A hot flash is a sudden intense feeling of heat, sweating and discomfort coming from within, like an internal furnace has been turned on. It typically lasts one to five minutes and usually is felt most strongly over the face, neck and chest. Hot flashes can quicken your heart rate, turn your skin blotchy and red as though you’re blushing, and make you feel anxious.

“You can fan yourself, you can roll the windows down, but it’s not going to matter. It’s not what’s happening on the outside that’s making you hot. It’s what’s happening on the inside,” said Kris E. Barnsfather, M.D., OB/GYN with Norton Women’s Care.

What about night sweats? They are just another name for hot flashes. Because they can wake you up drenched in sweat, night sweats can disrupt sleep, which can affect how well you function the next day.

How hot flashes are felt and how long they last differ from person to person. They may end with the arrival of menopause or continue after menopause.

What causes hot flashes?

Hot flashes happen as estrogen levels decline during the period of time leading up to menopause, called perimenopause. Estrogen is a hormone that plays many roles in the body. Researchers have recently learned that one of them has to do with regulating the body’s thermostat.

As estrogen levels decrease, the part of the brain responsible for controlling the body’s temperature — the hypothalamus — can mistakenly open up blood vessels in the skin and sweat glands to cool the body. This winds up having the opposite effect — making you suddenly feeling hot. It’s only when the hot flash goes away that you may feel chilly.

The hypothalamus is a structure deep in the brain about the size of an almond that is responsible for keeping the body in a stable state. This includes maintaining blood pressure, energy balance and body temperature.

Regulating body temperature can mean producing heat to warm the body or releasing heat through the skin and sweat glands to cool it off.

When estrogen levels drop, it disrupts a delicate balance in the hypothalamus. Estrogen normally quiets neurons in the brain that signal for the body to cool itself off. With lower estrogen levels, these signals become erratic.

“Those neurons start firing at a much more chaotic and rapid pace,” Dr. Barnsfather said. “That’s what causes us to get hot.”

Anxiety or mood changes can trigger hot flashes. Eating spicy foods, or drinking caffeinated drinks or alcohol also can trigger hot flashes.

Obesity and certain lifestyle choices can make the symptoms come sooner and last longer. These include alcohol use, smoking and lack of exercise.

Hot flashes can start as early as age 40 and typically occur over a period of seven to 14 years. They tend to linger two to four years longer for individuals who are Black or Latina.

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Vaginal atrophy also means your vagina has less natural lubrication and can result in vaginal bleeding or spotting during sex, while sex itself can become painful.

“Vaginal atrophy can affect your quality of life, your self-esteem and intimacy with your partner,” said Kris E. Barnsfather, M.D., an OB/GYN with Norton Women’s Care. “There’s no reason you have to accept that as a part of aging.”

Unlike other symptoms of menopause such as hot flashes and night sweats, which are temporary, vaginal symptoms will increase over time.

Roughly half of all women will experience vaginal symptoms after menopause.

RELATED: Hormone replacement therapy is different from over-the-counter supplementation

Your primary care provider or your gynecologist can diagnose vaginal atrophy and discuss possible treatments with you.  

One treatment option is hormone replacement therapy. This will raise estrogen throughout the body, which will address vaginal atrophy and other symptoms of menopause, such as hot flashes. Estrogen and progesterone replacement therapies come with risks, however. These include raising the risk for stroke, breast cancer and blood clots.

Alternatively, vaginal estrogen, which is available by prescription, will restore estrogen levels in your vagina. Vaginal estrogen is applied once or twice a day for a few weeks, followed by a maintenance dose of two or three times a week.

You should not use topical estrogen during nights you plan to have intercourse. Also, there’s no need to use vaginal estrogen until you are experiencing symptoms.

It’s unclear whether it is as safe as systemic hormone replacement therapy.

Water-based lubricants and long-acting vaginal moisturizers also can eliminate pain during intercourse. You should avoid alcohol-based lubricants, which will make symptoms of vaginal atrophy worse. You also should also avoid products with harsh chemicals or fragrances, because they may alter the vaginal pH and cause external irritation.

