Lifestyle Medicine and Vasomotor Symptoms: An Analytic Review

Abstract

This paper is an literature evaluation of the treatments based on the 6 pillars of Lifestyle Medicine (nutrition, physical activity, restorative sleep, stress management, positive social connection, and avoidance of risky substances) to improve vasomotor symptoms. Main findings were: (1) the Mediterranean diet and other plant-forward approaches may effectively reduce vasomotor symptoms; (2) stress can directly impact menopausal symptoms by increasing the frequency and intensity of hot flashes and other symptoms; (3) the incidence of sleep disturbances are high during the menopause transition; (4) evidence on the impact of physical activity and exercise on vasomotor symptoms is mixed, although moderate activity and strength training may be better for vasomotor symptom optimization than vigorous exercise and part of a healthy aging process; (5) evidence on the impact of social support on VMS is mixed with some studies suggesting benefit; and (6) evidence on the impact of risky substances is mixed but appears stronger for the effects of tobacco cessation than for alcohol cessation. In summary, while there is a variety of quality of evidence depending on the pillar, lifestyle medicine may be generally considered to improve vasomotor symptoms for patients that cannot use or decline hormone therapy.

Keywords

six pillars restorative sleep social connection risky substances nutrition physical activity stress management

“Evidence exists most strongly for stress reduction via cognitive-behavioral therapy, and clinical hypnosis, with mixed evidence for mindfulness-based stress reduction and other mind-body techniques.”

Introduction

While hormone therapy is the most effective treatment for vasomotor symptoms (VMS),¹ health care providers should still remain informed on evidence-based non-hormonal options to treat vasomotor symptoms in women that cannot use or may decline hormone therapy. The recent North American Menopause Society (NAMS) 2023 position statement covered non-hormonal therapies in detail; however, much of the review was focused on non-hormonal pharmaceuticals. This paper examines the evidence for the 6 pillars of Lifestyle Medicine—nutrition, physical activity, restorative sleep, stress management, positive social connection, and avoidance of risky substances—as a detailed analytic review on the topic of lifestyle elements and adjustments to improve vasomotor symptoms of menopause as a supplement to the recent NAMS position statement.

Methods

A comprehensive search was performed using PubMed, Auraria and Northwestern libraries’ website search function to search for articles pertaining to the pillars of Lifestyle Medicine and vasomotor symptoms. The search was conducted between 2021 and 2023, with articles from 2002-2023, and research published within the last 5 years prioritized for inclusion. Search words, including “vasomotor symptoms, menopause, menopausal, premenopausal, postmenopausal, hot flashes, night sweats, transition, flushes, and lifestyle medicine,” were used. In addition, words specific to each lifestyle medicine pillar helped narrow down the literature as follows.

Nutrition: nutrition, diet, soy, isoflavones, healthy eating, nutrient, Mediterranean, whole food, plant-based, DASH, vegan, vegetarian

Physical Activity: exercise, movement, yoga, aerobic, anaerobic, resistance, balance, sedentary, cardiometabolic, walking, moderate, vigorous

Sleep: sleep disturbances, sleep problems, insomnia, sleep disorder, sleep apnea, sleep quality, sleep efficiency, fatigue

Stress: psychological, oxidative stress, change, stressor, resilience, mindfulness, relaxation, perceived stress, cognitive-behavioral therapy, hypnotherapy

Social Connection: partner, spouse, relationship, social support, interpersonal, friend, community

Risky Substances: alcohol, tobacco, illicit drug

Mendeley reference management software was used to organize the literature. Paperpile was used to compile the reference list. Research articles published in the last 5 years were prioritized, unless there was a paucity of literature in the area of interest or if the study had a strong research cohort, prospective or randomized control trial, that was done prior to the five-year window. Randomized controlled trials, meta-analyses, and well-designed prospective studies were prioritized in the analytical review, although less robust studies were considered in the event of a paucity of available data.

Results

Each of six pillars of Lifestyle Medicine was examined for improvement in vasomotor symptoms in this analytic review.

Nutrition (Diet)

Recent studies have examined the potential benefits of specific dietary patterns and nutrients, as well as the impact of resultant weight change, in alleviating VMS. While many studies of natural products for VMS exist, this review focuses only on natural food sources.

Dietary Patterns

A limited body of evidence suggests that the Mediterranean diet and other plant-forward approaches may effectively reduce VMS [Table 1]. Existing studies support a diet characterized by high intakes of fruits, vegetables, whole grains, pulses and legumes, and having a higher proportion of healthier fats from foods such as oily fish, nuts and seeds, while limiting the intake of sugar and unhealthy fats. While plant-based diets may help to reduce the prevalence and severity of hot flushes, the greatest benefit appears to be with accompanying weight loss. Future studies should aim to separate the impact of weight and body composition from dietary patterns.

Table 1.

Studies on the Effect of Diet Patterns on VMS in Postmenopausal Women.

