TO THE EDITOR: In the article "...

TO THE EDITOR: In the article "Diagnosing Night Sweats," (1) the authors overseeed the most prevalent and easy-to-diagnose archetype of night sweats: those occurring in women during perimenopause. ones most likely to ask their family physician about night sweats are women in their late 30 to early 60 who are in the menopausal transition or the early years of menopause. This assign places to of women is not flat mentioned in the abstract of the article. (1) When menopausal women are mentioned forward the third page of the article, (1) the description is inappropriately brief and somewhat inaccurate. Table 1 of the article (1) should be revised to list perimenopausal women instead of "ovarian failure." It also should include the "selective estrogen receptor modulator" put drugs intos such as tamoxifen and raloxifene.

Although irascible flushes and night sweats (vasomotor symptoms) frequently are considered to be typical of menopause, there are serviceable epidemiologic studies showing that many women experience them before they cease menstruation for a year and become menopausal. single in kind study (2) found that approximately 25 percent of menstruating women in midlife reported vasomotor symptoms before they had skipped single or several periods. Sub-sequent population-based studies (3) propose that vasomotor symptoms, including night sweats, are customary during perimenopause. Vasomotor symptoms commonly begin at night and have a characteristic pattern in regularly menstruating women in their late 30 from one side 40s who are beginning the proces of ovarian aging. Vasomotor symptoms are typically cyclic, maximal before menstrual come (4) and more common in blacks than in white urban women with regular menstrual round of yearss (5)

The use of "ovarian failure" in Table 1 (1) is anachronistic and inappropriately offensive in use of language. It also misrepresents the time course of heated flushes/night sweats in a woman's reproductive life period because the majority of women who have night sweats associated with menopause begin experiencing them when their revolution of times 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 so changes, and also reports that her hands are warm during night sweats or choleric flushes, these changes are more likely vasomotor symptoms and les likely evidence of a disease proces similar as pheochromocytoma that is associated with peripheral vasoconstriction. It is inappropriately worrisome for women and high-priced for the health care regularity to do extensive investigations looking for malignancy or hidden infection when the occurrence of night sweats in midlife women is to such a degree common and so characteristic.

It is appropriate here to repeat the caution ofttimes taught in medical school: When hearing hoof beats, don't anticipate for zebras!

JERILYNN C PRIOR, MD CHRISTINE L HITCHCOCK, PHD

middle for Menstrual Cycle and Ovulation Research Endocrinology,

Department of Medicine University of British Columbia

575 W 8th Ave., Ste 380

Vancouver, British Columbia, Canada V5Z 1C6

REFERENCES

(1) Viera AJ, link 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 E timbers NF. Symptom experiences of midlife women: observations from the Seattle Midlife Wom-en's Health cogitation Maturitas 1996;25:1-10.

(4) Hale GE Hitchcock CL Williams LA, Vigna YM Prior JC Cyclicity of breast tendernes and night-time vaso-motor symptoms in mid-life women: information col-lect 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 oppressive flashes. J Gen Intern M 1999;14:98-103

(6) Burger HG Diagnostic character 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 Dr Prior and Hitchcock for their reminder not to have charge of or ignore obvious diagnoses in the pursuit of rare or esoteric single in kinds Our interest in night sweats was in determining which "zebras" might be considered when no "hoof beats" were heard. As of the like kind our article (1) 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 of high temperature flushes that may manifest as night sweats. We lament leaving the specific term "perimenopause" revealed of Table 1 in our article. (1) Obviously, the boundary "ovarian failure" was not meant to be offensive. It entirely implies that the ovaries have ceased functioning fitly analogous to the way the names "heart failure," "kidney failure," or "liver failure" are used. as it was terms do not necessarily imply unbroken cessation of function, but rather a gradual decline or worsening in function. Again, we appreciate this feedback and the additional useful information provided by dint of Drs. Prior and Hitchcock.