An oral medicine approved for painful intercourse, sold under the brand names Osphena and Senshio, has been shown to improve vaginal dryness, and other potential medications are being studied.

In addition to dryness and irritation, menopause also causes a loss of fat at the entrance of the vagina, called the vaginal introitus, which can become smaller over time. Physical therapy at home using mineral oil on the introitus helps keep the vaginal tissue healthy.  

Vaginal dryness can affect masturbation, arousal and physical and emotional pleasure. It also can cause pain during sex. Studies have found many patients attribute these symptoms to natural aging — rather than menopause — and don’t talk to their gynecologist or primary care provider about them.

If you are experiencing symptoms of vaginal atrophy, talk with your health care provider to determine the best treatment for you.

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Complaints of poor sleep quality, waking up during the night, not enough sleep and night sweats are common. So are mood changes, including depression and anxiety, which can contribute to poor sleep. 

“If you are going through menopause or are in menopause, and lack of sleep or poor sleep quality is affecting you during the day, talk to your provider,” said Kris E. Barnsfather, M.D., obstetrician/gynecologist with Norton Women’s Care. “There are things you can do and treatments available that can help.”

According to data from the National Institutes of Health, for about half of all women, difficulty sleeping doubles in the lead up to menopause and increases further after menopause. Women transitioning to menopause experience a drop in their estrogen levels. This is what causes hot flashes, night sweats and mood changes.

It’s not entirely clear how menopause disrupts sleep. What you eat also can affect the likelihood you will have insomnia after menopause. A study of 50,000 postmenopausal women found women who ate more fruits and vegetables had a lower chance of experiencing insomnia, while consuming sugars and carbohydrates increased the risk. 

Helpful strategies include a regular sleep schedule and a bedtime routine, such as listening to soothing music or taking a warm bath before bed. Avoid large meals close to bedtime and caffeine late in the day, do not nap in the late afternoon or evening, and try not watching TV or using your computer or mobile device in the bedroom. Keeping your bedroom at a comfortable temperature can help too, usually a couple degrees colder than you like it during the day.

Regular exercise also can help with your sleep quality, as long as it’s not too close to bedtime.

Cognitive behavioral therapy may be an option for women with insomnia as the result of menopause. Research has shown it is as effective as prescription sleep medications in the short term and better tolerated in the long term. There is also a technique called sleep restriction therapy that is designed to reduce middle-of-the-night awakenings.

Supplements and medications also are available for menopause-related insomnia. Some women use over-the-counter sleep aids such as melatonin for insomnia related to menopause. Prescription sleep aids may help, but these are designed for short-term use only.

Antidepressants called serotonin reuptake inhibitors, used to treat depression and anxiety, also have been shown to reduce the symptoms that cause sleep issues in women during the transition to menopause. Another drug that can help is gabapentin, which may decrease the menopause symptoms.

Drugs called benzodiazepines are used frequently for insomnia, but they may not be a good long-term solution because of concerns about their use in older patients. These drugs have been linked to lethargy, confusion, an increased risk of falls and impaired driving among the elderly. Estrogen replacement therapy can improve sleep, along with other menopausal symptoms, but carries risks associated with long-term use.

Insomnia can affect all aspects of your life, and lack of sleep has been linked to a higher risk of high blood pressure, diabetes, obesity, depression, heart attack and stroke. It’s important to speak with your health care provide to address your insomnia rather than hoping it will pass on its own. Your provider can help you consider options for treating your insomnia and what will work best for you.

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These behavioral changes happen because estrogen is not just a sex hormone. It also plays a role in the brain, and the transition to menopause can cause changes in how you feel and how you think. One symptom you may experience as your estrogen levels drop is anxiety. This can create a constant worry that gets in the way of your daily life and makes it hard to concentrate.

Anxiety also can be felt physically and result in sweating, muscle tension and nausea. You may even start having panic attacks. Panic attacks can cause your heart to pound, make you feel as if you can’t breathe, or even give you an intense fear that you are dying. It’s important to realize that these symptoms could be related to changes in your hormones, but if you start experiencing panic attacks, contact your health provider to rule out other potential causes.

