Perimenopause & Beyond
What is flushing in menopause?
Hot flashes are prevalent during menopause. They generally involve intense heat surges accompanied by physiological responses such as sweating and vasodilation (widening of the blood vessels) often referred to as vasomotor symptoms or VMS. Flushing can happen day or night to women in perimenopause and beyond. Despite impacting millions of women globally, the physiological mechanisms underlying hot flashes are not extensively researched. However, technological advancements are starting to illuminate this fundamental menopausal phenomenon.
The physiological changes associated with the hot flush are different from any other flushing condition. Hot flushes cause increased peripheral (outside of the core of the body and not including muscle) blood flow, a higher heart rate, and unique skin changes.
Exciting research by Lisa Mosconi PhD looking at the menopause and the brain has described hot flushes/flashes as neurological events. They are believed to result from changes in the brain's thermoregulatory control mechanisms. The hypothalamus, which functions as the brain's thermostat, plays a central role. Magnetic Resonance Imaging (MRI) studies also indicate the involvement of brain regions such as the insula, anterior cingulate, somatosensory, and limbic regions.
- Insula (INS): this region processes bodily sensations and integrates sensory-motor, emotional, and homeostatic information.
- Anterior cingulate cortex (ACC): involved in cognitive and emotional control, it helps regulate body temperature and blood pressure—suggesting the brain is working to maintain balance.
- Limbic lobes: linked to the autonomic responses involved in hot flashes, potentially explaining the emotional responses that can accompany these symptoms. (1)
These findings show the brain network involved in hot flushes, underscoring their complexity and validating many women's experiences. Continued research into this area is much needed In order to prevent associated disease if necessary (some studies link VMS to degrading cardiovascular health) (2) and to support women in the reduction of at times, such anxiety inducing, embarrassing & debilitating occurrences.
Do some women experience flushing more than others?
Data from the SWAN study has previously shown differences between racial/ethnic groups in the prevalence and the treatment of VMS. Women with moderate to severe VMS are up to three-fold more likely to have moderate–severe depressive symptoms than other women (3, 4)
Other factors associated with an increased likelihood of VMS include not only menopausal status (perimenopause, postmenopausal or surgical menopause vs. premenopausal) but also
· age (VMS decreases with age (5))
· VMS increases with a high BMI, (6)
· VMS increases with depression & anxiety, (3,4)
· poor physical health, (7,8)
· high perceived stress, (5, 7)
· active and passive smoking,( 6)
· and (in immigrant populations) acculturation. (8)
What are the natural ways can I reduce or prevent flushing?
Lifestyle measures have varying results when it comes to flushing severity, duration and frequency. Areas for intervention include but aren’t limited to:
o Weight management – Weight reduction may result in reduced VMS in overweight women (9, 10)
o Avoiding alcohol – some women note worsening of flushing as well as other symptoms of menopause with alcohol consumption. Track and monitor your own personal experiences to uncover if this is a trigger for you.
o Caffeine is another anecdotal link to symptoms of flushing with many women reporting the onset of severe flushing in relation to coffee, tea and soft drink consumption. Spicy foods and sugar intake are other sources of flushing for some. Elimination diets often reveal the impact of these foods on overall health & wellbeing.
o Stress management *higher perceived stress (more common among Black women than White women) was associated with a longer duration of VMS (5,7) and so management of stress may play a role in reduction of VMS, physiological and mental health outcomes
o Acupuncture - A 2018 systematic review concluded that evidence from randomised control trials (RCTs) supports the use of acupuncture as an adjunctive or stand-alone treatment for reducing VMS (11)
o Cognitive behaviour therapy (CBT) uses psychotherapeutic behaviour modification to help women manage VMS. CBT has been proven to significantly reduce VMS, according to (10, 12 – 15)
o Phytoestrogens & Isoflavones, Some studies show effectiveness of phytoestrogens from herbal extracts such as Black Cohosh, red clover and soy isoflavones in hot flush reduction, A systematic review in 2019 concluded that isoflavones reduce hot flashes when used in doses of between 40-72 mg (16) although they do state that VMS are subjective and difficult to quantify and acknowledge that another possible determinant of treatment effect is whether equol is produced by the gut bacteria of the individual. When soy is eaten, certain bacteria in the gut change the chemicals found in soy into something called equol, however, this change or ability only occurs in 20-60% of people. One study found that supplementing equol to equol nonproducers significantly lowered the incidence and/or severity of hot flashes in menopausal women (17)
*Please note that Isoflavones from Red Clover and Black Cohosh are not recommended for women who have had breast cancer by any of the international bodies. (18)
Prescription medications for menopause flushing
Oestrogen and progesterone hormone replacement therapy (HRT) for flushing is first line treatment for flushing via the NHS based on Nice guidelines and the BMS and is the basis for clinical guidance in India, Malaysia, Germany & via the The Clinical Guidelines Subcommittee (CGS) of The Endocrine Society. . (12-15) This is an effective way to tackle VMS but unfortunately is not suitable for some women, Others prefer to avoid HRT altogether.
Fezolinetant acts centrally in the brain to reduce VMS It may improve sleep quality by reducing nocturnal VMS. Fezolinetant has been approved for the treatment of VMS in some countries including the UK (9)
NICE guidelines ouline the following non-hormonal medications for possible use during menopause: (19)
Selective serotonin reuptake inhibitors (SSRIs, or serotonin and norepinephrine reuptake inhibitors (SNRIs,
Clonidine (an alpha-2 adrenergic receptor agonist).
