Prevalence of menopausal hot flashes in Lebanon: A cross-sectional study

Abstract Background Menopausal hot flashes or vasomotor symptoms are prevalent and could be debilitating in postmenopausal women. There is controversy regarding the risk factors for hot flashes, some of which may vary from one country or culture to another. Objective To shed light on this matter by assessing the prevalence of hot flashes, their effect on quality of life, and their association with certain factors such as physical exercise, caffeine, spicy food consumption, dietary intake, smoking, alcohol, etc. Materials and Methods A large cross-sectional study was conducted among 627 Lebanese women, aged 45-67 yr using a well-developed and comprehensive questionnaire, in order to better assess the prevalence of hot flashes, focusing on their characteristics, association with various factors, severity, and effect on the women's quality of life. Results 62.5% of participants experienced hot flashes. A statistically significant difference was noted between women who experience hot flashes and their counterparts with respect to smoking, body mass index, spicy food consumption, education level, age, menstrual status, and parity. An association was not found with physical activity or other dietary factors. Conclusion As an alternative for hormone therapy, clinicians should consider lifestyle changes to help manage hot flashes, which impose a tremendous physical and social toll on the women experiencing them.


Introduction
reported that having a mother who has had hot flashes or being a smoker were important risk factors (8

Ethical considerations
Each participant signed an informed consent form before their involvement in the study.

Prevalence of hot flashes and relation to lifestyle factors
Three hundred ninety-two females (63%) reported a history of hot flashes.

Management of hot flashes
Management of hot flashes and the relationship between hormone therapy and hot flashes were investigated as shown in Table IV. 89.1% of all participants did not use hormonal therapy, and hot flashes tended to be more prevalent among those who were non-users.

International Journal of Reproductive BioMedicine
Ahmadieh et al.

Discussion
The results of this study showed that there was a correlation between the occurrence of hot flashes and low level of educational attainment. This was also found in other studies (12,13). This relation can be attributed to the fact that a well-educated female is probably more aware of the menopausal stage and its complications and may be more likely to follows healthy protective lifestyle habits, which can ameliorate her hot flashes and even reduce their incidence (14). Our study showed a positive association between BMI (≥ 25 kg/m 2 ) and hot flashes among the postmenopausal females only. These findings were also shown in another study (15). On the other hand, other studies conducted in the United States (16) and the Netherlands (17) demonstrated a similar association but in perimenopause women only. Other studies have either reported no association between BMI and VMS (18) or have claimed a protective role of BMI (19), supporting the theory that excess adipose tissue is a source of aromatase that converts androstenedione to estrogens (20). We attribute our observed relationship to the thermoregulatory model of hot flashes, which states that in the presence of a narrow hypothalamic thermoneutral zone, the excess adipose tissue acts as a potent insulators preventing any heat dissipation, thereby elevating the core body temperature and precipitating hot flashes (21).
Our results revealed that a positive relationship existed between smoking and hot flashes showing that both current and former smokers were more likely to experience hot flashes. This association was also found while summarizing findings from Study of Women's Health across the Nation (22,23). One hypothesis for this association is that smoking causes hormonal fluctuations, because it interferes with estrogen enzymatic metabolism by CYP450 or alters the levels of adrenal androgens (24). Another possible hypothesis is the direct destruction of the ovarian follicles by the toxic hydrocarbons present in the cigarette (25). A third hypothesis is linked to the direct effect of nicotine on the hypothalamic nicotinic receptors (26).
Our study showed that coffee, soft drinks, and tea increased the incidence of hot flashes; however, only the results related to tea were statistically significant. Our results linked spicy food, fruits, and vegetables to the hot flashes. Similar results were shown in a prospective cohort study that examined relationships between six dietary patterns and hot flashes. The physiological link between these two variables could be attributed to the large amount of fiber and antioxidants, and low levels of transfatty acids present in fruits and vegetables. Spicy food consumption appears to increase levels of serotonin, which, in turn, lowers the hypothalamic thermal set point, precipitating hot flushes (27). Furthermore, our results indicated a statistically negligible association between hot flashes and various phytoestrogen-containing supplements including soybeans, whole grains, flaxseed, and fish. In contrast, it was noted that hot flashes were less prevalent among Asian females compared to their Western counterparts, proposing that the high intake of soy products in Asia (40-80 mg/day) was the cause (28)(29).
Various characteristics of hot flashes vary widely among studies. Unlike our results, for instance, the average duration was > 5 yr in the Melbourne Women's Midlife Health Project (30) and the median duration was four yr in a meta-analysis (31). The severity of hot flashes among our participants was generally mild and tolerable.
The limitations of our study include that since it was a cross-sectional study, no causal associations could be established. In addition, the majority of data were subjective and obtained from participants themselves. Moreover, participants had to recall information from the past, which could introduce recall bias.

Conclusion
In short, the dilemma of hot flashes has for so long ensnared the interest of investigators and confused them by their complex vague pathogenesis. By demonstrating significant associations between hot flashes and certain modifiable risk factors such as smoking, BMI, and spicy food consumption, our study sheds light on the important contribution of behavioral and lifestyle habits to the occurrence of hot flashes and suggests the possibility of tackling these symptoms by alternatives to hormone replacement therapy.