“It’s not as common as irritability, but I’ve had patients start having panic attacks and anxiety during perimenopause,” said Kris E. Barnsfather, M.D., an obstetrician and gynecologist with Women’s Care Physicians of Louisville in St. Matthews, a part of Norton Women’s Care. “If it’s one or two panic attacks a month and isn’t interfering with the patient’s life, understanding the cause and normalizing the anxiety seems to be enough for some women.”

The transition to menopause, called perimenopause, begins in the 40s and 50s, a time when many women are already feeling a lot of stress while managing demanding jobs, raising children and caring for elderly parents — sometimes all at once.

Researchers have found that the transition to menopause causes 4 in 10 women to have mood changes similar to premenstrual syndrome, or PMS. These include being tearful, moody or irritable. You may find that you have “a short fuse” and are angered by things that didn’t bother you before. Perimenopause causes estrogen levels to drop, but they do so in an irregular fashion, meaning there is no pattern to the changes in mood. This “perimenopausal mood instability” can last anywhere from a few months to four years or more.

Perimenopause also is associated with forgetfulness, trouble with words and an inability to concentrate, in what often is described as “brain fog.” Other changes in your behavior can include loss of self-esteem, loss of confidence, and feelings of sadness and depression. The transition to menopause can cause a range of changes in your body and brain. Researchers have found that during this time, women are at higher risk of developing depression, stress, anxiety and emotional distress. These changes may be unpleasant, but they are normal as the body adapts to new, lower levels of estrogen. It’s important to see your OB/GYN or primary care provider regularly to discuss how you are feeling.

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Why am I gaining weight during menopause?

Menopause weight gain can be caused by changes in hormones. The body’s estrogen levels drop during this time, which can reduce metabolism. This drop in estrogen also may cause fatigue combined with an increased appetite.

Lower estrogen levels can cause many people to gain weight around their abdomen or midsection area. Other bodily changes that happen naturally during the aging process, such as decreased muscle mass and increased fat, also may cause menopause weight gain. Genetics also can play a role.

Lifestyle factors, such as eating an unhealthy diet, being sedentary and not incorporating movement or exercise into your daily routine, also will cause weight gain.

RELATED: Menopause and anxiety: When to talk to your gynecologist

How can I stop menopausal weight gain?

Exercise

Aim for at least 30 minutes of physical activity per day. Aerobic or cardio exercises that get your heart rate pumping will help burn calories. Lifting weights and weight-bearing exercises — walking, jogging, climbing stairs, hiking, tennis and dancing — can increase the bone density typically lost during menopause.

Nutritious diet

Don’t be tempted to crash diet because of menopause weight gain — instead, incorporate a vitamin-rich diet and limit processed foods or sweet treats. Shop for vegetables, fruits, whole grains, lean proteins and healthy fats (like nuts, avocado and olive oil). Menopause bone density loss can be prevented by consuming calcium, including milk and dairy products; vitamin K, found in leafy greens; and vitamin D, which is in fish, egg yolks and mushrooms.

Sleep & stress reduction

The hormonal changes during menopause can affect sleep patterns. Many people going through menopause experience hot flashes and/or night sweats. Lack of sleep can increase stress, exacerbate negative moods and encourage unhealthy food cravings. Use relaxation techniques at bedtime, such as meditation and limiting screen time, to reduce stress and help encourage rest. If you are stressed, reach out to your support network, such as trusted family members, friends or a therapist.

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Lower estrogen levels can lead to vaginal dryness as blood supply to the vagina drops, thinning the vaginal wall and causing a general tightness. The result can be penetrative sex that’s uncomfortable or even painful (dyspareunia).

To understand your condition, your gynecologist will collect your health and sexual history, perform a pelvic exam and may order blood tests to check hormone levels and any disorders with the thyroid or liver and to look for diabetes and high cholesterol.

RELATED: Hormone replacement therapy is different from over-the-counter supplementation

Hormone therapy such as estrogen can address changes to the vagina. Testosterone in women is not approved by the Food and Drug Administration (FDA) and can have significant detrimental side effects.

