red face and a soaked kameez to a husband or a mother-in-law who has never heard the word. Having a word for it that you can say out loud is a start.