Authors/Reference	Study Type	Diet Pattern/Intervention	Participants
Kroenke et al, 2012²	RCT	Low-fat dietary pattern with high plant intake similar to the MedDiet	6014 post-men. women
Kroenke et al, 2012²	Results: In women with mild VMS, the likelihood of elimination of VMS within 12 months increased by 14% with intervention (OR = 1.14; 95 % CI: 1.01-1.28; P = .04); however, there was no significant improvement for women with moderate to severe VMS. Symptom resolution was more likely among those who lost more than 10 lbs (OR = 1.23; 95% CI:1.05, 1.46) or lost 10% or more of baseline bodyweight (OR = 1.56; 95% CI: 1.21, 2.02) compared to women who maintained weight over the year. Large wt. loss (>22 lbs), but not dietary changes, was also related to eliminating moderate/severe VMS.
Rotolo et al, 2019³	RCT	Lacto-ovo-vegetarian diet rich in omega-3 fats from flaxseed oil, walnuts and almonds (26 g/day) vs lacto-ovo-vegetarian diet rich in extra virgin olive oil (EVOO)	54 post-men. women
Rotolo et al, 2019³	Results: Women randomized to the omega-3 group showed significant improvement compared to the EVOO group in hot flashes (Δ = −3.3 ± 3.4 vs −1.3 ± 2.6; P = .04)
Barnard et al, 2022⁴	RCT	Low-fat, vegan diet (including ½ cup [86g] of cooked soybeans daily) vs control	84 post-men. women
Barnard et al, 2022⁴	Results: Total hot flash frequency in the intervention group decreased by 78% (P < .001) and 39% (P < .001) for the control group (between-group P = .003). The decrease in moderate to severe hot flashes in the intervention group was 88% (from 5.0 to .6 per day, P < .001), compared with 34% (from 4.4 to 2.9 per day, P < .001) among controls (between-group P < .001). Bodyweight also decreased in the intervention group, although the correlation between weight loss and symptom change was weak
Gold et al, 2006⁵	RCT	High-vegetable, high-fiber, reduced-fat diet vs control	2198 women with early-stage breast cancer
Gold et al, 2006⁵	Results: Daily fiber intake >30 g was associated with a 35% greater chance of decreased symptom severity; low fat intake was associated with less likelihood of decreased symptom severity at 12 months
Herber-Gast et al, 2013⁶	Prospective cohort study	Six dietary patterns identified from factor analysis: Cooked vegetables, fruit, Mediterranean-style, meat and processed meat, dairy, and high fat and sugar	6040 post-men. women
Herber-Gast et al, 2013⁶	Results: Med diet: significantly decreased the risk (OR = .80; 95% CI: .69-.92). Increased fruit intake: Significantly decreased the risk (OR = .81; 95% CI: .71-.93). High fat and sugar: Significantly increased the risk of VMS (OR = 1.23; 95% CI: 1.05-1.44)
Flor-Alemany et al, 2020⁷	Cross-sect. study	Mediterranean diet adherence	172 post-men. women
Flor-Alemany et al, 2020⁷	Results: Worse VMS symptomatology associated with greater consumption of poultry (bb: .18, P = .02) and skimmed dairy products (P < .05). Soy milk consumption associated with fewer vasomotor symptoms (bb: −.15, P = .04)
Soleymani et al, 2018⁸	Cross-sect. study	Three major dietary patterns: Vegetables and fruits (VF); mayonnaise, liquid oils, sweets, and desserts (MLSD); and solid fats and snacks (SFS)	400 post-men. women
Soleymani et al, 2018⁸	Results: VF dietary pattern inversely associated with physical symptoms (b ¼ 1.54; SE ¼ 1.09; P for trend <.001). SFS dietary pattern directly related to physical symptoms (b ¼ 1.24; SE ¼ 1.09; P for trend = .04)

Insulin resistance (IR) and metabolic syndrome have been correlated with VMS.^9,10 Dietary strategies such as low carbohydrate diets, intermittent fasting, and fasting mimicking diets may counter IR,¹¹ and theoretically relieve VMS; however, only anecdotal data for this indication exists. A study comparing 4 dietary patterns from the Women’s Health Initiative Observational Study: low-fat; reduced-carbohydrate; Mediterranean-style; and a diet consistent with the USDA’s Dietary Guidelines for Americans found that a reduced-carbohydrate diet, with moderate fat and high protein intake, may decrease the risk of weight gain in postmenopausal women, whereas a low-fat diet was associated with increased risk of weight gain.¹² While this study did not examine VMS, the link between weight, metabolic syndrome, and VMS postmenopause suggests a plausible benefit to lower carbohydrate diets.

Specific Dietary Components

Phytoestrogens are a group of plant-based compounds that have been found to have a similar chemical structure to estrogen and may weakly stimulate estrogen receptors. Conflicting evidence suggests that dietary consumption of phytoestrogens, specifically isoflavones, may demonstrate improvement in the incidence and severity of vasomotor symptoms in postmenopausal women (Table 2); however, the NAMS 2023 position statement states that soy foods and extracts are not recommended for the treatment of vasomotor symptoms. Lignans, another studied phytoestrogen, has not demonstrated efficacy in this regard as compared to placebo.^18,19 In contrast, other dietary components, including alcohol and spicy foods, have demonstrated a positive association with vasomotor symptoms.²⁰

Table 2.

