A New Mother with Night Sweats

MedicineToday PEER REVIEWED CLINICAL CASE REVIEW

A new mother with night sweats

Commentary by CASE SCENARIO JOHN EDEN MB BS, FRCOG, FRANZCOG, CREI Sally is a 35-year-old woman who presents for her three-monthly contraceptive injection of depot medroxyprogesterone. She mentions in passing that since the birth of her second child, A 35-year-old woman has been experiencing nine months previously, she has been experiencing night sweats three or four times a week. She has no obvious focus of infec- night sweats since the birth of her second tion, no pain and no other systemic symptoms, although she child nine months previously. says she often feels very tired. She also reports that she is still producing some breast milk despite having stopped breastfeed- MedicineToday 2013; 14(4): 67-68 ing six months previously. Sally recalls that about two years ago, before she conceived her second child, she was quite sick with an ‘ovarian infection’ and then an ectopic pregnancy. Sally’s pelvic ultrasound results are normal, as are the results of urine and blood tests, including a full blood count, erythrocyte sedimentation rate, C-reactive protein level, thyroid function and serum prolactin level. Her serum follicle-stimulating hormone and other reproductive hormone levels are in the normal range for the luteal phase of the menstrual cycle. Professor Eden is Associate Professor of Reproductive Endocrinology at the What could be causing Sally’s night sweats? University of New South Wales; Director of the Barbara Gross Research Unit at the Royal Hospital for Women and the University of New South Wales; COMMENTARY Director of the Women’s Health and Research Institute of Australia; and Hot flushes and sweats are not unusual in women who are having Director of the Sydney MenopauseCopyright _LayoutCentre and 1 Medical 17/01/12 Co-Director 1:43 PM of Pagethe 4 regular menstrual cycles, especially during the bleeding phase

MedicineToday R april 2013, Volume 14, Number 4 67 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2013. CLINICAL CASE REVIEW CONTINUED

common after the birth of a baby, espe- flushes 12 months after the birth of her cially during breastfeeding as this is a third child. low-oestrogen state. Most women do not Her gynaecologist had prescribed a complain about these symptoms because combined oral contraceptive, which had of their focus on the new baby and its no effect on the flushes. I suggested she care. Vaginal dryness is also common at try citalopram (for its antiflushing rather this time. than antidepressant effect) at a dose of Nevertheless, it is important to make 10 to 20 mg for a month. The flushes sure that Sally’s night sweats do not have ceased within one to two weeks. Citalo- a more sinister cause. Sally should take pram was continued for six months her temperature by mouth when she is and she was then weaned off it. At the woken by sensations of heat. ‘Hormonal’ time of writing, she was waiting to see causes of hot flushes raise skin tempera- whether the flushes returned. I postulate ture but not central temperature. If she that the oestrogen withdrawal that finds her mouth temperature is raised on occurred after each birth disturbed the a few occasions then she will need further serotonin balance in her temperature- investigations to determine the cause of regulating system.1 this fever. Clonidine and gabapentin also have More likely, her mouth temperature antiflushing effects and might be worth will be normal, suggesting a hormonal trying to treat postpartum hot flushes. cause for the night sweats. Hormonal The dose of clonidine needed to reduce causes of flushes include low-oestrogen hot flushes is usually 100 µg twice daily, states, hyperthyroidism, calcium disorders which has the side effect of hypotension. (e.g. hyperparathyroidism), medullary Most trials of gabapentin for hot flushes thyroid cancer, mast cell tumours, phaeo - have used a dose of 900mg daily. chromocytomas and carcinoid syndrome. Each of these has a specific presentation KEY POINTS that should be considered. • Hot flushes can occur in premeno - Depot medroxyprogesterone induces a pausal women during low-oestrogen low-oestrogen state and might also be the states, such as after giving birth. cause of the hot flushes. In most cases, • It is important to differentiate women using depot medroxyprogesterone hormonal hot flushes from fever, do not experience flushes because the and also to exclude hormonal causes moderate dose of progestin has an anti- other than low oestrogen, such as flushing effect, but this is not always so. hyperthyroidism. A treatment strategy would be to with- • Treatment strategies include a hold the medroxyprogesterone, perhaps combined oral contraceptive or replacing it with a combined oral contra- nonhormonal therapies with specific ceptive, and to assess whether the flushes antiflushing effects, such as citalopram, disappear. clonidine or gabapentin. MT Another possible treatment strategy is illustrated by a case of my own that was REFERENCE similar to Sally’s case. My patient was referred for treatment of severe hot flushes 1. Nelson HD, Vesco KK, Haney e, et al. Nonhormonal after the birth of her third child. She had therapies for menopausal hot flashes: systematic review experienced similar flushes after the birth and meta-analysis. Jama 2006; 295: 2057-2071. of each of her children, but the flushes settled within a few months after the first COMPETING INTERESTS: Professor Eden donates Copyright _Layout 1 17/01/12child 1:43 and PM six Page months 4 after the second. any honoraria received from pharmaceutical companies However, she was still experiencing severe to a charity, Glory Reborn, in the Philippines.

68 MedicineToday R april 2013, Volume 14, Number 4 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2013.