What are the causes and treatments of night sweats?

Night Sweats: Causes and Treatment

Most Common Causes

In older women, menopause is the most frequent cause of night sweats, presenting as recurrent episodes of flushing, perspiration, and sensations of warmth to intense heat on the upper body and face, sometimes followed by chills. 1

Primary Diagnostic Considerations by Frequency:

• Menopause/hormonal changes - Most common hormonal cause in women 1, 2
• Mood disorders (including panic attacks) - Frequently overlooked but common 3
• Gastroesophageal reflux disease (GERD) - Common association 3, 4
• Hyperthyroidism - Most frequent endocrine cause after menopause 3, 2
• Obesity - Independent risk factor 3
• Obstructive sleep apnea - Consider when night sweats disrupt sleep 4

Serious but Less Common Causes:

• Infections: Tuberculosis, HIV 5, 3, 4
• Malignancies: Lymphoma (especially Hodgkin), other hematologic cancers 5
• Autoimmune diseases: Various rheumatic conditions 5, 1
• Medications: Antihypertensives, antipyretics, SSRIs/SNRIs, alcohol 5, 4

Initial Assessment Approach

Determine frequency, severity, and impact on quality of life first, then assess for red flag symptoms. 1

Key Historical Features to Elicit:

• Weight loss, fever, or fatigue - Suggests infection, malignancy, or autoimmune disease 1
• Timing: Exclusively nocturnal vs. day and night 3
• Associated symptoms: Cough, lymphadenopathy, pruritus 5
• Medication review: Recent additions or changes 4
• Menopausal status and contraindications to hormone therapy 1

Red Flags Requiring Urgent Investigation:

• Weight loss + fever + night sweats = "B symptoms" suggesting lymphoma or tuberculosis 5
• Lymphadenopathy or masses 5
• Persistent symptoms despite empiric treatment 3

Diagnostic Testing Strategy

If history and physical examination do not reveal a specific cause, proceed with systematic laboratory and imaging studies. 3, 4

First-Line Testing:

• Complete blood count with differential 3, 4
• Tuberculosis testing (PPD or interferon-gamma release assay) 3, 4
• Thyroid-stimulating hormone 3, 4
• HIV testing 3, 4
• C-reactive protein or ESR 3, 4
• Chest radiography 3, 4

Second-Line Testing (if first-line negative and symptoms persist):

• CT chest and/or abdomen 4
• Polysomnography (if sleep disruption prominent) 4
• Bone marrow biopsy (if hematologic abnormalities present) 4

Important caveat: Most patients with persistent night sweats in primary care do not have serious underlying disorders, and the presence of night sweats alone does not indicate increased risk of death. 3, 6

Treatment Approaches

For Menopausal Night Sweats:

Consider hormone replacement therapy if no contraindications exist; otherwise, use non-hormonal approaches first. 1, 7

Contraindications to Hormone Therapy:

• History of breast cancer 1
• Coronary heart disease 1
• Previous venous thromboembolism 1
• Stroke 1
• Active liver disease 1

Non-Hormonal Pharmacologic Options:

SSRIs/SNRIs (venlafaxine, paroxetine) and gabapentin have moderate efficacy for vasomotor symptoms. 5, 7

• Venlafaxine, paroxetine, and gabapentin reduce frequency and severity of hot flashes 5
• Desvenlafaxine (SNRI) is under investigation 5
• Side effects are common but typically do not lead to discontinuation when symptoms are controlled 5

Non-Pharmacologic Approaches:

• Cognitive behavioral therapy - Reduces perceived burden of hot flashes 7
• Sleep hygiene improvements 1
• Relaxation techniques: Progressive muscle relaxation, guided imagery, meditation 1
• Lifestyle modifications: Weight loss if overweight, smoking cessation, limiting alcohol if it triggers symptoms 7

For Medication-Induced Night Sweats:

• Alpha-adrenergic blockers may reduce night sweats in patients taking serotonin reuptake inhibitors 6

For Severe Primary Sleep Hyperhidrosis:

• Oxybutynin (anticholinergic) can be highly effective with minimal side effects 8

For Specific Underlying Conditions:

• BRAF inhibitor-related pyrexia with night sweats: Discontinue therapy temporarily, use acetaminophen/NSAIDs, resume at reduced dose after resolution 5
• Polycythemia vera-associated pruritus/night sweats: Aspirin 300 mg daily 5
• Tuberculosis: Isoniazid for 9 months (with vitamin B6) for latent TB; multi-drug regimen for active disease 5
• Lymphoma: Curative treatment resolves night sweats; high-dose corticosteroids provide symptomatic relief during treatment 5

When Reassurance is Appropriate

If comprehensive evaluation including first-line testing is normal and no additional disorders are suspected, reassurance and continued monitoring are recommended. 3 The symptom of night sweats appears nonspecific in most primary care patients, and life expectancy is not reduced. 6