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Risk factors, management and consequences of severe menopausal vasomotor symptoms

Nature Reviews Endocrinology (2026)Cite this article

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Abstract

Menopause, particularly the consequences of severe symptoms, has become the subject of intense media interest. Reducing the prevalent stigma around women’s reproductive health has allowed more women to speak openly about their menopause experiences, the effects on their lives and the barriers they face. These effects are far-reaching and illustrate the importance of improving the understanding, management and awareness of severe menopausal symptoms. The cardinal symptoms are hot flushes (or flashes) and night sweats (vasomotor symptoms), although symptoms can vary by ethnicity. For example, some Asian women report other primary symptoms (such as bone and/or joint pain). Vasomotor symptoms affect around 70% of perimenopausal and postmenopausal women and are moderate or severe in around one-third of these women. The US Food and Drug Administration considers vasomotor symptoms to be severe if they cause the person to stop their current activity. Severe vasomotor symptoms drive treatment seeking and can affect quality of life, mental health and work ability. We review the incidence, management and potential long-term health consequences of severe vasomotor symptoms, including cardiovascular disease, diabetes mellitus, cognitive dysfunction, bone health and quality of life. We discuss potential underlying mechanisms and the efficacy of available treatments. Finally, we highlight the evidence gaps in this field and directions for future research.

Key points

  • The experience of menopause varies dramatically between women, and for the same woman over time. Differences in the frequency and severity of vasomotor symptoms and uptake of treatment are evident between racial, ethnic and socio-economic groups.

  • Emerging evidence suggests that severe vasomotor symptoms are associated with long-term adverse health outcomes, including cardiovascular disease and type 2 diabetes mellitus.

  • It is not currently known whether treating severe vasomotor symptoms modifies the associations with long-term disease. Current evidence does not support use of menopause hormone therapy (MHT, also termed hormone replacement therapy) for the primary or secondary prevention of chronic disease.

  • MHT appears to be the most effective therapy for severe vasomotor symptoms. Newer agents such as neurokinin receptor antagonists are also effective in reducing the frequency and severity of hot flushes and might also improve sleep and menopause-related quality of life.

  • Future consistent implementation of validated measurement tools will better facilitate the development and evaluation of medical therapies for vasomotor symptoms through direct comparisons of treatment efficacy.

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Fig. 1: Reproductive stages.
The alternative text for this image may have been generated using AI.
Fig. 2: Trajectories of vasomotor symptoms across midlife.
The alternative text for this image may have been generated using AI.
Fig. 3: Schema of links between KNDy neurons, regulation of GnRH section and vasomotor symptoms.
The alternative text for this image may have been generated using AI.

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References

  1. Harlow, S. D. et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. J. Clin. Endocrinol. Metab. 97, 1159–1168 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Waetjen, L. E. et al. Factors associated with developing vaginal dryness symptoms in women transitioning through menopause: a longitudinal study. Menopause 25, 1094–1104 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Tepper, P. G. et al. Characterizing the trajectories of vasomotor symptoms across the menopausal transition. Menopause 23, 1067–1074 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rance, N. E., Dacks, P. A., Mittelman-Smith, M. A., Romanovsky, A. A. & Krajewski-Hall, S. J. Modulation of body temperature and LH secretion by hypothalamic KNDy (kisspeptin, neurokinin B and dynorphin) neurons: a novel hypothesis on the mechanism of hot flushes. Front. Neuroendocrinol. 34, 211–227 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Hickey, M. et al. An empowerment model for managing menopause. Lancet 403, 947–957 (2024).

    Article  PubMed  Google Scholar 

  6. Brown, L. et al. Promoting good mental health over the menopause transition. Lancet 403, 969–983 (2024).

    Article  PubMed  Google Scholar 

  7. Mishra, G. D. et al. Optimising health after early menopause. Lancet 403, 958–968 (2024).

    Article  PubMed  Google Scholar 

  8. Zhu, D. et al. Type of menopause, age of menopause and variations in the risk of incident cardiovascular disease: pooled analysis of individual data from 10 international studies. Hum. Reprod. 35, 1933–1943 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Peate, M., Saunders, C., Cohen, P. & Hickey, M. Who is managing menopausal symptoms, sexual problems, mood and sleep disturbance after breast cancer and is it working? Findings from a large community-based survey of breast cancer survivors. Breast Cancer Res. Treat. 187, 427–435 (2021).

