Vasmotor Symptoms of Menopause (Perimenopause) or VMS is like a prankster (not the funny kind) living inside you and playing with your internal thermostat. The randomness of your engine overheating is enough to make your frustration fly off the charts let alone dealing with the actual overheating of your body. So what is VMS other than something that turns you from just a ‘hot’ tamale into a ‘hot messy’ tamale?
First, let’s remember your fabulous no matter how much you are overheating but let’s get to the bottom of VMS. VMS occurs during perimenopause and menopause because as hormones fluctuate and decline, it becomes hard for your brain to regulate temperature, disrupting your thermoregulatory system. More specifically, the theory is a decline in estrogen narrows the hypothalamic thermoregulatory system that controls core body temperature.
Reproduction and temperature control are tightly linked. For example, when progesterone increases at the midpoint between ovulation and menstruation, your temperature increases. The physiology of VMS is complicated and not fully understood. Estrogen is involved — if it weren't, estrogen therapy wouldn't relieve vasomotor symptoms as well as it does — but it's not the whole story. For example, researchers have found no differences in estrogen levels in women who have hot flash symptoms and those who don't. Some research indicates follicle stimulating hormone (FSH) which becomes elevated in menopause may have a role. Most research has been conducted on menopausal (post menopausal) women. Focusing on perimenopause might shed light on the causes of hot flashes and open the way to new treatments. Regardless, they happen during menopause and it is not fun, they have a serious impact on our quality of life.
VMS is actually a category representing a group of symptoms that includes:
Hot flashes
Night sweats
Heart palpitations
Increased sensitivity to temperature changes
The term hot ‘flash’ is not correct for something that comes on as a wave of heat that builds from the head, neck, chest, and arms, spreading across the upper body. You don’t just feel hot but your skin is actually warm. They range in severity from a fleeting sense of warmth to a feeling of being consumed by fire "from the inside out."
The rapid increase in temperature results in excessive sweating, flushing, or your skin turning reddish and possibly nausea, confusion and anxiety. Moreover, VMS is more than a ‘flash’, while they come on rapidly, they can last on average from two to four minutes as the body cools through vasodilation. Given you were not actually hot to begin with, the body temperature drops more than it needs to, creating chills and shivering in some women. If you feel like your thermostat is on a roller coaster, it is because it is.
This can happen on average 4 to 5 times in a day, and for some women, more than twenty five times in a day. VMS can impact sleep, mood, concentration and is one of the biggest contributors for women citing challenges at work. How are you supposed to be productive without sleep, feeling out of sorts, and anxious about what is happening to your mind, body, and spirit (and vagina!)?
If your phone autocorrected your messages to embarrassing typos 4 to 5 times a day, would you keep using it without checking the settings?
Just as you wouldn't tolerate your phone constantly embarrassing you with autocorrect fails and would investigate the settings to fix the issue, similarly, it's important to address VMS rather than ‘deal with it’, especially if it impacting your quality of life.
To make matters worse, there is no predictable triggers for when and why VMS will occur.
It is also one of the most common issues that occur during perimenopause and menopause. The prevalence of VMS is menopause is outlined below.
Night sweats and hot flashes are grouped together as vasomotor symptoms of menopause (VMS). Night sweats have been described as hot flashes that occur at night however some recent evidence suggests they may have different reasons for why they occur. A hot flash can occur during the day or night and may or may not be associated with sweating, whereas night sweats are periods of intense sweating that occur at night. A night sweat results in you waking up completely soaked in sweat through your pajamas and bed sheets, more intense sweating than a hot flash (5). Night sweats have been significantly associated with depression and stress, whereas hot flashes (even those at night) were significantly associated with only depression after adjusting for menopause status, financial comfort, and marriage. Women with the highest hot flash frequency at night had significantly higher depression scores compared with women who had the highest hot flash frequency during other times of the day. These results support the notion that sleep disruptions during menopause have a significant effect on quality of life and suggest that night sweats may have more severe consequences than hot flashes.