Studies on the Effect of Dietary Phytoestrogens on Vasomotor Symptoms (VMS).

Authors/Reference	Subjects	Intervention	Study Length	Findings
Carmignani et al, 2010¹³	Double blind RCT	90 mg soy isoflavone compared v. HRT v. placebo	16 weeks	Both soy and HRT groups had signif. reduced hot flashes and vaginal dryness comp. with plac. gp; no signif. diff. in endometrial thickness
Chen et al, 2015¹⁴	Meta-analysis of 10 studies	Phytoestrogen intake and hot flash frequency	n/a	Phytoestrogens significantly reduced VMS frequency
Hanachi, 2008¹⁵	37 postmen. women	Group 1: Soy milk product (12.5 g spy protein with 13 mg genistein and 4.13 mg daidzein	12 weeks	Hot flushes significantly improved with both soy interventions compared with control group
Hanachi, 2008¹⁵	37 postmen. women	Group 2: Soy milk product plus exercise	12 weeks
Lewis et al, 2006¹⁶	99 postmen. women	Group 1: Soy flour muffins (42 mg/d isoflavones)	16 weeks	No significant difference noted in vasomotor score, number of flushes per day, or severity of flushes for either group compared with control group
Lewis et al, 2006¹⁶	99 postmen. women	Group 2: Flaxseed muffins (50 mg/d lignans)	16 weeks
Nagata et al, 2001¹⁷	Cohort study of 1106 postmen. women	Soy intake dietary intake (44-116 g/day) and hot flash severity and frequency	6 years	Hot flashes were significantly inversely associated with consumption of soy products

Summary

Many potential mechanisms of diet on VMS exist, including the role of the gut microbiome in estrogen metabolism, insulin resistance, estrogen production in adipose tissue, hormone receptor modulation, and vasodilation. Given the correlation of VMS with cardiovascular disease risk,²¹ a plant-based diet is an appropriate option to both improve quality of life for women with VMS and prevent CVD, with consideration of reduced-carbohydrate diets in women at risk for weight gain and metabolic syndrome.

Avoidance of Risky Substances

The lifestyle medicine pillar of avoiding risky substances, such as alcohol and tobacco, may help decrease the occurrence of vasomotor symptoms.²² Beyond this, refraining from these substances results in known risk reduction of cardiovascular, cancer-related, and general health risks. The data appears stronger for tobacco cessation’s effects compared to those from alcohol cessation for reduction of VMS. (Table 3).

Table 3.

Studies on the Effect of Alcohol and Cigarette Smoking (Risky Substances) on Vasomotor Symptoms (VMS).

Authors/Reference	Study Type	Intervention	Participants
Wilsnack et al, 2016²³	Review	Alcohol use and menopause
Wilsnack et al, 2016²³	Results: Clinicians should periodically assess their menopausal patients’ alcohol use. Specific health hazards from excessive alcohol consumption, as well as potential benefits of low-level consumption (for cardiovascular disease, bone health, and type 2 diabetes), should be discussed with their patients who drink. Alcohol consumption is correlated with worsening VMS.
Anderson et al, 2020²⁴	Meta-analysis	Cross-sectional analysis of midlife women from 8 pooled studies, to investigate associations between smoking, body mass index, and VMS	21,460 midlife women
Anderson et al, 2020²⁴	Results: Higher body mass index and smoking more cigarettes with longer duration and earlier initiation were associated with more frequent or severe vasomotor symptoms. Smokers who were also obese had the highest risk of VMS, (RR 3.02; CI 95%, 2.41-3.78)
Zhang et al, 2020²⁵	RCT	To investigate association of alcohol with menopausal symptoms	4595 Chinese women
Zhang et al, 2020²⁵	Results: Alcohol consumption, greater than or equal to 3 times/week, was significantly associated with VMS aggravation (OR 3.051 (2.61-3.56, 95% CI), P < 00.1)

There are conflicting studies regarding positive, negative, or no association between the effects of alcohol and vasomotor symptoms.²³ Avoiding alcohol, along with other environmental triggers, is one lifestyle recommendation that may be helpful in the management of mild hot flashes.²⁶ However, the 2023 Non-hormonal Therapy position statement of the North American Menopause Society cites a 2020 Clinical Interventions in Aging study, which showed that menopausal women had a significant increase in vasomotor symptoms with alcohol consumption,^24,25 but also observed that other studies did not show this association.¹ For those who do not drink alcohol, there is no recommendation to start, especially due to other health risks associated with excessive alcohol.²³

Current smoking and past smoking are associated with an increased risk of vasomotor symptoms, possibly due to the anti-estrogenic effects of smoking.²⁷ Smoking has been associated consistently with an increased incidence of hot flashes.²⁶ A pooled analysis of eight observational studies looking at the associations between body mass index, smoking, and potential effects on vasomotor symptoms noted significant interactions between BMI and smoking status for increased risk of vasomotor symptoms (P < .001), especially among those who were obese. Smoking cessation before age 40 or quitting for more than 5 years may decrease the excess risk of vasomotor symptoms to similar levels as nonsmokers.²⁴