    Article  PubMed  Google Scholar 

  10. Zhao, D. et al. Treatment-induced menopause symptoms among women with breast cancer undergoing chemotherapy in China: a comparison to age- and menopause status-matched controls. Menopause 31, 145–153 (2024).

    Article  PubMed  Google Scholar 

  11. Hickey, M. et al. What happens after menopause? (WHAM): a prospective controlled study of vasomotor symptoms and menopause-related quality of life 12 months after premenopausal risk-reducing salpingo-oophorectomy. Gynecol. Oncol. 163, 148–154 (2021).

    Article  PubMed  Google Scholar 

  12. Toze, M. & Westwood, S. Experiences of menopause among non-binary and trans people. Int. J. Transgend. Health 26, 447–458 (2025).

    Article  PubMed  Google Scholar 

  13. Xin, M. Q. L. & Lane, R. Exploring the clinical, psychological, and social relevance of menopause for trans and gender diverse people: a qualitative study. Menopause 32, 288–294 (2025).

    Article  PubMed  Google Scholar 

  14. Thurston, R. C. & Joffe, H. Vasomotor symptoms and menopause: findings from the Study of Women’s Health across the Nation. Obst. Gynecol. Clin. North Am. 38, 489–501 (2011).

    Article  Google Scholar 

  15. Carpenter, J. S. et al. MsFLASH participants’ priorities for alleviating menopausal symptoms. Climacteric 18, 859–866 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Lan, Q., Hickey, M., Peate, M. & Marino, J. L. Priorities for alleviating menopausal symptoms after cancer. Menopause 30, 136–142 (2023).

    Article  PubMed  Google Scholar 

  17. Lensen, S. et al. A core outcome set for vasomotor symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative. Menopause 28, 852–858 (2021).

    Article  PubMed  Google Scholar 

  18. Nash, Z., Christmas, M., Gronlund, T. & Hickey, M. Top Ten menopause research priorities. Lancet 404, 2535–2536 (2025).

    Article  PubMed  Google Scholar 

  19. Santoro, N., Roeca, C., Peters, B. A. & Neal-Perry, G. The menopause transition: signs, symptoms, and management options. J. Clin. Endocrinol. Metab. 106, 1–15 (2021).

    Article  PubMed  Google Scholar 

  20. Mishra, G. D. & Kuh, D. Health symptoms during midlife in relation to menopausal transition: British prospective cohort study. BMJ 344, e402 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Avis, N. E. et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern. Med. 175, 531–539 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Anderson, D. J. et al. Obesity, smoking, and risk of vasomotor menopausal symptoms: a pooled analysis of eight cohort studies. Am. J. Obst. Gynecol. 222, 478.e1–478.e17 (2020).

    Article  Google Scholar 

  23. US Department of Health and Human Services, Food and Drug Administration & Center for Drug Evaluation and Research. Guidance for industry: estrogen and estrogen/progestin drug products to treat vasomotor symptoms and vulvar and vaginal atrophy symptoms — recommendations for clinical evaluation. FDA https://www.fda.gov/media/71359/download (2003).

  24. Williams, R. E. et al. Frequency and severity of vasomotor symptoms among peri- and postmenopausal women in the United States. Climacteric 11, 32–43 (2008).

    Article  CAS  PubMed  Google Scholar 

  25. Lensen, S. et al. Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium. Menopause 31, 582–590 (2024).

    Article  PubMed  Google Scholar 

  26. Rutherford, C. et al. Content validity, face validity and acceptability of three hot flash diaries for vasomotor symptoms: a cognitive interview study. Menopause https://doi.org/10.1097/GME.0000000000002696 (2025).

    Article  PubMed  Google Scholar 

  27. Iliodromiti, S. et al. Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review. BJOG 127, 320–333 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gold, E. B. et al. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: Study of Women’s Health Across the Nation. Am. J. Public Health 96, 1226–1235 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  29. Nappi, R. E. et al. Global cross-sectional survey of women with vasomotor symptoms associated with menopause: prevalence and quality of life burden. Menopause 28, 875–882 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kochersberger, A. et al. The association of race, ethnicity, and socioeconomic status on the severity of menopause symptoms: a study of 68,864 women. Menopause 31, 476–483 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  31. Kim, C. et al. Prospective early adulthood risk factors for vasomotor symptoms in the Coronary Artery Risk Development in Young Adults study. Menopause 31, 108–115 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Avis, N. E., Brambilla, D., McKinlay, S. M. & Vass, K. A longitudinal analysis of the association between menopause and depression. Results from the Massachusetts Women’s Health Study. Ann. Epidemiol. 4, 214–220 (1994).

