Hot flashes

Managing Menopause Symptoms

Recognizing menopause symptoms is the biggest challenge.

Most of the 6,000 American women who reach menopause each day experience one or more symptoms. For about one in five women, these symptoms—primarily hot flashes and night sweats—are so severe that they affect relationships, work, sleep, and mood. Unfortunately, too few women get the right help. Many doctors minimize or dismiss the symptoms that women are willing to bring up, while there are other symptoms that women are too embarrassed to discuss, and some that may not be recognized as stemming from menopause. Further, “there are not a lot of OB-GYNs who do menopause, and women don’t know where to find someone who does,” says Stephanie Faubion, MD, the Penny and Bill George Director for Mayo Clinic’s Center for Women’s Health and medical director for the North American Menopause Society (NAMS).

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That’s where convenient care clinicians can step in. By being familiar with the symptoms that could suggest menopause, you can help women find relief from the symptoms and guide them to the right specialists.

Unexpected Symptoms

While hot flashes are well-known signs of menopause, many women may not realize that symptoms like heart palpitations and anxiety can be related to menopause, too. “Women may have joint aches, palpitations, weight gain—a cluster of symptoms might be related in part to aging and in part to menopause,” says Dr. Faubion.

Adding to the confusion, research published in Menopause in September 2021 highlighted the fact that many women start to experience symptoms earlier than expected, during the late reproductive stage and before menstrual cycles become irregular.1

“Patients experiencing symptoms in their late 30s are often told they’re too young to get menopause symptoms, that it’s all in their head—that’s very destructive,” says Wen Shen, MD, assistant professor in the Johns Hopkins Medicine Department of Gynecology and Obstetrics, clinical director of the Menopause Consultation service and co-director of the Women’s Wellness and Healthy Aging Program. “A lot of women will blame themselves and say, ‘I’m going crazy’ rather than, ‘these symptoms are driving me crazy.’ That’s a terrible state of mind to be in.”

At any age, women need to be taken seriously so they can get relief from bothersome symptoms. Here’s a look at the most common issues.

Hormone Therapy

Hormone therapy (HT), when started within 10 years of menopause, can ease hot flashes, improve sleep, and reduce all-cause mortality and the risk of coronary disease, osteoporosis, and dementia, according to a review in Climacteric published in February 2021.1 Further, it can ease vaginal dryness, night sweats, and bone loss.2

Many women and clinicians, however, are reluctant to use it because a study published in 2002 linked HT to breast cancer and heart attack.3 Researchers have since learned that the link only exists when HT is started 10 or more years after menopause. Beginning therapy earlier is safer.

Though the findings were ultimately corrected, many clinicians have not received adequate training to feel comfortable prescribing HT. Furthermore, “Present-day hormones are very different from the one hormone therapy that was used when the 2002 study was done” says Wen Shen, MD, assistant professor in the Johns Hopkins Medicine Department of Gynecology and Obstetrics, clinical director of the Menopause Consultation service, and co-director of the Women’s Wellness and Healthy Aging Program.

“Overall, it’s much safer in regards to breast cancer and high blood pressure.” “The benefits of HT outweigh risks for most women in their 50s when started within 10 years of their last period,” adds Stephanie Faubion, MD, the Penny and Bill George Director for Mayo Clinic’s Center for Women’s Health and Medical Director for The North American Menopause Society.


1. Langer RD, Hodis HN, Lobo RA, Allison MA. Hormone replacement therapy - where are we now? Climacteric. 2021;24(1):3-10. 

2. Hormone therapy: benefits & risks. North American Menopause Society. Accessed January 20, 2022.

3. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.

Vaginal Dryness

For some women, the only symptom of menopause is vaginal dryness, which can cause pain during sex, but only 9% of women who experience vaginal dryness get treated for it, notes Dr. Fabion. While most women will bring up hot flashes with their doctor, they often don’t talk about vaginal dryness. If they did, they’d learn that there are several strategies that may help.

Over-the-counter vaginal moisturizers. Some products create a biofilm that can moisturize for two to three days. This can provide pain relief during sex, when sitting hurts, or when there’s discomfort any time urine gets close to the vaginal opening. Vaginal products with hyaluronic acid have been shown to help the skin retain water content.

Prescription drugs. If there is still pain when having sex, a patient might benefit from a prescription option that can help restore the layers of skin within the vagina, such as low-dose vaginal estrogen, available in a cream, ring, table, or insert; a vaginal insert of prasterone, also known as DHEA, (Intrarosa); or oral ospemifene (Osphena), a once-daily, nonhormonal pill.2,3 It’s important to discuss side effects, such as changes in Pap test results with prasterone, and drug interactions, as well as an increased risk for a condition that could lead to uterine cancer, with ospemifene.4,5

Urination Issues

Low estrogen levels can lead to urinary urgency, incontinence, and multiple nightly awakenings. Start by suggesting that your patient stop drinking any liquids after dinner and consider referring to a urogynecologist. An ultra-low-dose vaginal estrogen medication can help some women, while those with stress incontinence may benefit from physical therapy to treat pelvic floor dysfunction.

