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Hot Flashes *and* Estrogen Dominance?

June 16, 2025 | 23 Comments | SAFM Team

There’s a durable myth in popular health/medical communities that hot flashes are necessarily an indication that a woman has overall low estrogen levels.  In fact, research does Not generally show a correlation between circulating estrogen levels and the incidence (or severity) of hot flashes.

Surprised?  Many practitioners are.  A hot flash is triggered by the hypothalamus in the brain and occurs to release heat that has built up in the body in response to a surge of norepinephrine and/or epinephrine (catecholamines or “stress hormones”).

In fact, a woman can indeed be estrogen dominant (and even have relatively high levels of estrogen) and still wrestle with hot flashes.  It is a sudden drop in estrogen (meaning a higher level of variation in estrogen triggered receptor activation) that can trigger the cascade that causes a hot flash.  But it’s more complex than than…

High cortisol, low cortisol, low progesterone, or low serotonin can all be drivers for hot flashes!  Clinical study shows that no hot flash remedy works for even the majority of women, much less “everyone” (e.g.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1764641/ ). 

Here is a combination of interventions that – together! – help many late perimenopausal women with persistent (day and night) hot flashes, to reduce their frequency/severity: 

  • 2 Tbsp ground flaxseed daily
  • Vitex twice daily (e.g. Gaia Herbs Vitex Berry), especially if still menstruating, even irregularly. 
  • Caffeine reduction (esp. intense doses e.g. coffee)
  • Alcohol reduction or elimination, including especially the elimination of wine (especially red wine, which is notably higher in histamine) and other fermented alcoholic beverages 
  • Dedicated help with significant Stress Relief and stress management habits (this is easy for most patients – and practitioners – to overlook, yet it’s essential). 
  • Maca root powder daily (e.g. Maca-Go as found in Feminessence, 2g/day, divided). Color of the root matters here (an indication of the differing levels/types of phyonutrients it contains). Absorption also appears to be much better gelatinized or cooked maca vs. raw. Add this low’n’slow as you need enough for efficacy, but too much may worsen hot flashes.
  • Support as needed to ensure deep, consistent, lengthy sleep (at least 7 hrs/night, ideally 8)
  • For many women in the earlier stages of perimenopause, the natural, progressive reduction in progesterone (while estrogen remains normal) causes a marked shift in histamine overload that is a common culprit in hot flashes. For many, agents that help reduce/degrade histamine are helpful and sufficient. For others, bio-identical progesterone support (especially micronized oral progesterone –  not a progestin) is needed to notably reduce these symptoms. 

In comparison to acute or episodic moderate stress, chronic stress often causes HPATG axis imbalance or dysregulation that can promote suboptimal progesterone levels that promote imbalances in estrogen receptor sensitivity.  Not a surprise this affects many women with only mild stress given (1) the widespread incidence of PCOS and over anovulatory dynamics and (2) since the ovaries begin to make less and less progesterone 5+ years prior to menopause (and it drops more dramatically and sooner than estrogen does).  In these scenarios, we are limited to progestone made by the adrenal glands, and this may be paltry given its health/function given other stressors at play!

For people who awaken with a “hot flash” type of experience in the 2-4am timeframe (and really only struggle with the flashes at night), consider re: root causes that a surge of cortisol or adrenaline is usually the culprit (e.g. early histamine surge, low blood sugar, and/or early Cortisol Awakening Response).  Taking calming adaptogenic herbs at night before bed can help (e.g. holy basil, ashwaghanda) as well as plant extracts that help to calm the action of adrenaline (such as magnolia, l-theanine e.g. Xymogen’s CortiSolv).

 I hope this quick clinical tip serves you and your patients and clients!

Warmly,

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23 Questions for “Hot Flashes *and* Estrogen Dominance?”

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  1. 11
    Roanne says:
    June 9, 2024 at 5:26 pm

    CortiSolv sounds good, though I cannot find a full disclosure of ingredients. Do they contain magnesium stearate? What other fillers? What about women with breast cancer, in menopause, having hot flashes. Are these supplements safe?

    Reply
  2. 10
    Leah Barr says:
    February 11, 2022 at 11:22 am

    On using flaxseeds to treat estrogen dominance or hot flashes in the case of someone with hypothyroidism: From what I understand cooking neutralizes the goitrogenic properties of things like cruciferous veggies…But since we don’t heat/cook flax seeds could there be a concern here? I’m finding different sorts of guidance in my research ranging from total avoidance of flax in the case of hypothyroidism to allowing for up to 2 TBS.