    Article  CAS  PubMed  Google Scholar 

  33. Hickey, M., Schoenaker, D. A., Joffe, H. & Mishra, G. D. Depressive symptoms across the menopause transition: findings from a large population-based cohort study. Menopause 23, 1287–1293 (2016).

    Article  PubMed  Google Scholar 

  34. Paramsothy, P. et al. Duration of the menopausal transition is longer in women with young age at onset: the multiethnic Study of Women’s Health Across the Nation. Menopause 24, 142–149 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Herber-Gast, G. C. & Mishra, G. D. 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. 97, 1092–1099 (2013).

    Article  CAS  PubMed  Google Scholar 

  36. Di Donato, P. et al. Factors associated with climacteric symptoms in women around menopause attending menopause clinics in Italy. Maturitas 52, 181–189 (2005).

    Article  PubMed  Google Scholar 

  37. Mishra, G. D. & Dobson, A. J. Using longitudinal profiles to characterize women’s symptoms through midlife: results from a large prospective study. Menopause 19, 549–555 (2012).

    Article  PubMed  Google Scholar 

  38. Ruth, K. S. et al. Genetic insights into biological mechanisms governing human ovarian ageing. Nature 596, 393–397 (2021). This article provides vital insights into the biological mechanisms underlying ovarian ageing and how targeted therapeutics could be explored for future disease prevention.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Ruth, K. S. et al. Insights into the genetics of menopausal vasomotor symptoms: genome-wide analyses of routinely-collected primary care health records. BMC Med. Genom. 16, 231 (2023).

    Article  CAS  Google Scholar 

  40. Avis, N. E. et al. Change in health-related quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: Study of Women’s Health Across the Nation. Menopause 16, 860–869 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  41. Kumari, M., Stafford, M. & Marmot, M. The menopausal transition was associated in a prospective study with decreased health functioning in women who report menopausal symptoms. J. Clin. Epidemiol. 58, 719–727 (2005).

    Article  PubMed  Google Scholar 

  42. Blumel, J. E. et al. A multinational study of sleep disorders during female mid-life. Maturitas 72, 359–366 (2012).

    Article  PubMed  Google Scholar 

  43. Jack, G. et al. Menopause in the workplace: what employers should be doing. Maturitas 85, 88–95 (2016).

    Article  PubMed  Google Scholar 

  44. Rodrigo, C. H., Sebire, E., Bhattacharya, S., Paranjothy, S. & Black, M. Effectiveness of workplace-based interventions to promote wellbeing among menopausal women: a systematic review. Post. Reprod. Health 29, 99–108 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Faubion, S. S. et al. Impact of menopause symptoms on women in the workplace. Mayo Clinic Proc. 98, 833–845 (2023).

    Article  Google Scholar 

  46. Gartoulla, P., Worsley, R., Bell, R. J. & Davis, S. R. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause 22, 694–701 (2015).

    Article  PubMed  Google Scholar 

  47. Chung, H. F. et al. The role of sleep difficulties in the vasomotor menopausal symptoms and depressed mood relationships: an international pooled analysis of eight studies in the InterLACE consortium. Psychol. Med. 48, 2550–2561 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  48. Worsley, R., Bell, R. J., Gartoulla, P., Robinson, P. J. & Davis, S. R. Moderate-severe vasomotor symptoms are associated with moderate-severe depressive symptoms. J. Womens Health 26, 712–718 (2017).

    Article  Google Scholar 

  49. Maki, P. M. & Jaff, N. G. Brain fog in menopause: a health-care professional’s guide for decision-making and counseling on cognition. Climacteric 25, 570–578 (2022).

    Article  CAS  PubMed  Google Scholar 

  50. Maki, P. M. & Weber, M. T. A research primer for studies of cognitive changes across the menopause transition. Climacteric 24, 382–388 (2021).