Restorative Sleep

The incidence of sleep disturbances (SD) a high during the menopause transition, around 43%-47%.²⁸ Poor sleep can lead to dysfunction both in the short term resulting in memory loss, attention deficits and decreased quality of life; and long term with more serious effects including a higher prevalence of diabetes, obesity, depression and increased mortality due to cardiovascular disease.²⁹ The causes of SD in menopause are still not fully known; however, a five-year retrospective follow-up study found risk factors including but not limited to vasomotor symptoms (80%), CNS medications, personal crises, anxiety, and depression.³⁰ Women who experienced surgical menopause compared to those who develop naturally were found to be more affected.³¹

Hormone replacement therapy is the standard of care for evidence-based improvement of vasomotor symptoms, which can impair sleep quality; however, there is no direct evidence for treatment of sleep disorders.³² Sleep apnea and sleep-disordered breathing increases in the perimenopause transition.

It is important for patients to work with their clinical team to exclude underlying sleep pathology, including treatment of associated anxiety, depression, or psychosis.^33,34 Sleep hygiene is important which includes consistent bedtimes, early light exposure, and cooling bedding.³⁵ In addition, high fiber intake, especially in morning,³⁶ regular exercise,³⁷ and stress and mood management³⁸ have been shown to improve vasomotor symptoms and sleep in the menopausal transition, although causation should not be inferred. The addition of cognitive-behavioral therapy and maintaining healthy relationships also has a positive impact on quality sleep. In addition, avoidance of late-night meals, eating less processed foods,³⁹ and minimizing overall alcohol consumption has been shown to decrease sleep disturbances, but not VMS per se.^40,41

Stress Management

Stress can directly impact menopausal symptoms by increasing the frequency and intensity of hot flashes and other symptoms, making the menopausal transition more challenging.⁴² Managing stress is crucial as part of a comprehensive approach to menopausal symptom management, and many stress management techniques are available to help women cope with the physical and emotional challenges of menopause.

Menopausal symptoms can be managed through various mind-body approaches, including cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and clinical hypnosis. CBT aims to identify and change negative thought patterns and behaviors contributing to stress. A study published in the journal Menopause demonstrated the effectiveness of CBT in reducing the frequency and severity of hot flashes in menopausal women.⁴³ In addition, a randomized controlled trial involving 187 postmenopausal women found that clinical hypnosis significantly reduced the frequency and severity of hot flashes (74.2%) compared to a structured attention control group (Table 4).⁴⁴

Table 4.

Studies on Stress Management and Vasomotor Symptoms (VMS).

Authors/reference	Study Type	Intervention	Participants
Elkins et al, 2013⁴⁴	RCT	Evaluate impact of clinical hypnosis for hot flashes	187 women reporting >50 hot flashes/week
Elkins et al, 2013⁴⁴	Results: Participants reported a mean reduction of 74.16% hot flashes for the clinical hypnosis intervention vs a mean reduction of 17.13% hot flashes for controls (P < .001; 95% CI, 36.15-49.67) over a 12 week period
Ayers et al, 2012⁴⁵	RCT	Examine effectiveness of group and self-help cognitive-behavioral therapy in reducing VMS	140 women
Ayers et al, 2012⁴⁵	Results: Group (adjusted mean difference, 2.12; 95% CI, 1.36-2.88; P < .001) and self-help (adjusted mean difference, 2.08; 95% CI, 1.29-2.86; P < .001) CBT significantly reduced night sweat frequency at 6 and 26 weeks
Carmody et al, 2011⁴⁶	RCT	To analyze the effect of participation in a mindfulness training program (MBSR) on the degree of bother from hot flashes/night sweats	110 perimenopausal women
Carmody et al, 2011⁴⁶	Results: At 20 weeks, total reduction in bother for MBSR was 21.62% and 10.50% for controls (P = .04). In addition, the MBSR group made clinically significant improvements in quality of life (P = .022), subjective sleep quality (P = .009), anxiety (P = .005), and perceived stress (P = .001)

Structured stress management programs, which can effectively reduce stress and menopausal symptoms, should also be considered when creating a menopause management plan. While the NAMS 2023 position statement did not recommend yoga, relaxation, or mindfulness-based interventions, limited evidence exists for supporting mind-body therapies such as these overall during the menopause transition. One study found that a program combining mindfulness meditation, relaxation techniques, cognitive-behavioral therapy, and social support was effective in reducing perceived stress and menopausal symptoms in peri- and postmenopausal women.⁴⁵ In addition, a study examining the effect of mindfulness-based stress reduction for VMS demonstrated a 21.6% reduction in bothersome VMS vs 10.50% for controls. In addition, the MBSR group made clinically significant improvements in quality of life, subjective sleep quality, anxiety, and perceived stress.⁴⁶ These results suggest that a comprehensive approach to menopausal symptom management that includes structured stress management programs may significantly improve women’s well-being and quality of life during the menopausal transition beyond vasomotor symptoms alone.

