For years, Nora Barler lived by the fan. Literally: Barler had a fan on a stand in her office, plus a desk fan. Her bedroom was a chilly bunker, complete with central A/C, a window unit A/C, a ceiling fan and a bedside fan. Sometimes, even the fans weren't enough. "I'd go get the blue ice packs from the freezer," Barler says, "and sleep with those. I know it sounds over-the-top, but that's how it was."
Barler's enemy, the beast she hoped to slay with all those fans, was an all-too-common ailment: hot flashes, which afflict 75 percent of women during menopause. And despite a long tradition of knowing chuckles and dismissive humor around the malady, hot flashes are no joke.
"It's not just feeling sweaty for a few minutes," says Dr. David Walega, chief of pain medicine at Northwestern University Feinberg School of Medicine. "In the most severe hot flashes, women feel like they're having a panic attack. They feel like they need to flee or get away and the heart races, the fight or flight hormones are all going crazy. And all they can do is wait for it to end."
Luckily, Barler found Walega, and a treatment that may be the answer women with severe hot flashes have been desperately looking for. Walega's research has shown a startling impact on hot flashes with the use of a nerve-blocking shot that has been in use for pain management since the 1940s. In Barler's case, a single, expertly administered shot delivered two years of relief from symptoms that had tortured her for more than 20 years.
Walega's 40-patient pilot study of the use of the procedure, called a stellate ganglion block, for treatment of hot flashes showed that patients with severe symptoms experienced a 52 percent reduction in hot flashes, and got relief for an average of six to 12 months per treatment. His next phase of research, bolstered by a $3.4 million National Institutes of Health grant, is expanding that work to a larger sample size of 160 women and additional tests, including MRIs to capture the therapy's impact on the brain.
"Our research is ongoing," he says, "but from our pilot trial, it looks like there is a strong treatment effect. To me, this is a huge breakthrough."
Jean Medd would agree. She entered Walega's study when she spotted a flyer on the wall outside another doctor's office, soliciting participants who suffered debilitating hot flashes. Medd, a breast cancer survivor, struggled with hot flashes that might strike during her work day or up to 12 times per night, destroying her ability to sleep. "I was really in a bad place at work," she says. "I would sometimes sneak away and try to take a nap. I would be falling asleep at work. I was really not well."
A few days after she had the stellate ganglion procedure, she felt a change. "I had an incredible reduction in not only the frequency but the severity. The daytime hot flashes became very manageable for me. And in the evenings, my awakenings were reduced to three to five times a night. But, more importantly, I was able to fall back asleep right away. I would say that he changed my life."
For Medd and many like her, that kind of help from the medical establishment has been elusive, in spite of the disruptiveness of their condition. For about a third of women who experience hot flashes, the condition is so severe that it impacts relationships, work, sleep and even cognition.
Individual hot flashes can last up to 15 minutes and recur as quickly as 10 minutes later. The condition can persist for seven to 12 years, or longer for those who entered menopause as a result of cancer treatment. Women of color are more likely to experience greater intensity and longer duration of hot flashes, and the condition has been linked to cardiovascular disease, stroke, heart attack, weight gain and even cognition issues.
Yet current treatments are far from ideal. Hormone replacement therapy has been largely shunned by women and doctors after a 2002 NIH study showed a link between that therapy and breast cancer and heart attacks. Anti-depressants have been prescribed to treat hot flashes, but with limited efficacy. And alternative treatments such as flax and soy have been shown to have zero effect.
The lack of a viable, effective, safe therapy for a problem that affects so many makes this yet another area in which women's health seems to have gotten the short end of the stick. "Up until maybe 10 or 15 years ago, most gynecologists were men," Walega says. "And the only men who have hot flashes are men with low testosterone. So, hashtag MeToo. If men don't experience this, why would they think it's important? They've been counseling women, 'Oh, this will go away in a couple of years.' Your grandmother tells you, 'Oh, you know, it's a part of growing old; it's a right of passage.' "
When you suffer a sweaty panic attack in the middle of a workday, or have to give up attending events because you are afraid you'd need to change your soaked blouse mid-dinner, grandma's menopause jokes don't seem so amusing. "It's something that I find kind of disturbing because I think women's health gets so minimized in our pop culture," says Medd. "Someone's having a hot flash and it's a joke. Hot flashes can have a materially damaging effect on a lot of people."
Women, Medd and Barler say, misunderstand as often as men do. "People minimize it," Medd says. "I can't tell you how many times people would look at me and say, 'Oh yeah, I know what that's like,' and I'd think, 'You have no idea what this is like.' "
Walega, who had seen the effect of hot flashes via a good friend who is a cancer survivor, became curious about treatments after reading an article discussing a series of patients who had serendipitously experienced reduction of hot flashes after getting a stellate ganglion block, a procedure he performs regularly to treat pain from nerve issues or diseases such as shingles.
"It's a procedure that can be repeated indefinitely," he says, "and this is the same local anesthetic you would get if you were having a baby and had an epidural placed for labor."
Walega, guided by X-ray for precise placement of the anesthetic, administers a shot to the front of a patient's neck, delivering the medication directly to a cluster of nerves on the surface of the cervical spine. It needs to be administered by an experienced specialist, and Walega is able to perform the procedure in about a minute. Recovery is generally negligible – perhaps a slight bruise on the injection site – and patients typically get months of relief from hot flashes.
Scientists don't yet understand the cause of hot flashes, but Walega theorizes that their reduction post-stellate ganglion block may have something to do with neurotransmitters that come into play when nerves are over-excited and hypersensitive.
For now, he's just happy to know that the therapy seems to work, whatever the explanation. "When you're doing pilot studies of new stuff," he says, "you don't know what's going to happen. A lot of times it's like throwing horseshoes; you just miss. But we were very surprised not only at the treatment effect but the magnitude of the treatment effect."
With the new study, which will last for three to four years, Walega hopes to get closer to making stellate ganglion blocks a standard treatment for severe hot flashes. "I don't think this is the treatment for women who just power through an occasional hot flash," he says. "This is for women with debilitating, life-altering hot flashes."
He has done a preliminary analysis of potential costs of the treatment, and says that it balances out with the cost of hormone replacement therapy. Though it is unclear whether insurance companies will pay for the treatment, Barler, who has returned for multiple treatments over time, has found that her insurance would cover them. And, because the stellate ganglion block is already an established medical therapy, the treatment is, in theory, already available to women who seek it from pain specialists familiar with the procedure.
"It's exciting," says Walega. "If you had told me 10 years ago I was going to be a hot-flash expert, I would have said, 'You have the wrong number. I'm a pain specialist; we just do pain.' But here we are."
For Barler, it's more than just a potential answer for a nagging medical issue. 'It's a life changer," she says. "Day and night."