    Article  CAS  PubMed  Google Scholar 

  51. Islam, R. M. et al. Prevalence and severity of symptoms across the menopause transition: cross-sectional findings from the Australian Women’s Midlife Years (AMY) Study. Lancet Diabetes Endocrinol. 13, 765–776 (2025).

    Article  PubMed  Google Scholar 

  52. Nash, Z. et al. Protocol for a global menopause priority setting partnership. BMJ Open 15, e096401 (2025). This article acknowledges the importance of those with lived experience in determining the future priorities in menopause research. There is much potential benefit in developing a global research agenda that is relevant and valuable.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Hanton, T. et al. Women’s health research priorities in the UK: a consensus statement from RCOG. Lancet Obst. Gynaecol. Womens Health 1, E249–E250 (2025).

    Article  Google Scholar 

  54. Greendale, G. A., Karlamangla, A. S. & Maki, P. M. The menopause transition and cognition. JAMA 323, 1495–1496 (2020).

    Article  PubMed  Google Scholar 

  55. Furey, R. T., Thomas, E. H. X., Kulkarni, J. & Gurvich, C. Subjective versus objective cognition during menopause: a systematic review and meta-analysis. J. Int. Neuropsychol. Soc. 31, 459–477 (2025). This systematic review highlights the difficulties of understanding the cognitive symptoms increasingly reported by perimenopausal and postmenopausal women. It demonstrates the challenges in classifying these cognitive changes, showing the need for high-quality research in this important area.

    Article  PubMed  Google Scholar 

  56. Zhu, C. et al. Factors associated with subjective cognitive symptoms during the menopause transition. Menopause 33, 340–348 (2025).

    Article  Google Scholar 

  57. Maki, P. M. et al. Hot flashes are associated with altered brain function during a memory task. Menopause 27, 269–277 (2020).

    Article  PubMed  Google Scholar 

  58. Thurston, R. C. et al. Menopausal vasomotor symptoms and white matter hyperintensities in midlife women. Neurology 100, e133–e141 (2023). This article demonstrates an important understanding of the effects of vasomotor symptoms on white matter in the brain. It provides vital foundational evidence for future research to explore whether vasomotor symptoms can serve as a female-specific midlife marker of brain health.

    Article  PubMed  Google Scholar 

  59. Williams, M. & Maki, P. M. A review of cognitive, sleep, and mood changes in the menopausal transition: beyond vasomotor symptoms. Obst. Gynecol. 146, 350–359 (2025).

    Article  Google Scholar 

  60. Drogos, L. L. et al. Objective cognitive performance is related to subjective memory complaints in midlife women with moderate to severe vasomotor symptoms. Menopause 20, 1236–1242 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  61. Peterson, A., Gottesman, R. T., Miller, E. C. & Tom, S. E. The association of vasomotor symptoms during the menopausal transition and cognition in later life. Menopause 29, 832–839 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  62. Hayashi, K. et al. Complaints of reduced cognitive functioning during perimenopause: a cross-sectional analysis of the Japan Nurses’ Health Study. Womens Midlife Health 8, 6 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  63. Greendale, G. A. et al. Menopause-associated symptoms and cognitive performance: results from the Study of Women’s Health Across the Nation. Am. J. Epidemiol. 171, 1214–1224 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  64. Andy, C. et al. Systematic review and meta-analysis of the effects of menopause hormone therapy on cognition. Front. Endocrinol. 15, 1350318 (2024).

    Article  Google Scholar 

  65. Gleason, C. E. et al. Long-term cognitive effects of menopausal hormone therapy: findings from the KEEPS continuation study. PLoS Med. 21, e1004435 (2024). This study demonstrates the lack of empirical support for preventative use of menopause hormone therapy (MHT) for cognitive function, an increasingly common challenge for perimenopausal and postmenopausal women and prescribers of MHT.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Thurston, R. C. Vasomotor symptoms and cardiovascular health: findings from the SWAN and the MsHeart/MsBrain studies. Climacteric 27, 75–80 (2024).