Social Connection

The interaction between menopausal vasomotor symptoms and social connectedness is difficult to study and has little data, but is likely bidirectional. Menopause can be a time of social isolation for some women; moreover, negative attitudes towards menopause can lead to underreporting. In one study, 25% of women reported that vasomotor symptoms impacted quality of life through social embarrassment, physical discomfort, and disturbed sleep.⁴⁷ Not only can menopause lead to social disconnection, but lack or presence of social connectedness may also shape a woman’s experience of this period. For example, Asian women living in the UK attributed more symptoms to menopause compared with Asian women living in Delhi. In cultures where older women are held in high respect, generally fewer symptoms are reported.⁴⁸ There is evidence that strong social networks and higher social support may reduce symptom severity and frequency.^49,50 Exactly how this happens is not well understood but may be hypothesized to be secondary to better health behaviors, less depression, and less stress. Conversely, other studies have not found that increased social support leads to reduced VMS or moderates the relationship between stress and its impact on such symptoms.⁵¹

Physical Activity

Physical activity and exercise are part of a healthy lifestyle and have accepted benefits for many menopausal concerns including cardiovascular risk, blood pressure control, osteoporosis, and mood.⁵² Evidence on physical activity and exercise for vasomotor symptoms, however, is mixed.^53–55 While there are some trials showing that aerobic and strength training exercise programs can decrease the frequency of hot flashes, other studies have linked higher levels of vigorous physical activity to a greater risk of hot flashes.^52,54–56

There is also research that shows that separate from formal exercise, reducing levels of sedentary behavior may help prevent vasomotor symptoms.^54,55 One confounding factor appears to be the difference between reported hot flashes and ones that are measured via skin temperature changes, as several studies showed higher levels of physical activity increase objective but not subjective symptoms.^47,54,55,57 Another is fitness level, as increases in physical activity appear to precipitate hot flashes in women with lower baseline fitness.^55,57,58 Currently, there is not enough evidence to recommend physical activity for vasomotor menopause symptoms specifically, although moderate activity and strength training may be better for vasomotor symptom optimization than is vigorous exercise. (Table 5).

Table 5.

Studies on Physical Activity and Vasomotor Symptoms (VMS).

Authors/Reference	Study Type	Intervention	Participants
Haimov-Kochman et al, 2013⁴⁷	Cross-sectional	To assess the association between lifestyle parameters and climacteric syndrome severity	151
Haimov-Kochman et al, 2013⁴⁷	Results: Exercise was the lifestyle parameter most significantly correlated with reduced climacteric scores (Greene score) (17.0 ± 11.0 vs 22.6 ± 11.3) (P = .01)
Daley et al, 2014⁵⁹	Meta-analysis	Cochrane review: 5 RCTs comparing exercise with no treatment, exercise with yoga, and exercise with hormone therapy	733 women
Daley et al, 2014⁵⁹	Results: Evidence was low quality, with limitations in study design. Available evidence showed no difference between groups in frequency or intensity of vasomotor symptoms between exercise and sedentary activity (SMD -.10, 95% CI -.33 to .13, three RCTs, 454 women); nor was any evidence found when exercise was compared with yoga (SMD -.03, 95% CI -.45 to .38, two studies, n = 279 women)
Zhang et al, 2020²⁵	RCT	To investigate association of exercise with menopausal symptoms	4595 Chinese women
Zhang et al, 2020²⁵	Results: VMS varied based on daily exercise intensity. Heavy exercise with associated with increased VMS (OR 1.22), while mild exercise was associated with decreased VMS (OR .233). Regular exercise improved other symptoms of menopause, including sleep quality and mood

Discussion

This analytic review examined the evidence of the pillars of Lifestyle Medicine’s impact on vasomotor symptoms (Table 6).

Table 6.

Lifestyle Pillars and Effects on Vasomotor Symptoms Recommendations.

Lifestyle Medicine Pillar	Recommendations
Nutrition (Diet)	Diet characterized by high intakes of fruits, vegetables, whole grains, pulses, and legumes, and having a higher proportion of healthier fats from foods such as oily fish, nuts and seeds, while limiting the intake of sugar and unhealthy fats, reduce VMS.
Physical activity/exercise	Reducing levels of sedentary behavior may reduce VMS. Moderate exercise may reduce VMS. Vigorous exercise may increase VMS.
Restorative sleep	No current data to conclusively link reductions in VMS and sleep. Clinical team may consider excluding underlying sleep pathology
Stress management	Structured stress management programs may reduce stress and menopausal symptoms. Clinical hypnosis and CBT associated with lower VMS.
Positive social connection	Maintaining strong social networks and higher social support may reduce VMS; low quality evidence available
Avoidance of risky substances	Smoking cessation and lowering alcohol intake is associated with reduction of VMS.

