Introduction

Hot flushes affect up to 80% of women during menopause and can be severe and debilitating.¹ 

While the precise cause of menopausal hot flushes is not fully understood, this case study highlights an often-unrecognised mediator of menopausal hot flushes as a potential symptom of histamine excess or intolerance.²  

Mast cells are sensitive to oestrogen fluctuations, with mast cell degranulation and subsequent histamine release playing an important role in ovulation and implantation.³ Studies examining the role of histamine in menopausal flushing are lacking, however one randomised controlled trial found anti-histamine medication significantly reduced hot flushes in menopausal women.⁴ Stabilising mast cells and reducing histamine load may therefore reduce the frequency and severity of hot flushes.     

Oestrogen fluctuations, adrenal function and hot flushes are also tightly linked. Catecholamines play a key role in thermoregulation via central adrenergic receptors. They are thought to be the primary trigger for menopausal hot flushes. Fluctuating oestrogen levels impact the production of catecholamines from the adrenal glands and modulate the number of adrenergic receptors in the brain, increasing the brain’s sensitivity to core temperature fluctuations.¹ On the other hand, the adrenal glands should at least partially compensate for the reduced ovarian production of sex hormones in menopause. During perimenopause, the adrenal production of dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEA-S) and androstenediol significantly increases. These hormones can ultimately be converted to oestrogen and oestrogenic compounds, easing the menopausal transition.⁵ However prolonged stress may cause adrenal fatigue and impact the ability of the adrenals to provide this compensatory mechanism. Thus, it is important to also support the adrenal glands to relieve menopausal symptoms.

Initial Presentation

A 48-year-old woman presented to my clinic suffering debilitating hot flushes, up to 4 times per hour, accompanied at times by widespread pruritis. She also experienced poor libido, vaginal dryness, depression and exhaustion. Her menstrual cycle had become irregular over the previous 18 months, and absence of menses for 8 months. She had been under extreme stress for the past 2 years, caring for her mother through a terminal illness. She also suffered allergic rhinitis and mild asthma, which had both worsened along with her peri-menopausal symptoms. She occasionally used a Ventolin puffer to relieve her asthma and an over the counter anti-histamine for her allergic rhinitis.

Her diet was healthy, but analysis found it to be high in histamine containing and histamine liberating foods. Careful questioning revealed that her hot flushes were less severe on days she had taken anti-histamine medication for her allergic rhinitis. 

Treatment Plan

Provide symptomatic relief from hot flushes and other menopausal symptoms, support adrenal function, reduce histamine load and stabilise mast cells.

Initial Prescription

• A tablet containing supportive herbs for menopause such as: Dioscorea villosa (Wild Yam), Asparagus racemosus (Shatavari), Actaea racemosa (Black Cohosh) root, Hypericum perforatum (St John’s Wort). Dosed at 3 tablets twice daily.
• Glycyrrhiza glabra (Licorice) and Rehmannia glutinosa (Rehmannia) tablet for adrenal support. Dosed at 1 tablet twice daily
• Quercetin + C tablet, containing quercetin, bromelains and ascorbic acid. Dosed at 2 tablets twice daily
• Low Histamine Diet; restricting histamine containing and histamine liberating foods, including aged cheeses, alcohol, aged and smoked meats, fermented foods and beverages, black and green tea, shellfish, chocolate, citrus fruits, tomato, avocado, spinach and banana
• Minimise exposure to known allergens, such as dust mites

6-Week Follow-Up

Compliance with the treatment plan was very good. The patient had noticed a significant reduction in hot flushes, from 4 per hour down to 1 every few hours. The intensity of the flushes had also decreased.  She had noticed a definite correlation between high histamine foods and her hot flushes, having attended a wedding where she drank champagne and ate smoked meats, aged cheeses and chocolate. Her hot flushes and itching were significantly worse for several days following. Her mood and energy had improved somewhat, and her asthma and allergic rhinitis symptoms were stable.

Treatment Plan

Continue previous treatment plan with a slight reduction in dose.

Prescription

• Herbal Menopause Support tablet, 2 tablets twice
• Adrenal Support tablet, 1 tablet twice daily
• Quercetin + C tablet, 2 tablets twice daily
• Low Histamine Diet

12-Week Follow-Up

The patient’s hot flushes were now well controlled, occurring only occasionally when exposed to high temperatures or exercising. Her mood and energy had lifted considerably. She still experienced some vaginal dryness, but it was less noticeable and her libido was higher. She had not experienced any asthma attacks in the past month and her allergic rhinitis was considerably better. She was however missing cheese and wine greatly.

Treatment Plan

Gradually reintroduce histamine containing and liberating foods, to point of tolerance. Continue to support adrenal function and mast cell stability and provide symptomatic relief of menopausal symptoms at a reduced dose.

Prescription

• Herbal Menopause Support tablet, 1 tablet twice daily
• Adrenal Support tablet, 1 tablet twice daily
• Quercetin + C tablet, 1 tablet twice daily
• Reintroduction of histamine containing and liberating foods

16-Week Follow-Up

The reintroduction of histamine foods went well, with most foods being tolerated in moderate amounts, except alcohol which triggered flushes. Her menopausal symptoms, asthma and allergic rhinitis were all well controlled, even with the reduction in supplement dosages.

Treatment Plan

Maintain gentle adrenal and hormonal support.

Prescription

• Herbal Menopause Support tablet, 1 tablet twice daily
• Adrenal Support tablet, 1 tablet twice daily

Conclusion

Histamine excess or intolerance may play an unappreciated role in menopausal hot flushes. Identifying those patients for whom histamine is an issue may help them to avoid years of uncomfortable menopause symptoms.

References

1. Huguet I, Grossman A. Management Of endocrine disease: Flushing: current concepts. European journal of endocrinology. 2017 Nov 1;177(5):R219-29.
2. Izikson L, English III JC, Zirwas MJ. The flushing patient: differential diagnosis, workup, and treatment. Journal of the American Academy of Dermatology. 2006 Aug 1;55(2):193-208.
3. Zierau O, Zenclussen AC, Jensen F. Role of female sex hormones, estradiol and progesterone, in mast cell behavior. Frontiers in immunology. 2012 Jun 19;3:169.
4. Sikon A, Thacker HL. Treatment options for menopausal hot flashes. Cleveland Clinic journal of medicine. 2004 Jul 1;71(7):578-82.
5. Lasley BL, Crawford S, McConnell DS. Adrenal androgens and the menopausal transition. Obstetrics and Gynecology Clinics. 2011 Sep 1;38(3):467-75.