Real Health in Focus: Menopause Series - Part 2

As discussed in the first of this two-part series, menopause is a natural and inevitable change in a woman’s body, occurring typically after the age of 40. As noted, however, the experience of menopause can be quite variable from woman to woman, and while some women coast through menopause without much fanfare, most women experience symptoms that have an appreciable effect on their quality of life, albeit to varying degrees. As Dr. Jen Gunter, OBGYN and author of the best-selling book The Menopause Manifesto, puts it, “the only thing predictable about menopause is its unpredictability.”¹ In Part 2, SHIFT Physicians explore three common symptoms experienced by women during this phase of life and provide strategies to address them.

Hot Flashes

When one thinks of menopause, “hot flashes” (vasomotor symptoms) typically come to mind first even as many lack a basic understanding of what a hot flash is and why it occurs. In truth, the underlying mechanism of hot flashes is complex and not fully understood, but it is thought to be related to hormonal changes that affect the body’s thermoregulation, a process controlled in the brain by the hypothalamus. When estrogen levels decline, the body becomes extremely sensitive to minor temperature increases and triggers a chain of events in an effort to cool down: blood vessels dilate, blood is shunted to the skin (causing flushing), sweat glands are activated, and heart rate increases. A hot flash (sometimes called ‘hot flush’) is a constellation of symptoms including most notably a wave of heat that envelops the upper body. Associated symptoms typically include redness or flushing in the face, neck, and upper chest, sweating, increased heart rate, agitation, and anxiety. Oftentimes, this experience is followed by a sensation of a cold chill. When hot flashes occur at night, they are referred to as ‘night sweats’ and can lead to sleep disturbances.

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While the majority of women (~60-80%) experience hot flashes at some point during the transition into menopause,² the severity and duration of these symptoms are highly variable. Many women experience hot flashes for six months to two years, but they can occur for considerably longer. Unfortunately, there is no reliable way to predict when they will begin, end, or their severity.

A single hot flash lasts an average of 2-4 minutes and can occur infrequently or multiple times per day. Although individual hot flashes are short-lived, they can be disruptive and disturbing for the woman experiencing them. The good news is that there are a variety of coping strategies and lifestyle changes that can help manage hot flashes. For example:

• Dress in layers so that you can quickly remove clothing when needed.
• Keep your environment cool by using fans and air conditioning.
• Practice mindfulness and slow, deep breathing techniques to lower the heart rate and blood pressure during a hot flash.
• Engage in cognitive behavioral therapy (CBT). There is strong evidence that CBT can improve a woman’s experience of hot flashes and how disruptive they are.² While there is no doubt that a hot flash is a real physiologic phenomenon, CBT addresses the mind-body connection, as these symptoms can profoundly impact how we feel and vice versa.

In addition to these basic techniques, multiple safe and effective prescription medications are available to provide relief when hot flashes continue to disrupt the quality of daily life. Hormone medications with estrogens (and progestins for women with a uterus) are well-studied and highly effective at reducing menopausal symptoms, especially hot flashes. Nonhormonal drugs, including selective serotonin reuptake inhibitors (SSRIs) and gabapentin, can be effective for women who decline hormone therapies or who have specific contraindications. If you think you may benefit from pharmaceutical treatment for persistent hot flashes, then please discuss options with your SHIFT physician to determine which is best for you.

Genitourinary Symptoms

Another common group of symptoms experienced by women in this phase of life is termed genitourinary syndrome of menopause (GUSM). Reduced estrogen levels or decreased blood flow to the tissues or both cause hormonal and anatomical changes, which prompt a broad spectrum of signs and symptoms involving the lower genital and urinary systems. Most commonly, symptoms include:

• Vaginal dryness
• Vaginal burning or itching
• Pain with sexual intercourse
• Decreased libido
• Urinary discomfort or urgency
• Recurrent urinary tract infections

Studies show that vaginal dryness is the most prevalent and bothersome of these symptoms.⁵ While 15% of women experience GUSM in the perimenopausal stage, 50-80% of women with these symptoms are postmenopausal, with the most frequent and intense experiences in women five years out from their last menstrual period.⁵