There was strong support for the reduction and/or avoidance of risky substances, particularly tobacco products, in reducing VMS. There was evidence that a Mediterranean-style plant-forward dietary pattern may effectively reduce vasomotor symptoms, specifically as it relates to weight loss (Table 1). There was a linear correlation observed for an increasing fiber and reduction in VMS, with the best results observed for a WFPB diet. Hot flushes were significantly inversely associated with consumption of soy products, and phytoestrogens reduced hot flash frequency compared to placebo (Table 2).^{14,17,60–62} Evidence exists most strongly for stress reduction via cognitive-behavioral therapy, and clinical hypnosis, with mixed evidence for mindfulness-based stress reduction and other mind-body techniques. While restorative sleep and positive social connections have been associated with longevity and successful aging, the evidence could not support specific recommendations regarding vasomotor symptom relief.

Conclusion

Vasomotor symptoms are a common feature of the menopause transition, and while hormone therapy is the first-line recommendation, women may not utilize this form of treatment due to medical contraindications or personal preference. This review found evidence that utilizing the pillars of Lifestyle Medicine may be an effective strategy to improving vasomotor symptoms in a nonpharmacologic approach. It should be explicitly stated that the scope of this paper is for vasomotor symptoms alone; all pillars of Lifestyle Medicine should be re-evaluated for other elements of menopause, including cardiovascular health, bone health, and longevity. Follow-up systematic reviews on a broader scope of health after the menopause transition using the pillars of Lifestyle Medicine would be an area of future interest for clinical practice and patient education.⁶³

Footnotes

Acknowledgments

The authors wish to thank Metropolitan State University of Denver students (now graduates) Andrea Musick and Olivia Till, who assisted with the initial literature searches, and Dr Martin Bonsangue, for proofreading and editing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anne Kennard

References

“The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society” Advisory Panel . The 2023 nonhormone therapy position statement of the North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200

Kroenke

Caan

Stefanick

, 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.

Rotolo

Zinzi

Veronese

, et al. Women in LOVe: lacto-ovo-vegetarian diet rich in omega-3 improves vasomotor symptoms in postmenopausal women. An exploratory randomized controlled trial. Endocr, Metab Immune Disord: Drug Targets. 2019;19(8):1232-1239.

Barnard

Kahleova

Holtz

, et al. The Women’s Study for the Alleviation of Vasomotor Symptoms (WAVS): a randomized, controlled trial of a plant-based diet and whole soybeans for postmenopausal women. Menopause. 2021;28(10):1150-1156.

Gold

Flatt

Pierce

, et al. Dietary factors and vasomotor symptoms in breast cancer survivors: the WHEL Study. Menopause. 2006;13(3):423-433.

Herber-Gast

GCM

Mishra

. Fruit, Mediterranean-style, and high-fat and -sugar diets are associated with the risk of night sweats and hot flushes in midlife: results from a prospective cohort study. Am J Clin Nutr. 2013;97(5):1092-1099.

Flor-Alemany

Marín-Jiménez

Coll-Risco

Aranda

Aparicio

. Influence of dietary habits and Mediterranean diet adherence on menopausal symptoms. The FLAMENCO project. Menopause. 2020;27(9):1015-1021.

Soleymani

Siassi

Qorbani

, et al. Dietary patterns and their association with menopausal symptoms: a cross-sectional study. Menopause. 2019;26(4):365-372.

Thurston

El Khoudary

Sutton-Tyrrell

, et al. Vasomotor symptoms and insulin resistance in the study of women’s health across the nation. J Clin Endocrinol Metab. 2012;97(10):3487-3494.

10.

Tuomikoski

Savolainen-Peltonen

. Vasomotor symptoms and metabolic syndrome. Maturitas. 2017;97:61-65.

11.

Ludwig

. The ketogenic diet: evidence for optimism but high-quality research needed. J Nutr. 2020;150(6):1354-1359.

12.

Ford

Chang

Vitolins

, et al. Evaluation of diet pattern and weight gain in postmenopausal women enrolled in the Women’s Health Initiative Observational Study. Br J Nutr. 2017;117(8):1189-1197.

13.

Carmignani

Pedro

Costa-Paiva

Pinto-Neto

. The effect of dietary soy supplementation compared to estrogen and placebo on menopausal symptoms: a randomized controlled trial. Maturitas. 2010 Nov;67(3):262-269. doi:10.1016/j.maturitas.2010.07.007

14.

Chen

Lin

Liu

. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2015 Apr;18(2):260-269. doi:10.3109/13697137.2014.966241

15.

Hanachi

Golkho

. The effect of soymilk on menopausal symptoms and total antioxidant levels in menopausal women. Malaysian J Med Health Sci. 2008;4:33-40.

16.

Lewis

Nickell

Thompson

Szalai

Kiss

Hilditch

. A randomized controlled trial of the effect of dietary soy and flaxseed muffins on quality of life and hot flashes during menopause. Menopause. 2006;13(4):631-642.

17.

Nagata

. Soy intake and chronic disease risk: findings from prospective cohort studies in Japan. Eur J Clin Nutr. 2021;75:890-901. doi:10.1038/s41430-020-00744-x

18.