“Keep in mind that if a partner is using medication for erectile dysfunction, they could be adding to the discomfort. A more robust erection is not a good combination with vaginal atrophy and the thinner, dryer and inflamed vaginal walls that come with it,” said Amy E. Farrell, M.D., a gynecologist with Norton Women’s Health.

“If vaginal dryness is an issue, you may use a daily moisturizer that is safe for the vaginal area. Lubricants may also be used with intercourse to decrease friction and improve sensation,” Dr. Farrell said.

Counseling also can help with sexual conditions and low sex drive. Counseling typically will cover understanding sexual response and techniques. Addressing relationship issues may also help increase feelings of intimacy and desire.

Hypoactive sexual desire disorder

If the condition is a total loss of interest in sex — hypoactive sexual desire disorder — there are some new medications available.

Two new drugs include bremelanotide (Vyleesi) and flibanserin (Addyi). Vylessi was approved by the FDA in 2019 and is taken as an injection 45 minutes before anticipated sexual activity. It has been shown through clinical trials to increase desire and satisfaction. Addyi was approved in 2015 and targets serotonin receptors. It’s a daily pill that will interact with alcohol and can cause sleepiness and fainting.

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Estrogen levels drop significantly during menopause, causing bone loss that can lead to osteoporosis.

“Even though it is impossible to recover the bone density of one’s youth, there are simple healthy habits that can help prevent rapidly thinning bones,” said Angela L. Bell, M.D., OB/GYN with Norton Women’s Care.

6 tips to increase bone density and help prevent osteoporosis

1) Do bone-building exercises.

Weight-bearing exercises — walking, jogging, climbing stairs, hiking, tennis and dancing — can increase bone density. Lifting weights also can strengthen bones. Aim for 30 minutes of physical activity per day. If you have osteoporosis, talk to your doctor before starting an exercise routine, as movements like bending or twisting can harm the spine.

2) Eat your vitamins.

Ensure your diet is rich in calcium, including milk and dairy products; vitamin K, found in leafy greens; and vitamin D, which is in fish, egg yolks, mushrooms and also absorbed by spending time in the sunshine. Talk to your doctor about taking vitamin supplements.

3) Maintain a healthy weight.

Being underweight, or having a low body mass index (BMI), can lead to greater bone loss later in life, while obesity can cause health conditions (such as high blood pressure or diabetes) that can be risk factors for low bone density.

4) Stop smoking.

Tobacco use decreases bone density, and smoking is a risk factor for osteoporosis. Studies show that quitting smoking, even later in life, can help decrease bone loss.

5) Limit alcohol use.

Excessive drinking can interfere with the absorption of key nutrients in bone health, such as calcium. Overindulging also can increase the risk of broken bones from falls.

6) Talk to your doctor about medications.

Although there is no cure for osteoporosis, prescription medicines may slow bone loss and help manage osteoporosis in postmenopausal patients.

Bone mass tends to stay stable from about age 30 until menopause. The menopausal transition usually begins between ages 45 and 55, and rapid bone loss may occur during the first few years of menopause. While the initial speed of bone loss eventually slows, the loss of bone density will continue gradually over the years.

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Perimenopause, also called the menopausal transition, describes the months or years leading up to menopause, when the body goes through vast changes. This transition can be more difficult for some than menopause due to dramatic fluctuations in reproductive hormone levels. During perimenopause, these hormones are sometimes underproduced and sometimes overproduced. In menopause, reproductive hormones are at constantly low levels.

“We used to think perimenopause started only months before the onset of menopause. Now we know perimenopause can begin four or more years before menopause,” said Tamara L. Callahan, M.D., gynecologist with Norton Women’s Care.

Addressing perimenopause and menopause symptoms

Signs of perimenopause include menstrual irregularities, hot flashes, night sweats, mood swings, trouble sleeping and vaginal dryness.

You don’t have to live with these symptoms. Managing them is important for quality of life. For many, continuous low-dose birth control pills can provide steady estrogen that treats symptoms and provides contraception.