    Reply
  3. 9
    Silvia Wheeler says:
    December 20, 2021 at 11:51 pm

    Would you recommend maca for a patient suffering with hot flashes and peri-menopausal Melasma? Would you add Vitex and DIM ?

    Reply
    • 9.1
      SAFM Team says:
      January 4, 2022 at 6:53 am

      Vitex and DIM would be great for someone who indeed has low progesterone and issues with estrogen clearance and thus relatively high estrogen levels that could be contributing to the melasma. If this is the true context of the case then maca may not be the best choice at first. One would want to work on the improvement of estrogen clearance and balance. As for melasma, hormone imbalance is just one of the root causes and it is worth exploring other factors. Here are a couple of recent reviews on this topic:
      https://pubmed.ncbi.nlm.nih.gov/31735001/
      https://pubmed.ncbi.nlm.nih.gov/31793496/

      Reply
  4. 8
    Nadene Richter says:
    September 14, 2021 at 12:24 pm

    What could be the possible cause of someone getting hot flashes only in the 7 pm to 7 am window, and only in the cooler months of the year, from mid-Fall to mid-Spring?

    Reply
  5. 7
    Nan Foster says:
    December 2, 2020 at 6:47 pm

    While waiting for a DUTCH test to be administered and then weeks for the results, and with poor sleep due to hot flashes, is it safe to offer Vitex without knowing progesterone levels? This is for a menopausal 54 year old. I started her on 2 T of flax meal and eliminating wine, but that is not doing the trick.

    Reply
    • 7.1
      Nathalie says:
      December 4, 2020 at 8:53 am

      When it comes to hormone replacement or recommendation of any supplements that may cause changes to hormone levels SAFM always teaches to ‘test don’t guess” to avoid fueling a possible unwanted dynamic (e.g. estrogen dominance, cancer..)
      While studies about Vitex seem to show that it is mostly safe to use, there is no way to know exactly how a unique person may respond to a supplement. It’s important to mention that Vitex is not a fast-acting herb and symptoms relief might not occur immediately but rather may take up to 2-3 months. For that reason, perhaps it might make sense to wait for the test results. While Vitex doesn’t appear to contain any active hormones itself, it does work on hormones via dopamine, the opioid system and prolactin possibly increasing both estrogen and progesterone which may or may not be beneficial for a given person at a given time. As we discuss at SAFM, night hot flashes are generally caused by the release of cortisol and a dysregulation of the HPATG axis. Perhaps considering the use of calming adaptogenic herbs before bed could help (e.g. holy basil, Ashwaghanda) as well as extracts that help to calm the action of cortisol (e.g. magnolia, l-theanine). Encouraging calming activities such as yoga, but also ensuring optimal sleep and maintaining blood sugar levels is also very helpful.

      Reply
  6. 6
    Dina Assaad says:
    August 7, 2019 at 11:32 am

    What would be the protocol for someone with low estrogen ?

    Reply
    • 6.1
      SAFM Team says:
      August 18, 2019 at 7:13 am

      It will greatly depend on WHY estrogen is low and what are the levels of all the other sex hormones. As you know, the functional medicine approach is about going after the root cause vs just correcting what’s high or low on any given test. Also, when you consider hormone levels you have to do is in a global context of all the other hormones in the body and everything else that may be at play. Possible reasons for low estrogen could be menopause, very low-calorie diet, issues with fat digestion and absorption, excessively low cholesterol levels, stress, trauma and/or toxins and reversing of this state depends on the unique situation of the person with low estrogen.

      Reply
  7. 5
    Donna Rafferty says:
    March 5, 2019 at 8:45 pm

    If you have a client that is hypothyroid, early menopause, overweight and can’t seem to lose any weight. What tests would you say would be the most important tests to determine which is the driving force of the issue.

    Reply
    • 5.1
      SAFM Team says:
      March 15, 2019 at 5:22 pm

      First, I’d think which issue is the most pressing and the likely root cause of the current situation – hypothyroidism can be driving the weight gain and the early menopause so I’d be asking what’s causing the hypothyroid state: is it an issue with thyroid hormone production due to lack of nutrients (are the food choices generally poor, or is it GI function issue, T4 to T3 conversion or general toxicity issue) or is it driven by an autoimmune dynamic. For this reason, I would ask for a full thyroid panel: TSH, total T4, total T3, free T4, free T3, antibodies against TPO and Tg. Next, since you are mentioning the early menopause I’d like to find out about the hormone balance and if the funds and willingness are there I’d ask for a DUTCH complete to asses the sex and adrenal hormones. You may also enjoy this case study that speaks to the testing that I just described:
      https://schoolafm.com/ws_clinical_know/menopausal-client-where-to-begin/

      Reply
  8. 4
    Christine says:
    July 31, 2017 at 8:43 am

    I’ve recently experimented and found the ketogenic lifestyle has eliminated my hot flashes. I stop eating at 6 pm which eliminated my hot flashes and a huge side benefit of weight loss too. Reducing a lot of unwanted pounds. Can this be sustainable long term?