    Article  CAS  PubMed  Google Scholar 

  67. Carson, M. Y. & Thurston, R. C. Vasomotor symptoms and their links to cardiovascular disease risk. Curr. Opin. Endocr. Metab. Res. 30, 100448 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Thurston, R. C., Sutton-Tyrrell, K., Everson-Rose, S. A., Hess, R. & Matthews, K. A. Hot flashes and subclinical cardiovascular disease: findings from the Study of Women’s Health Across the Nation Heart Study. Circulation 118, 1234–1240 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  69. Lambrinoudaki, I. et al. Menopausal symptoms are associated with subclinical atherosclerosis in healthy recently postmenopausal women. Climacteric 15, 350–357 (2012).

    Article  CAS  PubMed  Google Scholar 

  70. Thurston, R. C. et al. Hot flashes and carotid intima media thickness among midlife women. Menopause 18, 352–358 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  71. Thurston, R. C. et al. Trajectories of vasomotor symptoms and carotid intima media thickness in the Study of Women’s Health Across the Nation. Stroke 47, 12–17 (2016).

    Article  PubMed  Google Scholar 

  72. Ryu, K. J. et al. Vasomotor symptoms and carotid artery intima-media thickness among Korean midlife women. Maturitas 159, 1–6 (2022).

    Article  CAS  PubMed  Google Scholar 

  73. Thurston, R. C. et al. Menopausal vasomotor symptoms and risk of incident cardiovascular disease events in SWAN. J. Am. Heart Assoc. 10, e017416 (2021).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. Herber-Gast, G., Brown, W. J. & Mishra, G. D. Hot flushes and night sweats are associated with coronary heart disease risk in midlife: a longitudinal study. BJOG 122, 1560–1567 (2015).

    Article  PubMed  Google Scholar 

  75. Dam, V., Dobson, A. J., Onland-Moret, N. C., van der Schouw, Y. T. & Mishra, G. D. Vasomotor menopausal symptoms and cardiovascular disease risk in midlife: a longitudinal study. Maturitas 133, 32–41 (2020).

    Article  CAS  PubMed  Google Scholar 

  76. Jackson, E. A. et al. Hot flash frequency and blood pressure: data from the Study of Women’s Health Across the Nation. J. Womens Health 25, 1204–1209 (2016).

    Article  Google Scholar 

  77. Thurston, R. C. et al. Vasomotor symptoms and accelerated epigenetic aging in the Women’s Health Initiative (WHI). J. Clin. Endocrinol. Metab. 105, 1221–1227 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  78. Carpenter, J. S. et al. Palpitations across the menopause transition in SWAN: trajectories, characteristics, and associations with subclinical cardiovascular disease. Menopause 30, 18–27 (2023).

    Article  PubMed  Google Scholar 

  79. Zhu, D. et al. Vasomotor menopausal symptoms and risk of cardiovascular disease: a pooled analysis of six prospective studies. Am. J. Obst. Gynecol. 223, 898.e1–898.e16 (2020). This study pooled results from more than 23,300 women and demonstrated that women with severe vasomotor symptoms had more than double the risk of cardiovascular disease than those without vasomotor symptoms. It shows that severity of vasomotor symptoms is an important potential marker for those with underlying cardiovascular vulnerability.

    Article  Google Scholar 

  80. Armeni, A. et al. Vasomotor symptoms and risk of cardiovascular disease in peri- and postmenopausal women: a systematic review and meta-analysis. Maturitas 171, 13–20 (2023).

    Article  PubMed  Google Scholar 

  81. Gray, K. E. et al. Vasomotor symptom characteristics: are they risk factors for incident diabetes? Menopause 25, 520–530 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  82. Herber-Gast, G. C. & Mishra, G. D. Early severe vasomotor menopausal symptoms are associated with diabetes. Menopause 21, 855–860 (2014).

    Article  PubMed  Google Scholar 

  83. Thurston, R. C. et al. Vasomotor symptoms and insulin resistance in the Study of Women’s Health Across the Nation. J. Clin. Endocrinol. Metab. 97, 3487–3494 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  84. Tural, A., Yoldemir, T. & Erenus, M. Assessment of bone mineral density should be considered earlier in perimenopausal women with vasomotor symptoms. Int. J. Gynaecol. Obst. 107, 114–116 (2009).