Menopause officially begins when there are no more periods for 12 consecutive months. This usually happens between ages 45 and 55, with the average age of 51.

“One thing we’ve learned about menopause is that lower estrogen levels mean more than vaginal dryness, decreased libido and painful intercourse,” Dr. Callahan said. “Less estrogen also can affect the bladder and urethra, potentially resulting in pain and burning with urination, urinary frequency, urgency and an increase in bladder and kidney infections. Patients often don’t associate these symptoms with menopause.”

Collectively, these vaginal and urinary symptoms are known as genitourinary syndrome of menopause (GSM).

Hypoactive sexual desire disorder (HSDD) can also happen during perimenopause and menopause. While there are some medications to help increase sex drive during perimenopause, options are limited for addressing libido during menopause.

“This is frustrating for patients and providers given that half of all patients experience at least one sexual symptom of menopause,” Dr. Callahan said.

Loss of estrogen during menopause also can result in “brain fog,” making concentration and finding words difficult.

Menopause can mean less time spent in deep sleep, too. As a result, quality of sleep becomes less restorative, which can be distressing and disruptive.

Then there’s the weight gain that comes from hormone changes and a decrease in metabolism. The extra weight is redistributed differently. Instead of added pounds accumulating on the hips and thighs as in younger women, the weight collects around the abdomen.

“Females typically live to age 75 and beyond, therefore they are living more than one-third of their lives in menopause,” Dr. Callahan said. “That’s a long time to live with distressing symptoms.”

Menopausal hormone therapy

Fortunately, menopausal hormone therapy (MHT) can help with most symptoms.

“When started within 10 years of the last menstrual period, in healthy women without contraindications, MHT is both safe and effective,” Dr. Callahan said. “In general, MHT can be used with minimal risk up to age 59. But transitioning off it needs to be done in conversation with the patient’s health provider.”

For those who cannot or choose not to use MHT, there are effective and safe non-estrogen therapies to treat hot flashes and night sweats. These include low-dose gabapentin and selective serotonin reuptake inhibitors (SSRIs), among others.

Low-dose vaginal estrogens can help with relieving the genital and urinary symptoms of menopause.

“Education is some of the most potent medicine we have — not just for the patient but for the partner, family and provider,” Dr. Callahan said. “We can work as a team to navigate this challenging time.”

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During the time before menopause, called perimenopause, the ovaries decrease production of estrogen and progesterone. Sleep issues can start during this phase, but generally ramp up after menopause, when a woman has gone without a period for one year.

Hot flashes and obstructed breathing are the most common causes of sleep issues for women during menopause.

“Before a hot flash, body temperature rises, which results in waking up,” said James M. Graham, M.D., OB/GYN with Women’s Care Physicians of Louisville, a Part of Norton Women’s Care. “These flashes can last around three minutes. If a woman experiences several hot flashes during the night, it can lead to low-quality sleep and next-day drowsiness.”

RELATED: Menopause and anxiety: When to talk to your gynecologist

Additionally, as a woman ages, the throat muscles lose tone, impinging on the airway during sleep. This can cause obstructive sleep apnea (OSA).

Hot flashes will go away in one to three years for most women, but because OSA has impacts on heart health, mental health and more, it requires medical attention.

Read more:  The link between heart disease and sleep apnea.

The good news is lifestyle changes may be all it takes. Losing weight, eating a balanced diet that includes soy and getting enough exercise can help.

Avoid nicotine, and keep caffeine and alcohol to a minimum. Alcohol can increase hot flashes. Sleep in lightweight clothing and avoid heavy blankets. Use a fan or air conditioner to circulate air.

Hormone or medication therapy as well as a variety of treatments for OSA also are options if lifestyle changes don’t work.

The first step is making sure your health provider is aware of your sleep issues. A good night’s sleep is too important to your overall health to not do something about.

“Life is one big adaptation. You go through puberty and motherhood. Menopause is another change that you have to adapt to,” Dr. Graham said. “And your doctor can help you find solutions.”

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