Sleep Trouble

According to research published in Medicina, sleep difficulties affect about a third of women during the menopausal transition and increase to up to 56% of postmenopausal women.6 Women may have trouble falling asleep, wake up several times, not get enough sleep, or develop sleep apnea. Since sleep deprivation is a risk factor for cardiovascular disease, diabetes, obesity, and neurobehavioral dysfunction, it’s important to address it.

Women may be able to improve sleep with lifestyle changes. Recommend daily exercise, avoidance of caffeine, a cool and dark bedroom, and turning off electronic devices well before bedtime. Hormone therapy and other medications may also enhance sleep quality. Consider referring patients to a sleep specialist if these measures don’t help.

Depression and Anxiety

Because of the huge roller-coaster action of hormones, one of the first symptoms many women experience is anxiety with heart palpitations, says Dr. Shen. “First, make sure the patient doesn’t have any cardiac issues going on. Then, consider that it’s perimenopause,” she says. If a patient is still cycling on a very regular monthly basis, you can see if a short-term trial of low-dose birth control pills helps resolve symptoms.

“Depression is more tightly tied to perimenopause than menopause,” says Dr. Faubion. “We call it the window of vulnerability in terms of mood.” Women who experienced depression earlier in life and those who had premenstrual syndrome or premenstrual dysphoric disorder or postpartum mood disorders are at the highest risk. Treatment options include hormone therapy, antidepressants, and cognitive behavioral therapy. Mind-body therapies such as yoga, meditation, and breathing exercises may also improve mood when added to other treatments.

Brain Fog

Problems with concentration and memory can be part of menopause. According to a report by neurologist Gayatri Devi, MD, that was published in Obstetrics & Gynecology, it’s important to identify the cognitive changes related to menopause so that symptoms aren’t mistakenly attributed to a neurodegenerative disease and can be addressed appropriately.7

Some proven brain-boosting interventions include losing any excess weight, regular exercise, following the Mediterranean diet or Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, and learning new things to stimulate the brain. Improving sleep and decreasing stress are also helpful since lack of sleep and stress overload can make brain fog worse.8

Vasomotor Symptoms

Seventy-five to 80% of women are affected by vasomotor symptoms. Hot flashes can last up to 10 years or even longer and vary widely in degree—they’re mild for some, severe for others. The standard treatment is hormone therapy (see sidebar), but there are alternatives for women who can’t or don’t want to use HT:

• Cognitive behavioral therapy and hypnosis might reduce the perception of hot flashes and night sweats.9 Both techniques might also help improve sleep.

• Tracking how things like weather, smoking, caffeine, spicy or sugary foods, alcohol, tight clothing, and stress affect hot flashes allows women to take measures to reduce exposure to those triggers.

• Losing excess weight can ease symptoms.

• Moving more can help. Sedentary behavior can increase the likelihood of nighttime hot flashes, according to preliminary results of a new study of pre-, peri-, and postmenopausal women presented at the 2021 NAMS Annual Meeting.

• Mindfulness and acupuncture may provide small but real benefits.

• Keeping a bedside fan and a glass of ice water nearby can reduce the disruption of night sweats.

• Don’t put too much stock in supplements. Neither red clover nor black cohosh have shown benefits in clinical trials, despite anecdotal reports of benefits.10,11


1. Coslov N, Richardson M, Woods NF. Symptoms experienced during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey. Menopause. 28(9):1012-1025.

2. Labrie F, Archer DF, Koltun W, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2018;25(11):1339-1353.

3. FDA approves Intrarosa for postmenopausal women experiencing pain during sex. News release. U.S. Food and Drug Administration. November 17, 2016. Accessed January 20, 2022. 

4. Intrarosa. Updated August 24, 2021. Accessed January 20, 2022.

5. Ospemifene. University of Michigan Health. Accessed January 20, 2022.

6. Gava G, Orsili I, Alvisi A, et al. Cognition, mood and sleep in menopausal transition: the role of menopause hormone therapy. Medicina. 2019;55(10): 668.

7 Bilodeau K. Sleep, stress, or hormones? brain fog during perimenopause. Harvard Health Publishing. April 9, 2021.Accessed January 20, 2022.

8. Hot flashes. Mayo Clinic. August 31, 2021. Accessed January 20, 2022.

9. Kanadys W, Barańska A, Błaszczuk A, et al. Evaluation of clinical meaningfulness of red clover (Trifolium pratense L.) extract to relieve hot flushes and menopausal symptoms in peri- and post-menopausal women: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 22021;13(4):1258.

10. Black cohosh: fact sheet for health professionals. National Institutes of Health: Office of Dietary Supplements. Updated June 3, 2020. Accessed January 20, 2022.