Hot flashes and night sweats, from the outside

In brief

• What this helps with. Knowing what a hot flash is, what it looks like from outside, and what to do in public and at home.
• One thing to do. Get cold water in front of her without comment, and know where the exit is.
• One thing to ask. "When it happens in public, do you want me to notice or not?"

She is halfway through a sentence at dinner when her face goes red. She stops, pulls off her cardigan, reaches for the water and fans herself with the menu while everyone at the table pretends not to notice. Three minutes later it is over, and she picks the sentence back up. From the outside it looked like a moment. From the inside it was the fourth one today.

What a flash actually is

A hot flash is a sudden wave of heat that starts in the chest, neck and face and spreads outward. Her skin flushes, she sweats, sometimes heavily, and her heart may race. When it passes she can be left damp, chilled and shivering. Most last a few minutes. They can arrive once or twice a week or several times an hour, and they are the same event whether she is in a meeting, in the car or asleep.

The cause sits in the brain, not the skin. The part of the brain that regulates body temperature works within a comfortable range, and as estrogen swings during perimenopause that range narrows until the thermostat becomes hair-trigger. A tiny rise in core temperature now sets off a full cooling response, which is what a flash is. It is a physical event with a known mechanism, not nerves and not drama.

How common, and for how long

Hot flashes and night sweats affect up to four in five women during the transition. In the Study of Women's Health Across the Nation, women with frequent hot flashes reported them for a median of 7.4 years, and the median ranged from just under five years for Japanese women to more than ten for Black women. Those are medians across large groups in one study, not forecasts for her.

The pattern varies as much as the length. When researchers tracked flashes across the transition they found four broad trajectories, from early and fading to late and persistent. Neither of you will know in advance which is hers, so plan as if it could be years, and be glad if it is shorter.

Night sweats are the same thing in the dark

A night sweat is a hot flash that happens while she is asleep. It wakes her drenched, often with her heart pounding, and she may need to change her shirt and the sheets before she can lie down again, only to lie awake. Three nights a week for a year, and you have the exhaustion that runs underneath everything else. The article on why she is not sleeping covers this issue and bedroom (sleep environments) changes that can help in detail.

What you see, and what she feels

From the outside you see a woman who flushes, strips off layers, goes quiet, fans herself, or steps out of the room. You might see her hesitate at the door of a warm restaurant or turn down a hug.

What she feels is different. Heat, first, and sweat running down her back in a room full of people. Then, often, the embarrassment of being visibly out of control in front of colleagues or strangers. Then the dread, because once a flash has passed many women are already waiting for the next one, and that waiting can shape a whole day. Many women describe a flash as the moment they feel oldest and most watched.

In public

• Stay quiet. Do not announce it, point at it or ask if she is all right in front of others. She knows what is happening.
• Get water in front of her. Cold, without comment.
• Ask once, and privately. "Do you want to step outside?" Then take her answer.
• Hold the exit. Know where the door is, sit near it when you can, and be ready to leave early without making it her job to explain.
• Find a Fan or a vent nearby if you're indoors.

At home

Agree on a temperature that errs cool and keep it there. A layer on your side costs less than a flash on hers. Put a fan where she sits and one on her side of the bed, and keep a spare shirt and a towel near the bed so a middle-of-the-night sheet change is a joint task, not her problem. If you do not live with her, the equivalent is choosing the cooler restaurant, the table by the door, and the evening walk rather than the noon one.

Be clear-eyed about what this does. Fans and cool rooms do not treat hot flashes, and the evidence for cooling techniques as a treatment is weak. They make each flash easier to live through, which is worth doing.

Triggers are her observation, not your rule

Many women notice that alcohol, spicy food, hot rooms, caffeine or a stressful meeting seem to set off a flash. Those observations are hers to make and act on. The Menopause Society's 2023 nonhormone position statement found that avoiding triggers has not been shown to reduce hot flashes, so this is not a rule for you to enforce. If she says the wine did it, believe her. If she orders the wine anyway, say nothing.

Treatments exist, and they help

For women who are appropriate candidates, hormone therapy is the most effective treatment for hot flashes and night sweats. Several prescription medicines that do not involve hormones also reduce them, including certain antidepressants, gabapentin, oxybutynin and fezolinetant. Cognitive behavioral therapy does not stop flashes but reduces how much they interfere with her life, and the evidence for that is good. All of these need a clinician's evaluation, because contraindications exist and the right choice depends on her history.

Your job is not to pick one. It is to know that care exists, to say so once and gently, and then to leave the decision with her. Getting to that care is not always easy. Cost, time off work and finding a clinician who knows menopause well can all stand in the way, and if she stalls there, practical help with the logistics is worth more than another reminder.

What not to say

"Is it hot in here or is it just you?" "You're glowing." "Again?" "My mother never made a fuss." Every joke about a hot flash risks telling her that the thing she is dreading is entertaining to you. Try "Do you want the window open?" and then open it.

Where to start this week

• Agree a cooler temperature tonight and put a fan on her side of the bed.
• Carry water and a light layer when you go out together.
• Agree in daylight on one private signal for "let's leave".
• Retire every hot flash joke you have ever made.

If she shares hot flashes with you in the app, ask whether she wants you to mention them, act on agreed requests, or wait for her to bring them up.

Related reading

• Why she is not sleeping, and how to help
• Hormone therapy, explained for supporters
• Nonhormonal options for hot flashes and sleep
• Practical ways to help, without being asked

Frequently asked questions

Sources

• National Institute on Aging. Hot Flashes: What Can I Do? U.S. National Institutes of Health.
• Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women's Health Across the Nation. Obstetrics and Gynecology Clinics of North America. 2011;38(3):489-501.
• Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine. 2015;175(4):531-539. SWAN cohort, n=1,449.
• Tepper PG, Brooks MM, Randolph JF Jr, et al. Characterizing the trajectories of vasomotor symptoms across the menopausal transition. Menopause. 2016;23(10):1067-1074.
• The Menopause Society. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
• The Menopause Society. The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society. Menopause. 2023;30(6):573-590.

Disclaimer

This article is for education and support. It is not medical advice, and it is not a substitute for care from a qualified healthcare provider. Decisions about treatment, including hormone therapy and other prescription medicines, belong to the person experiencing menopause and her clinician.