Simbalista

Sauerbronn

Aldrighi

Arêas

JAG

. Consumption of a flaxseed-rich food is not more effective than a placebo in alleviating the climacteric symptoms of postmenopausal women. J Nutr. 2010;140(2):293-297.

19.

Pruthi

Qin

Terstreip

, et al. A phase III, randomized, placebo-controlled, double-blind trial of flaxseed for the treatment of hot flashes: North Central Cancer Treatment Group N08C7. Menopause. 2012;19(1):48-53.

20.

Hunter

Gentry-Maharaj

Ryan

, et al. Prevalence, frequency and problem rating of hot flushes persist in older postmenopausal women: impact of age, body mass index, hysterectomy, hormone therapy use, lifestyle and mood in a cross-sectional cohort study of 10,418 British women aged 54-65. BJOG. 2012;119(1):40-50.

21.

Carson

Thurston

. Vasomotor symptoms and their links to cardiovascular disease risk. Curr Opin Endocr Metab Res. 2023;30:100448. doi:10.1016/j.coemr.2023.100448

22.

Kaunitz

Manson

. Management of menopausal symptoms. Obstet Gynecol. 2015;126:859-876.

23.

Wilsnack

. Alcohol use and menopause. Menopause. 2016;23:458-460.

24.

Anderson

Chung

H-F

Seib

, et al. Obesity, smoking, and risk of vasomotor menopausal symptoms: a pooled analysis of eight cohort studies. Am J Obstet Gynecol. 2020;222:478.

25.

Zhang

Ruan

Cui

Mueck

. Menopausal symptoms and associated social and environmental factors in midlife Chinese women. Clin Interv Aging. 2020;15:2195-2208.

26.

Bansal

Aggarwal

. Menopausal hot flashes: a concise review. J Midlife Health. 2019;10:6-13.

27.

Gold

Sternfeld

Kelsey

, et al. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Am J Epidemiol. 2000;152:463-473.

28.

Matthews

Chang

Brooks

et al. Identifying women who share patterns of reproductive hormones, vasomotor symptoms, and sleep maintenance problems across the menopause transition: group-based multi-trajectory modeling in the Study of Women’s Health across the Nation. Menopause. 2020;28(2):126-134. doi:10.1097/GME.0000000000001663

29.

Dias

RCA

Kulak Junior

Ferreira da Costa

Nisihara

. Fibromyalgia, sleep disturbance and menopause: is there a relationship? A literature review. Int J Rheum Dis. 2019;22(11):1961-1971. doi:10.1111/1756-185X.13713

30.

Lampio

Saaresranta

Engblom

Polo

Polo-Kantola

. Predictors of sleep disturbance in menopausal transition. Maturitas. 2016 Dec;94:137-142. doi:10.1016/j.maturitas.2016.10.004

31.

Hickey

Moss

Krejany

et al. What happens after Menopause? (WHAM): a prospective controlled study of sleep quality up to 12 months after premenopausal risk-reducing salpingo-oophorectomy. Gynecol Oncol. 2021;162:447-453. doi:10.1016/j.ygyno.2021.05.036

32.

Schaedel

Holloway

Bruce

Rymer

. Management of sleep disorders in the menopausal transition. Post Reprod Health. 2021;27(4):209-214. doi:10.1177/20533691211039151

33.

Tandon

Sharma

Mahajan

Tandon

. Menopause and sleep disorders. J Mid Life Health. 2022;13(1):26-33. doi:10.4103/jmh.jmh_18_22

34.

DePree

Houghton

Shiozawa

, et al. Treatment and resource utilization for menopausal symptoms in the United States: a retrospective review of real-world evidence from US electronic health records. Menopause. 2023;30(1):70-79. doi:10.1097/GME.0000000000002095

35.

Avis

Levine

Coeytaux

. Results of a pilot study of a cooling mattress pad to reduce vasomotor symptoms and improve sleep. Menopause. 2022;29(8):973-978. doi:10.1097/GME.0000000000002010

36.

Yan

Andrew

Marlow

, et al. Dietary fibre intervention for gut microbiota, sleep, and mental health in adults with irritable bowel syndrome: a scoping review. Nutrients. 2021;13(7):2159. doi:10.3390/nu13072159

37.

Sternfeld

Guthrie

Ensrud

, et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause. 2014 Apr;21(4):330-338. doi:10.1097/GME.0b013e31829e4089

38.

Darehzereshki

Dehghani

Enjezab

. Mindfulness-based stress reduction group training improves of sleep quality in postmenopausal women. BMC Psychiatr. 2022;22:254. doi:10.1186/s12888-022-03869-4

39.

Godos

Grosso

Castellano

Galvano

Caraci

Ferri

. Association between diet and sleep quality: a systematic review. Sleep Med Rev. 2021 Jun;57:101430. doi:10.1016/j.smrv.2021.101430

40.

