By Leanna Coy, FNP-BC
Donna sleeps naked. She’s too hot at night to wear pajamas. She regularly wakes around 2:00 am drenched in sweat, and her husband says he feels the heat coming off her body at night. Suzi has a different experience. Around her 47th birthday, she began having random, sudden episodes of feeling heat rising from her chest up to her face, with both turning red. Her heart races and, sometimes, she feels anxious.
If you aren’t either of these women, you know them. These are both examples of vasomotor symptoms (VMS), commonly called hot flashes, hot flushes, and night sweats. This isn’t a random complaint. It’s the norm. According to the Menopause Society, up to 80% of women experience VMS during menopause, with symptoms persisting for up to 10 years or more.
What’s happening in the brain
The hypothalamus is part of the brain that regulates body temperature. It acts as the body’s thermostat, keeping your core temperature balanced through vasomotor changes. When your body gets too warm, the hypothalamus signals blood vessels to dilate, increasing blood flow to capillaries near the skin surface to cool you down. Often this is accompanied by sweating. It is believed that hormone changes that occur during perimenopause and menopause cause a dysfunction in this thermostat that narrows the body’s temperature comfort zone. This means slight temperature changes that previously went unnoticed now cause an exaggerated reaction from the body, triggering VMS.
Hot flashes vary widely based on race, body mass, smoking status, and level of physical activity. Some women experience them once daily, others almost hourly, and some only once a week. The symptoms often start in the chest, head, or neck and then spread to other areas of the body. Symptoms include flushing of the face and neck, sweating, a racing heart, and anxiety lasting 1 to 5 minutes. Chills often follow a hot flash.
Hot flashes vs night sweats
When comparing hot flashes and night sweats, the difference isn’t biological. It is timing. Night sweats are hot flashes that occur at night. For most women, night sweats tend to show up first, beginning during perimenopause. Perimenopause is the transitional phase of hormonal fluctuations and irregular menses that leads up to a woman’s last menstrual period.
VMS can greatly impact a woman’s life. With mild symptoms, a woman may just feel hot and kick off bedding to cool down. Those with more severe episodes may wake with damp bedding and clothing from sweat. After the episode passes, chills and shivering may occur. Nighttime symptoms that affect sleep can lead to fatigue, brain fog, mood changes, and a lack of focus the next day. Daytime episodes often disrupt work and social situations.
Treatments that actually help
The most effective treatment of VMS is hormone replacement therapy (HRT), which is approved by the Food and Drug Administration (FDA) as a first-line treatment for bothersome hot flashes that impact a woman’s well-being. HRT is estrogen with or without the use of progesterone and comes in many forms – pills, patches, sprays, gels, or a vaginal ring. In all forms, the hormones are delivered systemically through the bloodstream.
There are risks to HRT use, including heart attacks, strokes, blood clots, and breast cancer. However, for most users, the benefits outweigh the risks. It is safest and most effective to begin HRT within 5 years of entering menopause. Researchers at Stanford and Harvard have found that early use of HRT decreases the risk of dementia. Starting HRT after this window of opportunity increases the cardiovascular risks and the risk for dementia.
For women who choose to use HRT, it is not always a lifetime prescription. Because symptoms typically only last 10 years, women can try to stop treatment after 5 to 10 years. Some women will have their symptoms return and may decide to resume the hormones indefinitely.
Women with mild VMS or who have contraindications to HRT may use lifestyle modification as their first-line treatment. These include managing their environment by wearing layers of clothing that can be easily removed when symptoms start and using a cooling mattress or bedding. They avoid known triggers such as spicy foods, caffeine, and alcohol. Cognitive behavioral therapy and paced breathing can also be effective.
Sometimes home management isn’t appropriate. If someone is experiencing unexplained weight loss, chest pains, fainting, severe heart palpitations, or a persistent fever, they should seek urgent evaluation.
Why this hits different in rural Oregon
A 2024 study by Oregon Health and Science University (OHSU) found that more Oregonians aren’t getting adequate treatment for the VMS. The study found more than 60% of Oregonians with moderate to severe symptoms received no treatment. The main driver was a lack of treatment recommendations from their healthcare provider. This isn’t surprising, given that a Mayo Clinic survey found only about 7% of OB-GYN residents nationally felt prepared to manage menopause. More than 20% of residents reported receiving no training in menopause care.
Women in rural areas, like Tillamook County, have even more barriers to treatment. There are fewer OB-GYNs, and many of the primary care providers also lack confidence in treating menopause. Often, both patients and providers are unclear about the most up-to-date information. Traveling outside the county for care may not be feasible.
Not surprisingly, a 2024 University of Washington study found women living rurally are experiencing more menopause symptoms than their urban counterparts. This isn’t just because their healthcare team lacks training or confidence. Many of the women surveyed reported a lack of awareness of HRT as an option or were using homeopathic methods instead due to poorly informed safety concerns. Some rural women also reported they planned to “just tough it out” instead of seeking care.
OHSU is trying to close the education gap for rural providers. In 2024, the OHSU Center for Women’s Health began offering virtual menopause training through the Extension for Community Healthcare Outcomes (ECHO) program. The program helps healthcare providers statewide expand their knowledge by learning from clinical experts. Providers receive education on identifying menopause symptoms and counseling patients on managing the physical, emotional, and sexual changes with a variety of treatment options.
If your symptoms are bothersome enough to keep you awake at night, cause flushing, or disrupt your work, consider exploring treatment options. If you have questions or concerns about your symptoms, talk with your healthcare provider. If you’ve tried this approach and worry your provider lacks the knowledge to treat you, find a menopause specialist. The Menopause Society has guidance on how and where to find a trained provider. If traveling to a menopause specialist is a challenge, there are also specialists available via telehealth. Women shouldn’t feel like they must suffer through and wait out their menopause symptoms.