Unfortunately, GUSM is underdiagnosed because many women fail to seek help due to a lack of awareness about available treatments or embarrassment and thus suffer unnecessarily. However, there are both pharmacologic and non-pharmacologic interventions that can significantly improve quality of life. Regular vulvar care (e.g., using gentle cleansers instead of soaps, wearing 100% cotton underwear, using lubricants during sex, and daily vaginal moisturizing) can combat vaginal dryness and irritation symptoms as well as discomfort during intercourse. Vaginal estrogen is considered the gold standard for medication treatment for GUSM. Several other hormonal and non-hormonal medications are also available.

Brain Fog and Depression

Up to two-thirds of women will notice difficulties in concentration and impairments in memory during the menopause transition and through early postmenopause.¹ This is commonly referred to as “brain fog,” which manifests in many ways, including having trouble concentrating or focusing, difficulties with word recall, or misplacing personal affects. These changes in brain function are typically temporary and tend to disappear once the menopause transition is complete. Clinical studies confirm the influence of hormones on neural networks involved in attention, memory, and other cognitive functions.⁶ Thus, the decline in estrogen is likely a large factor in developing these symptoms. However, other common symptoms during menopause, such as depression, anxiety, and sleep disturbances, likely contribute significantly. In addition, aging and stress are known to impair cognitive function.

The menopause transition is also associated with an increased risk of depressive symptoms, which studies suggest 19-36% of women will experience.¹ This is likely due to a combination of multiple factors, including hormonal changes, poor sleep, life stressors in this phase, and sometimes a predisposition to depression.

It is important to boost your brain’s defenses to combat impairments in cognitive function and reduce risk of depression. We recommend the following lifestyle modifications for women:

• Maintain an extensive social network by fostering existing and new relationships.
• Remain physically active, exercising regularly to achieve a goal of at least 150 minutes of moderate activity per week.
• Be diligent about optimal sleep hygiene and stress management.

Nourish your body with foods that will sustain you and keep you energized, such as high-quality complex carbohydrates, lean proteins, healthy fats, fruits, and vegetables. Some research supports the association between anti-inflammatory diets and a lower risk of cognitive decline, depression, and multiple other disease states. Talk to a SHIFT Registered Dietitian for more information.

All women will experience menopause, but none need face it alone. We encourage you to ask questions, address concerns, and start a conversation with your SHIFT physician to develop an individualized approach for this challenging phase of life.

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In Real Health,

Dr. Jessica Benjamin & the SHIFT Physician Team

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Reference List

1. Gunter, Jen. The Menopause Manifesto: Own Your Health with Facts and Feminism. Random House Canada, 2021.
2. Crandall, C. (2019). In Menopause practice: A clinician’s guide (6th ed.). essay, North American Menopause Society.
3. Deecher DC, Dorries K. Understanding the pathophysiology of vasomotor symptoms (hot flushes and night sweats) that occur in perimenopause, menopause, and postmenopause life stages. Arch Womens Ment Health. 2007;10(6):247-57. doi: 10.1007/s00737-007-0209-5. Epub 2007 Dec 12. PMID: 18074100.
4. Shen W, Stearns V. Treatment strategies for hot flushes. Expert Opin Pharmacother. 2009 May;10(7):1133-44. doi: 10.1517/14656560902868217. PMID: 19405789.
5. Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020 Apr 8;12(4):e7586. doi: 10.7759/cureus.7586. PMID: 32399320; PMCID: PMC7212735.
6. 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
7. Gangwisch JE, Hale L, Garcia L, Malaspina D, Opler MG, Payne ME, Rossom RC, Lane D. High glycemic index diet as a risk factor for depression: analyses from the Women's Health Initiative. Am J Clin Nutr. 2015 Aug;102(2):454-63. doi: 10.3945/ajcn.114.103846. Epub 2015 Jun 24. PMID: 26109579; PMCID: PMC4515860.