You have seen your GP. You may even have started HRT. But the hot flushes are still there. You arrive at meetings sweaty, they wake you at night, and you dread getting the tube in the summer.

Dr Mayoni Gooneratne, PHC's Chief Functional Medicine Officer, wants women in this position to know there is a lot more that can be done. As she puts it, "there's a huge amount we can do before we say things aren't working."

First, make sure the flushes are menopausal

Before anything else, Dr Gooneratne wants to be confident that the flushes really are related to this time of life. Most of the time they are, but some patterns need particular assessment:

  • Flushes with unexplained weight loss
  • Drenching night sweats that soak through the bedding
  • Fever
  • Flushes that start suddenly or get dramatically worse, with no hormonal or cyclical pattern

These need a review. Thyroid function, medications, infections and rarer conditions can all cause flushes. "I'd like to say it's usually the menopause," she says, but it still needs proper checks.

Has your HRT really been optimised?

If the flushes are menopausal, this is her first question. "This is the commonest gap I see."

Standard doses are good enough for many women, but they are not right for everyone. If a woman starts on a standard dose of oestrogen and feels 30% better, everyone may think that is great. Dr Gooneratne looks further:

  • Dose. Some women need a higher dose of oestrogen.
  • Absorption. Some women absorb oestrogen through the skin poorly, and occasionally blood levels are worth checking.
  • The progestogen. The type of progestogen is often what causes trouble. Some women feel worse on certain types, and reviewing it can help.
  • Timing. Many women are still having perimenopausal cycles, and a regimen that works against your own cycle can feel chaotic. Sometimes the strategy is to suppress your cycle, and sometimes it is to support it.

All of this takes time and iteration, which is exactly what a standard appointment does not allow for.

Are non-hormonal options being used?

Her second question is whether everything else has been considered. There are several prescription non-hormonal treatments with good evidence for reducing hot flushes. Some can be a good option when HRT is not suitable.

They need careful prescribing. Some interact with breast cancer treatments, so a full medical history matters. There is also a newer class of non-hormonal medicines that act directly on the brain's temperature control pathway. Availability in the UK is still evolving, so ask your clinician what is right for you.

Cognitive behavioural therapy for hot flushes

Dr Gooneratne always mentions CBT for menopausal symptoms. "It doesn't touch a single hormone," she says, but it helps take the distress out of hot flushes. That matters, because stress is closely linked with hot flushes and can make them worse.

Start with the foundations

This is the area Dr Gooneratne loves to spend the most time on, and the one that is often treated last. At PHC, it is where she starts.

In her words, "we need to repair the foundations of your house and do some deep restoration work before we start putting in silk curtains."

That means looking at:

  • Your genetics, including how your body processes oestrogen and how well your liver breaks it down
  • Your timeline: when the flushes started relative to your hormones, and what makes them better or worse
  • Your history, including early life experiences, which she sees as closely connected with this stage of life

Why hot flushes deserve to be taken seriously

Dr Gooneratne takes hot flushes seriously, not just because they are miserable, but because of their important links with cardiovascular health. They are worth treating properly, not putting up with.

If flushes are also breaking your sleep, read why you wake at 3am in perimenopause.

Frequently Asked Questions

Why didn't HRT work for my hot flushes?

Often, HRT has not yet been optimised. The dose of oestrogen may be too low for you, you may absorb it poorly through the skin, the type of progestogen may not suit you, or the regimen may be working against your own cycle. Getting it right takes time and adjustment.

Are hot flushes a sign of something more serious?

Usually they are related to perimenopause or menopause. But flushes with unexplained weight loss, drenching night sweats, fever, or flushes that start suddenly and worsen without a hormonal pattern need review. Thyroid problems, medications, infections and rarer conditions can all cause flushes.

What if I can't take hormones?

There are prescription non-hormonal treatments with good evidence for reducing hot flushes, including a newer class that acts on the brain's temperature control pathway. Some interact with breast cancer treatments, so your full history matters. CBT for menopausal symptoms can also help, without using hormones.

Can CBT help with hot flushes?

Yes. CBT for menopausal symptoms does not change your hormones, but it can reduce the distress hot flushes cause. Because stress is linked to hot flushes and can make them worse, that can make a real difference.

Are hot flushes linked to heart health?

Dr Mayoni Gooneratne takes hot flushes seriously because of their important links with cardiovascular health. That is one reason they are worth treating properly rather than simply putting up with.

What else can cause hot flushes?

Thyroid problems, some medications, infections and rarer conditions can all cause flushes. That is why it is worth confirming that flushes are menopausal, particularly if they come with weight loss, fever or drenching night sweats.