Gabapentin (off-label), depending on local prescribing guidelines.
Looking forward
Classifying hot flashes and night sweats merely as symptoms of menopause, rather than as manifestations of an underlying autonomic and vascular dysregulation, has impeded scientific investigation into the mechanisms governing these phenomena. This has consequently delayed the understanding of different aging trajectories in women attributable to oestrogen deficiency. (20, 21)
“Autonomic neurovascular dysregulation” may not be the only or final term to describe these physiological responses. However, the name describes a physiological phenomenon that can help to focus attention and research on the underlying control mechanisms. (20)
References
1 Mosconi, L., Berti, V., Dyke, J. et al. Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Sci Rep 11, 10867 (2021). https://doi.org/10.1038/s41598-021-90084-y
2 https://doi.org/10.1016/j.coemr.2023.100448
3 Fooladi E, Bell RJ, Masoumi M, et al. Bothersome menopausal symptoms amongst postmenopausal iranian women. Climacteric. 2018;21(6):586–593. doi: 10.1080/13697137.2018.1493452.
4 Worsley R, Bell RJ, Gartoulla P, et al. Moderate-severe vasomotor symptoms are associated with moderate-severe depressive symptoms. J Womens Health. 2017;26(7):712–718. doi: 10.1089/jwh.2016.6142.
5 El Khoudary SR, Greendale G, Crawford SL, et al. The menopause transition and women’s health at midlife: a progress report from the study of women’s health across the nation (SWAN). Menopause. 2019;26(10):1213–1227. doi: 10.1097/GME.0000000000001424
6 Gartoulla P, Worsley R, Bell RJ, et al. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause. 2018;25(11):1331–1338. doi: 10.1097/GME.0000000000001237.
7 Harlow SD, Burnett-Bowie SM, Greendale GA, et al. Disparities in reproductive aging and midlife health between black and white women: the study of women’s health across the nation (SWAN). Womens Midlife Health. 2022;8(1):3. doi: 10.1186/s40695-022-00073-y. .
8 Melby MK, Anderson D, Sievert LL, et al. Methods used in cross-cultural comparisons of vasomotor symptoms and their determinants. Maturitas. 2011;70(2):110–119. doi: 10.1016/j.maturitas.2011.07.010.
9 The 2023 nonhormone therapy position statement of the North American menopause society. Menopause. 2023;30(6):573–590.
10 Kroenke CH, Caan BJ, Stefanick ML, et al. Effects of a dietary intervention and weight change on vasomotor symptoms in the women’s health initiative. Menopause. 2012;19(9):980–988. doi: 10.1097/gme.0b013e31824f606e.
11 Befus D, Coeytaux RR, Goldstein KM, McDuffie JR, Shepherd-Banigan M, Goode AP, Kosinski A, Van Noord MG, Adam SS, Masilamani V, Nagi A, Williams JW Jr. Management of Menopause Symptoms with Acupuncture: An Umbrella Systematic Review and Meta-Analysis. J Altern Complement Med. 2018 Apr;24(4):314-323. doi: 10.1089/acm.2016.0408. Epub 2018 Jan 3. PMID: 29298078.
12 Meeta DL, Agarwal N, Vaze N, et al. Clinical practice guideline on menopause, 2nd ed. India: Indian Menopause Society; 2020.
13 Obstetrical and Gynaecological Society of Malaysia MMS. Clinical practice guidelines management of menopause in Malaysia. Kuala Lumpur: Obstetrical and Gynaecological Society of Malaysia, Malaysian Menopause Society; 2022.
14 Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975–4011. doi: 10.1210/jc.2015-2236.
15 Ortmann O, Beckermann MJ, Inwald EC, et al. Peri- and postmenopause-diagnosis and interventions interdisciplinary S3 guideline of the association of the scientific medical societies in Germany (AWMF 015/062): short version. Arch Gynecol Obstet. 2020;302(3):763–777. doi: 10.1007/s00404-020-05682-4.
16 Chen LR, Ko NY, Chen KH. Isoflavone Supplements for Menopausal Women: A Systematic Review. Nutrients. 2019 Nov 4;11(11):2649. doi: 10.3390/nu11112649. PMID: 31689947; PMCID: PMC6893524.
17 Daily JW, Ko BS, Ryuk J, Liu M, Zhang W, Park S. Equol Decreases Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Med Food. 2019 Feb;22(2):127-139. doi: 10.1089/jmf.2018.4265. Epub 2018 Dec 28. PMID: 30592686.
18 04-BMS-ConsensusStatement-Non-hormonal-based-treatments-SEPT2024-A.pdf
20 Miller VM, Kling JM, Files JA, Joyner MJ, Kapoor E, Moyer AM, Rocca WA, Faubion SS. What's in a name: are menopausal "hot flashes" a symptom of menopause or a manifestation of neurovascular dysregulation? Menopause. 2018 Jun;25(6):700-703. doi: 10.1097/GME.0000000000001065. PMID: 29381665; PMCID: PMC5970009.
21 Kingsberg, S. A., Schulze-Rath, R., Mulligan, C., Moeller, C., Caetano, C., & Bitzer, J. (2023). Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review. Climacteric, 26(6), 537–549. https://doi.org/10.1080/13697137.2023.2256658