On average, hot flashes and night sweats last on average seven years but can go on for 10 years or more for almost 25% of women. Women whose hot flashes appear early in the menopause transition are more likely to have hot flashes last longer, as are those whose VMS appears at a younger age. There is also other interesting factors that can influence VMS including:
Seasonality/Climate. VMS can be worse in hot months of the year with heat and humidity serving as triggers compared to cooler months.
Ethnicity. African-American women to have the longest duration and more severe VMS, followed by Hispanic women, White women, Japanese, and Chinese women. In addition,
Psychosocial factors. Early and persistent VMS are associated with a more adverse psychosocial and health profile. Childhood abuse and trauma, poverty and lower education are associated with increased risk of VMS (1,2)
Lifestyle behaviors. Smokers have a longer duration of VMS (3,4). Light alcohol consumption may reduce VMS but heavier drinking is likely to increase VMS. Beverages and food containing high levels of caffeine such as coffee or tea as well as spicy foods may trigger VMS.
Body Weight. A high BMI tends to be protective against VMS later in the menopause transition and beyond.
While evidence VMS impacts quality of life including the factors outlined above (and more!), it was thought that VMS did not impact overall health. There is some research emerging however, that this may not be the case. Some studies show women with more frequent VMS have poorer cardiovascular disease risk factor profiles including elevated blood pressure or hypertension, insulin resistance or diabetes, and dyslipidemia. Women with more frequent or persistent VMS have also been found to have an elevated risk for clinical cardiovascular disease (CVD) events such as myocardial infarction and stroke as women age. Whether treating VMS reduces later life risk for cardiometabolic disease or if CVD and VMS share similar risk factors is being further explored.
The Study of Women’s Health Across the Nation (SWAN) gleaned four patterns for North American women with VMS. They are outlined below:
Meet Anya. Anya is a 50 year old Executive Vice President at a Fortune 500 company. She has three children in university and is going through a very volatile divorce. While her life has a lot of stressors, she felt like she was navigating them all well, she eats healthy, exercises, but only gets four hours of sleep a night at best. Recently, she started to get overcome by hot flashes during the day. She tried to figure out any patterns or triggers: morning, afternoon, before big deadlines, if she exercised, if she missed exercise, if she skipped her nightly glass of wine or had it. There was no pattern. With little time to spare in her day, she just ‘dealt with it’. During quarterly business planning, she was beginning her presentation to the board of directors. As she stood in front of the room she felt a pang of panic realizing she was about to get a hot flash. A sensation of heat started in her neck and head and quickly spread throughout her upper body. Her face went beat red and her heart was racing. She could not remember her words, she tried with all she had to keep her composure and calm in the room full of men. Anya stumbled and fumbled her words, sweat beating down her face, her make up running. It was all she could do just to get through.
Do you see yourself in Anya?
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Avis NE, Crawford SL, Greendale G, et al.; Study of Women’s Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.
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Depypere H, Timmerman D, Donders G, et al. Treatment of menopausal vasomotor symptoms with fezolinetant, a neurokinin 3 receptor antagonist: a phase 2a trial. J Clin Endocrinol Metab 2019;104:5893-5905.
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Pinkerton JV, Constantine G, Hwang E, Cheng RF; Study 3353 Investigators. Desvenlafaxine compared with placebo for treatment of menopausal vasomotor symptoms: a 12-week, multi-center, parallel-group, randomized, double-blind, placebo-controlled efficacy trial. Menopause.2013;20(1):28-37.
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During our peak reproductive years, the amount of estrogen in circulation rises and falls fairly predictably throughout the menstrual cycle. Estrogen levels are largely controlled by two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates the follicles — the fluid-filled sacs in the ovaries that contain the eggs — to produce estrogen. When estrogen reaches a certain level, the brain signals the pituitary to turn off the FSH and produce a surge of LH. This in turn stimulates the ovary to release the egg from its follicle (ovulation). The leftover follicle produces progesterone, in addition to estrogen, in preparation for pregnancy. As these hormone levels rise, the levels of FSH and LH drop. If pregnancy doesn't occur, progesterone falls, menstruation takes place, and the cycle begins again.