Hot Flashes, Menopausal Transition, and Early Postmenopause: Beyond Hormones

Background:  Understanding factors promoting symptom severity is essential to developing innovative symptom management models.  To date research about hot flashes emphasizes the role of hormones to the exclusion of the role of personal, behavioral and environmental factors.

Purpose: To investigate patterns of hot flash severity during the menopausal transition  (MT) and early postmenopause (PM) and associated factors, we studied effects of:  age, MT factors (MT stages, age at stages and final menstrual period (FMP), estrogen, FSH), stress-related factors (cortisol, catecholamines, perceived stress), health-related factors (BMI, smoking, alcohol use, exercise, sleep, number of live births), and personal factors (depressed mood, education, anxiety).

Methods:  A subset of Seattle Midlife Women’s Health Study participants (n= 291 with up to 6973 observations) provided data during the late reproductive, early, and late MT stages and early PM, including menstrual calendars, annual health updates 1990, and symptom diaries and urine specimens assayed for hormones several times per year.    Multilevel modeling with an r program was used to test models accounting for hot flash severity. Separate models of endocrine factors and stress-related, health-related, and personal factors were tested using p<.05. 

Results:  Hot flash severity persisted through the MT stages and peaked during the late MT stage, diminishing after the first year PM.  In individual analyses hot flash severity was associated with being older, being in the late MT stage or early PM, beginning the late MT stage at a younger age, having less education, and reporting greater anxiety.   In a model including only endocrine factors, hot flash severity was significantly associated with higher FSH, lower estrone and lower cortisol levels.  An integrated model revealed dominant effects of menopause-related factors with anxiety contributing  to hot flash severity. 

Conclusions and Implications:  Hot flash severity was affected largely by factors related to reproductive aging and anxiety.  These findings are consistent with prior research linking hot flash severity to stress exposure, anxiety, and accelerated reproductive aging attributable to adverse experiences over the lifespan. Taken together, these findings suggest symptom management models that affect anxiety and may, in turn, enhance women’s experience of menopause.