English

Stoykova

Slota

et al. Qualitative study: burden of menopause-associated vasomotor symptoms (VMS) and validation of PROMIS Sleep Disturbance and Sleep-Related Impairment measures for assessment of VMS impact on sleep. J Patient Rep Outcomes. 2021 Apr 26;5(1):37. doi:10.1186/s41687-021-00289-y

41.

Britton

Fat

Neligan

. The association between alcohol consumption and sleep disorders among older people in the general population. Sci Rep. 2020;10:5275. doi:10.1038/s41598-020-62227-0

42.

Swartzman

Edelberg

Kemmann

. Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychol. 1990;9(5):529-545. doi:10.1037//0278-6133.9.5.529

43.

Hunter

Liao

. A psychological analysis of menopausal hot flushes. Br J Clin Psychol. 1995 Nov;34(4):589-599. doi:10.1111/j.2044-8260.1995.tb01493.x

44.

Elkins

Fisher

Johnson

Carpenter

Keith

. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause. 2013 Mar;20(3):291-298. doi:10.1097/gme.0b013e31826ce3ed

45.

Ayers

Smith

Hellier

Mann

Hunter

. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012 Jul;19(7):749-759. doi:10.1097/gme.0b013e31823fe835

46.

Carmody

Crawford

Salmoirago-Blotcher

Leung

Churchill

Olendzki

. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause. 2011 Jun;18(6):611-620. doi:10.1097/gme.0b013e318204a05c

47.

Haimov-Kochman

Constantini

Brzezinski

Hochner-Celnikier

. Regular exercise is the most significant lifestyle parameter associated with the severity of climacteric symptoms: a cross sectional study. Eur J Obstet Gynecol Reprod Biol. 2013;170(1):229-234. doi:10.1016/j.ejogrb.2013.06.018

48.

Gupta

Sturdee

Hunter

. Mid-age health in women from the Indian subcontinent (MAHWIS): general health and the experience of menopause in women. Climacteric. 2006;9(1):13-22. doi:10.1080/13697130500515776

49.

Yazdkhasti

Keshavarz

Khoei

et al. The effect of support group method on quality of life in post-menopausal women. Iran J Public Health. 2012;41(11):78-84.

50.

Thoits

. Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav. 2011;52(2):145-161.

51.

Arnot

Emmott

Mace

. The relationship between social support, stressful events, and menopause symptoms. PLoS One. 2021;16(1):e0245444. doi:10.1371/journal.pone.0245444

52.

Shifren

Gass

. The North American Menopause Society recommendations for clinical care of midlife women. Menopause. 2014;21:1038-1062. doi:10.1097/GME.0000000000000319

53.

Martinez-Dominguez

Chedraui

Alonso-Ventura

, et al. Effects of exercise on menopausal prevalent conditions. Postmenopaus Diseas Disord. 2019;2019:467-484. doi:10.1007/978-3-030-13936-0_30

54.

Witkowski

Evard

Rickson

White

Sievert

. Physical activity and exercise for hot flashes: trigger or treatment? Menopause. 2023;30(2):218-224. doi:10.1097/GME.0000000000002107

55.

Elvasky

Proctor

Williams

Henderson

. Effects of physical activity on vasomotor symptoms, examination using objective and subjective measures. Menopause. 2012;19(10):1095-1103. doi:10.1097/gme.0b013e31824f8fb8

56.

Berin

Hammar

Lindblom

Lindh-Astrand

Spetz-Holm

. Effects of resistance training on quality of life in postmenopausal women with vasomotor symptoms. Climacteric. 2021;126:55-60. doi:10.1016/j.maturitas.2019.05.005

57.

Gibson

Matthews

Thurston

. Daily physical activity and hot flashes in the study of women’s health across the nation (SWAN) flashes study. Fertil Steril. 2014;101(4):1110-1116. doi:10.1016/j.fertnstert.2013.12.029

58.

Whitcomb

Whiteman

Langenherb

Flaws

. Physical activity and risk of hot flashes among women in midlife. J Wom Health. 2007;16(1):124-133. doi:10.1089/jwh.2006.0046

59.

Daley

Stokes-Lampard

Thomas

MacArthur

. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2014 Nov 28;2014(11):CD006108. doi:10.1002/14651858.CD006108.pub4

60.

Levis

Griebeler

. The role of soy foods in the treatment of menopausal symptoms. J Nutr. 2010 Dec;140(12):2318S-2321S. doi:10.3945/jn.110.124388

61.

Van Patten

Olivotto

Chambers

, et al. Effect of soy phytoestrogens on hot flashes in postmenopausal women with breast cancer: a randomized, controlled clinical trial. J Clin Oncol. 2002;20(6):1449-1455.

62.

Haytowitz

Bhagwat

. USDA Database for the Flavonoid Content of Selected Foods, Release 3.3. Washington, DC: US Department of Agriculture; 2018. https://www.ars.usda.gov/ARSUserFiles/80400525/Data/Flav/Flav3.3.pdf

63.

What Is Lifestyle Medicine. Chesterfield MO: American College of Lifestyle Medicine; 2023. Accessed June 18, 2023 at https://lifestylemedicine.org/