    Article  Google Scholar 

  85. Anagnostis, P. et al. The association of vasomotor symptoms with fracture risk and bone mineral density in postmenopausal women: a systematic review and meta-analysis of observational studies. Osteoporos. Int. 35, 1329–1336 (2024). This timely systematic review demonstrates that although vasomotor symptoms are associated with lower bone mineral density, they do not appear to confer an increased fracture risk. Severity of symptoms was also not associated with fracture risk. These findings demonstrate the lack of empirical support for preventative use of MHT in postmenopausal women of average age where not otherwise indicated for symptoms.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Gast, G. C. et al. Vasomotor symptoms are associated with a lower bone mineral density. Menopause 16, 231–238 (2009).

    Article  PubMed  Google Scholar 

  87. Crandall, C. J. et al. Associations of menopausal vasomotor symptoms with fracture incidence. J. Clin. Endocrinol. Metab. 100, 524–534 (2015).

    Article  CAS  PubMed  Google Scholar 

  88. Kapoor, E. et al. Association of adverse childhood experiences with menopausal symptoms: results from the Data Registry on Experiences of Aging, Menopause and Sexuality (DREAMS). Maturitas 143, 209–215 (2021).

    Article  PubMed  Google Scholar 

  89. Thurston, R. C. et al. Childhood abuse or neglect is associated with increased vasomotor symptom reporting among midlife women. Menopause 15, 16–22 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  90. Carson, M. Y. & Thurston, R. C. Childhood abuse and vasomotor symptoms among midlife women. Menopause 26, 1093–1099 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  91. Chung, H. F. et al. Age at menarche and risk of vasomotor menopausal symptoms: a pooled analysis of six studies. BJOG 128, 603–613 (2021).

    Article  PubMed  Google Scholar 

  92. Yang, Y. et al. Premenstrual disorders, timing of menopause, and severity of vasomotor symptoms. JAMA Netw. Open 6, e2334545 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  93. Faubion, S. S. et al. Hypertensive disorders of pregnancy and menopausal symptoms: a cross-sectional study from the data registry on experiences of aging, menopause, and sexuality. Menopause 28, 25–31 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  94. Kingsberg, S. A., Larkin, L. C. & Liu, J. H. Clinical effects of early or surgical menopause. Obst. Gynecol. 135, 853–868 (2020).

    Article  Google Scholar 

  95. Hickey, M. et al. What happens after menopause? (WHAM): a prospective controlled study of vasomotor symptoms and menopause-related quality of life 24 months after premenopausal risk-reducing salpingo-oophorectomy (RRSO). Gynecol. Oncol. 191, 201–211 (2024).

    Article  PubMed  Google Scholar 

  96. Hickey, M. et al. Managing menopause after cancer. Lancet 403, 984–996 (2024).

    Article  CAS  PubMed  Google Scholar 

  97. Marino, J. L. et al. How does adjuvant chemotherapy affect menopausal symptoms, sexual function, and quality of life after breast cancer? Menopause 23, 1000–1008 (2016).

    Article  PubMed  Google Scholar 

  98. Gold, E. B. et al. Vasomotor symptoms in midlife women with incident breast cancer: pink SWAN. Breast Cancer Res. Treat. 191, 125–135 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  99. Bauld, R. & Brown, R. F. Stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women. Maturitas 62, 160–165 (2009).

    Article  PubMed  Google Scholar 

  100. Sood, R. et al. Association of mindfulness and stress with menopausal symptoms in midlife women. Climacteric 22, 377–382 (2019).

    Article  CAS  PubMed  Google Scholar 

  101. Gibson, C. J. et al. Associations of intimate partner violence, sexual assault, and posttraumatic stress disorder with menopause symptoms among midlife and older women. JAMA Intern. Med. 179, 80–87 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  102. Cao, V., Clark, A. & Aggarwal, B. Obesity and severity of menopausal symptoms: a contemporary review. Curr. Diabetes Rep. 23, 361–370 (2023).

    Article  CAS  Google Scholar 

  103. Shobeiri, F., Jenabi, E., Poorolajal, J. & Hazavehei, S. M. The association between body mass index and hot flash in midlife women: a meta-analysis. J. Menopausal Med. 22, 14–19 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  104. Gold, E. B. et al. Longitudinal analysis of changes in weight and waist circumference in relation to incident vasomotor symptoms: the Study of Women’s Health Across the Nation (SWAN). Menopause 24, 9–26 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  105. Kroenke, C. H. et al. Effects of a dietary intervention and weight change on vasomotor symptoms in the Women’s Health Initiative. Menopause 19, 980–988 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  106. Jenabi, E. & Poorolajal, J. The association between hot flushes and smoking in midlife women: a meta-analysis. Climacteric 18, 797–801 (2015).

