Why am I having hot flashes in the middle of a benzodiazepine taper?
Hot flashes, drenching night sweats, and swings from chilled to sweating are a recognized physical symptom of benzodiazepine withdrawal. The Ashton Manual lists flushing, sweating, and palpitations in Table 1 of Chapter 3, and the same chapter, under bodily sensations, says that sensations of hot and cold are not uncommon during withdrawal. Professor C. Heather Ashton described the flushing, sweating, and pounding heart of withdrawal as the expression of an overactive autonomic nervous system, not heart or lung disease.
Yet, when you describe these symptoms at an appointment, they usually get filed elsewhere. A woman in her late forties hears menopause. Everyone else hears thyroid or anxiety, and anxiety is often the reason the benzodiazepine was prescribed in the first place, so the circle closes neatly.
The reduction you made two weeks ago is rarely on the list. Withdrawal is expected to look like anxiety and insomnia, and a body temperature problem does not fit. So, how do you tell whether your hot flashes are hormonal, glandular, nervous, or the taper?
Menopause, the thyroid, and anxiety are the three usual explanations.
Each of the three is a reasonable guess, and each can be checked. Menopause is the default for women in the perimenopausal years, which are also the years when many people have taken a benzo for a decade or more. While an overactive thyroid produces sweating, palpitations, and heat intolerance too, it is a simple blood test to rule out.
Anxiety is the trickiest of the three, because it is incomplete rather than wrong. Withdrawal does raise anxiety, and anxiety does raise heart rate and sweating. Yet, a nervous system reacting to a lower drug level is a different thing from a person who is worried about something.
Dr. Leeds’ view is that the three explanations deserve their turn. The problem is that the fourth one, the taper itself, so often never gets one.
What do withdrawal-related temperature swings feel like?
Patients describe episodes that arrive without a trigger, in a cool room, sitting still, at any hour. The heat comes with flushing of the face and chest, sweating, sometimes a pounding heart, tremor, and an inner agitation that can be louder than the heat itself. Then it passes, and what follows is sometimes the opposite.
The opposite is a chill that no blanket reaches. Some people describe hours of shivering followed by an hour of sweating, with abrupt transitions. This alternation is one of the more distinctive features, because menopause and an overactive thyroid tend to run in one direction.
There is also a mismatch between what you feel and what your body is doing. You may feel as if you are burning while a partner’s hand on your forehead finds cool skin, or frozen in a warm room. The fault is in the control system rather than the room.
Why should a drug for anxiety do this? The brain’s temperature control is thought to run partly through the same GABA, or gamma-aminobutyric acid, signaling that the benzodiazepine acted on for years, and that system does not reset the moment a dose comes down. That is about as far as the evidence takes us.
The time-locking test is the tell.
Symptoms that begin or worsen in the days after a dose reduction, and settle when the dose is held, are pointing at the taper. Menopause does not read your taper calendar. Neither does a thyroid.
So, keep one. Write down the date of each reduction and, separately, the days the hot flashes or night sweats were worst, then look at the two side by side. If the worst days cluster in the week or two after each reduction, you have your answer, in a form your doctor can read in thirty seconds.
An old shower is a fair picture of the problem, with limits.
Think of an old shower with a slow mixer valve. You turn the handle toward cold, nothing changes, so you turn it further, and a few seconds later the water goes icy. You swing back toward hot, overshoot again, and the swings only settle when you learn to make small turns and wait.
A nervous system coming off a benzodiazepine behaves something like that valve. The drug held it at one setting for years, and with each reduction the system overshoots hot and cold before finding its level. While this is not a perfect analogy, since a shower has one valve and you have a great many receptors, it fits what patients describe.
It also fits the remedy. Small turns, and wait.
Both can be true at once.
A woman in the perimenopausal years who is tapering a benzodiazepine can have hormonal hot flashes and withdrawal hot flashes at the same time. The two follow different calendars. The hormonal ones track her cycle and the years, and the withdrawal ones track her reductions.
Your doctor may check a follicle-stimulating hormone, or FSH, level and thyroid function, and look for other causes if the picture is unusual. What the tests cannot do is tell you how much of the heat is the taper, since there is no blood test for withdrawal.
Response is the better guide. A common pattern is a woman who starts hormone therapy for hot flashes that began, to the day, after her second reduction, gets partial relief, and finds the rest when the taper is held. Both things were true.
Withdrawal flushing also tends to keep company. Tingling, sensitivity to light and sound, muscle twitches, and gastrointestinal, or GI, upset sit on the same Ashton table, and a hot flash that arrives with several of them is more likely to be withdrawal than one that arrives alone.
Slowing or holding the taper is the first relief.
Fortunately, the calendar that finds the symptom also points at the relief. If reductions bring on the heat, fewer and smaller reductions bring on less of it. Chapter 2 of the Ashton Manual says to design the schedule around your own symptoms and to stand still for a few weeks and have a vacation from further withdrawal if circumstances call for it, and the Maudsley Deprescribing Guidelines describe hyperbolic tapering, with reductions that shrink as the dose falls, because the low doses are where each step is felt most.
Unfortunately, a patient who asks to slow down is sometimes treated as though they were clinging to the drug. Physical dependence is not addiction. Dependence is the nervous system’s adaptation to a medication taken as prescribed, and the pace at which it can un-adapt belongs to the nervous system, not to willpower.
What a hold does not mean is stopping. The 2020 United States Food and Drug Administration (FDA) benzodiazepine label update warns that abrupt discontinuation or rapid dose reduction can bring on severe withdrawal, including seizures. A hold keeps the dose steady until your temperature control catches up, and the pace after that is a conversation between you and your doctor.
What do patients try for the episodes themselves?
None of this is a cure, and the evidence for any of it is thin, so what follows is what patients report, which varies. Layers that come off in seconds, a fan by the bed, a cool bedroom, and separate covers so a night sweat does not wake two people are the common ones. Some keep a cold drink or a damp cloth within reach, and some find slow, paced breathing takes the edge off the agitation that comes with a flush.
Every medication added for the heat brings its own dependence or discontinuation profile into a taper that already has one, and the drugs offered for menopausal hot flashes are no exception. The comfort medications that come up most often are compared, with their trade-offs, in clonidine versus propranolol for symptom relief. Hormone therapy for a hormonal piece is a decision for you and your doctor, and it will not reach the withdrawal piece.
Sometimes the heat is not withdrawal, and it needs to be checked.
Withdrawal is a diagnosis you settle on after other things have been looked at. A fever with the sweats, unexplained weight loss, night sweats with swollen glands, a cough that will not clear, or a fast or irregular heartbeat that does not settle between episodes are reasons to be examined rather than reassured, and so are hot flashes with no relationship to your reductions.
Chest pain, fainting, a seizure, or a sudden loss of vision or hearing is a reason for emergency care that day. It is not a note for the next appointment. A taper never makes any of those safe to wait on.
For most patients, the swings settle.
The heat is temporary for most patients, even when it has gone on long enough to feel permanent. The nervous system recalibrates at its own pace, and for many people the thermal symptoms ease over the months after the taper ends, along with the broader picture known as benzodiazepine-induced neurological dysfunction, or BIND. No one can give you a date, and an honest doctor will say so.
What you can do is hand your doctor the calendar. If the reductions are too big for your temperature control, your doctor can help you make them smaller, and if the holds are working, the two of you can agree on when to move again. The calendar that proved the heat was the taper will, in time, show you the day it stopped coming.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.