    Reply
    • 4.1
      SAFM Team says:
      August 7, 2017 at 6:51 pm

      Good for you! Alas, we are not able to give responsible, individual guidance in this type of venue; I encourage you to consult with your physician for your unique situation and needs. In principle, a ketogenic lifestyle can be healing and powerful as long as you are getting ample antioxidants via your food choices and as long as your blood sugar remains very well controlled and as long as your cortisol (stress hormone) levels remain optimal and balanced. This approach works well for many and not for others – a great example of the fact that there is no single “right” way of eating that is applicable to all. Many individuals with your type of experience find that long-term they are able to make a transition from a ketogenic to more of a low-carb diet which allows a richer variety of plant foods and high-antioxidant intake with more ease and convenience – while still maintaining your high energy and healthy weight.

      Reply
  9. 3
    Tiana says:
    July 10, 2017 at 1:24 pm

    Do you recommend “raw” or “gelatinized” maca?

    Reply
    • 3.1
      SAFM Team says:
      July 16, 2017 at 6:01 pm

      This is an interesting question. For the longest time, I never had a client have an issue with just using raw maca, so I happily recommended it to all who could benefit. But a couple years ago, I had three clients in a row struggle with GI upset, so I have moved to recommend gelatinized. I personally use raw for my own wellness and love it. Regardless – as you probably know – a strong and acquired taste; some people simply cannot palate it period.

      Reply
  10. 2
    Kim Rio says:
    May 24, 2017 at 10:19 am

    Are maca capsules (500mg) brand NOW ok to use instead of Maca powder?
    I’m not a fan of the taste.

    Reply
    • 2.1
      SAFM Team says:
      May 24, 2017 at 1:30 pm

      Yes, of course! But I would choose an organic brand (there are many). Indeed, the flavor is quite strong; I have found that client tend to either savor or highly dislike it. Capsules are a good item for our toolbox. Thanks for making that point.

      Reply
  11. 1
    Alison Middleton says:
    October 9, 2016 at 6:11 am

    Hi Tracy
    Can you please clarify when you might use vitex and when you might use maca? I am trying to understand their different functions. My naturopath suggests stopping vitex once clients are into menopause and then concentrating on black cohosh and maca and I am struggling to undertand why that might be. Thanks! Alison

    Reply
    • 1.1
      SAFM Team says:
      October 13, 2016 at 4:47 pm

      I don’t think about these as either/or options. They are both excellent tools; some people need them in combination actually. I have had many clients use either and some use both beneficially. So bottom line: both could be helpful! Either separately or in tandem. And certainly each unique person may find through experimentation that one agent works better for them than another. The principle of vitex is to increase a woman’s progesterone level, and the believe has been that it does so by increasing ovarian output. Your ND’s mindset likely comes from the notion that post-menopausally (or even late perimenopause) – when the ovaries are making very little progesterone in general – that vitex will not be as effective. However, there is some research showing that vitex can be effective postmenopausally as well for reducing hot flashes *in some people* (even though this largely goes against our current understanding of the vitex mode of action). But of course, herbs are complex and *often* have multiple modes of action that we may not fully understand scientifically. Again, vitex in this scenario in research studies helps some but not all. We know much less about maca’s mode of action, and it’s believed to work via increasing the action of multiple hormones. I don’t recommend maca when high testosterone is an issue because I do not want to risk boosting testosterone. I will recommend vitex specifically when low progesterone is a known issue. I typically find people need to take quite a bit of maca (2 tsp to 2 Tbsp) to get a therapeutic effect; some people love the taste while others hate it. So some people simply aren’t well suited for choosing maca. To your specific question, if someone is using vitex and it’s working, I wouldn’t stop it postmenopause but rather add other agents to it as necessary to continue symptom relief (as you say e.g. black cohosh, maca, and also ground flaxseed). I hope that’s helpful!

      Reply
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