Letters to the Editor
Night Sweats Are Commonly Vasomotor Symptoms
to the editor: In the article "Diagnosing Night Sweats,"1 the authors overlooked the most prevalent and easy-to-diagnose type of night sweats: those occurring in women during perimenopause. Persons most likely to ask their family physician about night sweats are women in their late 30s to early 60s who are in the menopausal transition or the early years of menopause. This group of women is not even mentioned in the abstract of the article.1 When menopausal women are mentioned on the third page of the article,1 the description is inappropriately brief and somewhat inaccurate. Table 1 of the article1 should be revised to list perimenopausal women instead of "ovarian failure." It also should include the "selective estrogen receptor modulator" drugs, such as tamoxifen and raloxifene.
Although hot flushes and night sweats (vasomotor symptoms) often are considered to be typical of menopause, there are good epidemiologic studies showing that many women experience them before they cease menstruation for a year and become menopausal. One study2 found that approximately 25 percent of menstruating women in midlife reported vasomotor symptoms before they had skipped one or several periods. Subsequent population-based studies3 suggest that vasomotor symptoms, including night sweats, are common during perimenopause. Vasomotor symptoms commonly begin at night and have a characteristic pattern in regularly menstruating women in their late 30s through 40s who are beginning the process of ovarian aging. Vasomotor symptoms are typically cyclic, maximal before menstrual flow,4 and more common in blacks than in white urban women with regular menstrual cycles.5
The use of "ovarian failure" in Table 11 is anachronistic and inappropriately offensive in use of language. It also misrepresents the time course of hot flushes/night sweats in a woman's reproductive life cycle because the majority of women who have night sweats associated with menopause begin experiencing them when their cycles are still regular or becoming irregular. At this stage, follicle-stimulating hormone is highly variable and not diagnostic.6
In summary, whenever a woman reports night sweats, the attending physician must ask about other changes in her menstrual patterns and cyclic experiences. If she has experienced such changes, and also reports that her hands are warm during night sweats or hot flushes, these changes are more likely vasomotor symptoms and less likely evidence of a disease process such as pheochromocytoma that is associated with peripheral vasoconstriction. It is inappropriately worrisome for women and costly for the health care system to do extensive investigations looking for malignancy or occult infection when the occurrence of night sweats in midlife women is so common and so characteristic.
It is appropriate here to repeat the caution often taught in medical school: When hearing hoof beats, don't look for zebras!
REFERENCES
1. Viera AJ, Bond MM, Yates SW. Diagnosing night sweats. Am Fam Physician 2003;67:1019-24.
2. Kaufert PA. The perimenopausal woman and her use of the health services. Maturitas 1980;2:191-205.
3. Mitchell ES, Woods NF. Symptom experiences of midlife women: observations from the Seattle Midlife Women's Health Study. Maturitas 1996;25:1-10.
4. Hale GE, Hitchcock CL, Williams LA, Vigna YM, Prior JC. Cyclicity of breast tenderness and night-time vasomotor symptoms in mid-life women: information collected using the Daily Perimenopause Diary. Climacteric 2003;6:128-39.
5. Grisso JA, Freeman EW, Maurin E, Garcia-Espana B, Berlin JA. Racial differences in menopause information and the experience of hot flashes. J Gen Intern Med 1999;14:98-103.
6. Burger HG. Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition-an analysis of FSH, oestradiol and inhibin. Eur J Endocrinol 1994;130:38-42.
in reply: We thank Drs. Prior and Hitchcock for their reminder not to overlook or ignore obvious diagnoses in the pursuit of rare or esoteric ones. Our interest in night sweats was in determining which "zebras" might be considered when no "hoof beats" were heard. As such, our article1 was meant to aid the physician who was evaluating a patient complaining of night sweats without an obvious cause. We agree that the gradual decline in ovarian function seen in women in their perimenopausal years can lead to hot flushes that may manifest as night sweats. We regret leaving the specific term "perimenopause" out of Table 1 in our article.1 Obviously, the term "ovarian failure" was not meant to be offensive. It merely implies that the ovaries have ceased functioning properly, analogous to the way the terms "heart failure," "kidney failure," or "liver failure" are used. Such terms do not necessarily imply complete cessation of function, but rather a gradual decline or worsening in function. Again, we appreciate this feedback and the additional useful information provided by Drs. Prior and Hitchcock.
REFERENCE
1. Viera AJ, Bond MM, Yates SW. Diagnosing night sweats. Am Fam Physician 2003;67:1019-24.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy medical department or the U.S. Navy at large.
Potential Interaction Between Soy Milk and Warfarin
to the editor: In the article, "Panax ginseng,"1 the authors caution readers about the concomitant use of panax ginseng with warfarin (Coumadin). Besides ginseng, several other herbal medications, such as garlic and danshen (Salvia miltiorrhiza), may interact with warfarin, decreasing or increasing its anticoagulant effect.2 The most recent addition to this list is soy milk, which was reported to cause subtherapeutic international normalized ratio.3 Although soy milk is not a herbal medication, it is widely advocated as a nutritional supplement by practitioners of Western and traditional medicine.
Recently, there has been a surge of interest in soy milk as a health food for its antihypertensive4 and antihyperlipidemic5 properties and for use as a natural alternative to hormone therapy.6 The latter use has attracted special attention in light of the disquieting findings from the Women's Health Initiative trial, which demonstrated an increased incidence of cardiovascular events and breast cancer in women taking hormone therapy.
The use of warfarin in the management of atrial fibrillation, coronary artery disease, congestive heart failure, and strokes has become widespread. Also, the use of complementary or alternative medicine in the United States has become increasingly popular. For these reasons, every physician should be on the alert for possible interactions where excessive bleeding or unexpected prolongation of the international normalized ratio is encountered in any patient taking warfarin who otherwise has had good anticoagulant control.
REFERENCES
1. Kiefer D, Pantuso T. Panax ginseng. Am Fam Physician 2003;68:1539-42.
2. Cheng TO. Herbal interactions with cardiac drugs. Arch Intern Med 2000;160:870-1.
3. Cambria-Kiely JA. Effect of soy milk on warfarin efficacy. Ann Pharmcother 2002;36:1893-6.
4. Rivas M, Garay RP, Escanero JF, Cia P Jr, Cia P, Alda JO. Soy milk lowers blood pressure in men and women with mild to moderate essential hypertension. J Nutr 2002;132:1900-2.
5. Ho SC, Woo JL, Leung SS, Sham AL, Lam TH, Janus ED. Intake of soy products is associated with better plasma lipid profiles in the Hong Kong Chinese population. J Nutr 2000;130:2590-3.
6. Stark A, Madar Z. Phytoestrogens: a review of recent findings. J Pediatr Endocrinol Metab 2002;15:561-72.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
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Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
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