    Article  CAS  PubMed  Google Scholar 

  107. Witkowski, S., Evard, R., Rickson, J. J., White, Q. & Sievert, L. L. Physical activity and exercise for hot flashes: trigger or treatment? Menopause 30, 218–224 (2023).

    Article  PubMed  Google Scholar 

  108. Liu, T., Chen, S., Mielke, G. I., McCarthy, A. L. & Bailey, T. G. Effects of exercise on vasomotor symptoms in menopausal women: a systematic review and meta-analysis. Climacteric 25, 552–561 (2022).

    Article  CAS  PubMed  Google Scholar 

  109. Dunneram, Y. et al. Soy intake and vasomotor menopausal symptoms among midlife women: a pooled analysis of five studies from the InterLACE consortium. Eur. J. Clin. Nutr. 73, 1501–1511 (2019).

    Article  CAS  PubMed  Google Scholar 

  110. Beezhold, B., Radnitz, C., McGrath, R. E. & Feldman, A. Vegans report less bothersome vasomotor and physical menopausal symptoms than omnivores. Maturitas 112, 12–17 (2018).

    Article  PubMed  Google Scholar 

  111. Hunter, M. S., O’Dea, I. & Britten, N. Decision-making and hormone replacement therapy: a qualitative analysis. Soc. Sci. Med. 45, 1541–1548 (1997).

    Article  CAS  PubMed  Google Scholar 

  112. Sarri, G., Pedder, H., Dias, S., Guo, Y. & Lumsden, M. A. Vasomotor symptoms resulting from natural menopause: a systematic review and network meta-analysis of treatment effects from the National Institute for Health and Care Excellence guideline on menopause. BJOG 124, 1514–1523 (2017).

    Article  CAS  PubMed  Google Scholar 

  113. Hillman, S., Shantikumar, S., Ridha, A., Todkill, D. & Dale, J. Socioeconomic status and HRT prescribing: a study of practice-level data in England. Br. J. Gen. Pract. 70, e772–e777 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  114. Kaunitz, A. M. Oral contraceptive use in perimenopause. Am. J. Obst. Gynecol. 185, S32–S37 (2001).

    Article  CAS  Google Scholar 

  115. Shargil, A. A. Hormone replacement therapy in perimenopausal women with a triphasic contraceptive compound: a three-year prospective study. Int. J. Fertil. 30, 18–28 (1985).

    Google Scholar 

  116. Casper, R. F., Dodin, S. & Reid, R. L. The effect of 20 µg ethinyl estradiol/1 mg norethindrone acetate (Minestrin™), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 4, 139–147 (1997).

    Google Scholar 

  117. Corbelli, J., Shaikh, N., Wessel, C. & Hess, R. Low-dose transdermal estradiol for vasomotor symptoms: a systematic review. Menopause 22, 114–121 (2015).

    Article  PubMed  Google Scholar 

  118. Gaudard, A. M. et al. Bioidentical hormones for women with vasomotor symptoms. Cochrane Database Syst. Rev. 2016, CD010407 (2016).

    PubMed  PubMed Central  Google Scholar 

  119. Constantine, G. D. et al. TX-001HR is associated with a clinically meaningful effect on severity of moderate to severe vasomotor symptoms in the REPLENISH trial. Menopause 27, 1236–1241 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  120. Furness, S., Roberts, H., Marjoribanks, J. & Lethaby, A. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database Syst. Rev. 8, CD000402 (2012).

    Google Scholar 

  121. Lemaitre, R. N. et al. Hormone replacement therapy and associated risk of stroke in postmenopausal women. Arch. Intern. Med. 162, 1954–1960 (2002).

    Article  CAS  PubMed  Google Scholar 

  122. Canonico, M., Plu-Bureau, G., Lowe, G. D. & Scarabin, P. Y. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ 336, 1227–1231 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  123. Rovinski, D., Ramos, R. B., Fighera, T. M., Casanova, G. K. & Spritzer, P. M. Risk of venous thromboembolism events in postmenopausal women using oral versus non-oral hormone therapy: a systematic review and meta-analysis. Thromb. Res. 168, 83–95 (2018).

    Article  CAS  PubMed  Google Scholar 

  124. LaCroix, A. & Ensrud, K. The flash dance of midlife: the Skylight 1 trial. Nat. Med. 29, 1324–1325 (2023).

    Article  CAS  PubMed  Google Scholar 

  125. Maki, P. M. et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. J. Womens Health 28, 117–134 (2019).

    Article  Google Scholar 

  126. Mangione, C. M. et al. Hormone therapy for the primary prevention of chronic conditions in postmenopausal persons: US Preventive Services Task Force Recommendation Statement. JAMA 328, 1740–1746 (2022).

    Article  PubMed  Google Scholar 

  127. Ockene, J. K. et al. Symptom experience after discontinuing use of estrogen plus progestin. JAMA 294, 183–193 (2005).

    Article  CAS  PubMed  Google Scholar 

  128. Brunner, R. L. et al. Menopausal symptom experience before and after stopping estrogen therapy in the Women’s Health Initiative randomized, placebo-controlled trial. Menopause 17, 946–954 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  129. Melville, M. et al. Menopause hormone therapy and risk of mild cognitive impairment or dementia: a systematic review and meta-analysis. Lancet Healthy Longev. 6, 100803 (2025).

    Article  PubMed  Google Scholar 

  130. Gupta, P. et al. Menopausal symptoms in women treated for breast cancer: the prevalence and severity of symptoms and their perceived effects on quality of life. Climacteric 9, 49–58 (2006).

    Article  CAS  PubMed  Google Scholar 

  131. Marino, J. L. et al. Nature and severity of menopausal symptoms and their impact on quality of life and sexual function in cancer survivors compared with women without a cancer history. Menopause 21, 267–274 (2014).

    Article  PubMed  Google Scholar 

  132. Bernhard, J. et al. Patient-reported outcomes with adjuvant exemestane versus tamoxifen in premenopausal women with early breast cancer undergoing ovarian suppression (TEXT and SOFT): a combined analysis of two phase 3 randomised trials. Lancet Oncol. 16, 848–858 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  133. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause 30, 573–590 (2023).

  134. Johnson, K. et al. A phase 3, randomized, placebo-controlled, 12-week, double-blind study, plus a non-controlled extension treatment period, to assess efficacy and safety of fezolinetant, a neurokin-3 receptor antagonist, in women with moderate-to-severe vasomotor symptoms associated with menopause. Menopause 28, 1450 (2021).

    Google Scholar 

  135. Ruan, X. et al. Efficacy and safety of fezolinetant for moderate to severe vasomotor symptoms associated with menopause among women in East Asia: a phase 3 randomized study (MOONLIGHT I). J. Int. Med. Res. 52, 3000605241247684 (2024).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  136. Pinkerton, J. V. et al. Elinzanetant for the treatment of vasomotor symptoms associated with menopause: OASIS 1 and 2 randomized clinical trials. JAMA 332, 1343–1354 (2024).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  137. Panay, N. et al. Elinzanetant for the treatment of vasomotor symptoms associated with menopause: a phase 3 randomized clinical trial. JAMA Intern. Med. 185, 1319–1327 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  138. US Food and Drug Administration. FDA adds warning about rare occurrence of serious liver injury with use of Veozah (fezolinetant) for hot flashes due to menopause. FDAhttps://www.fda.gov/drugs/drug-safety-and-availability/fda-adds-warning-about-rare-occurrence-serious-liver-injury-use-veozah-fezolinetant-hot-flashes-due (2024).

  139. Hunter, M. S. Cognitive behavioral therapy for menopausal symptoms. Climacteric 24, 51–56 (2021).

    Article  CAS  PubMed  Google Scholar 

  140. Elkins, G. R., Fisher, W. I., Johnson, A. K., Carpenter, J. S. & Keith, T. Z. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause 20, 291–298 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  141. Elkins, G. et al. Self-administered hypnosis vs sham hypnosis for hot flashes: a randomized clinical trial. JAMA Netw. Open 8, e2542537 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  142. Christmas, M. M. et al. Variation in outcome reporting and measurement tools in clinical trials of treatments for genitourinary symptoms in peri- and postmenopausal women: a systematic review. Menopause 27, 1070–1080 (2020).

    Article  PubMed  Google Scholar 

  143. Lensen, S. et al. A core outcome set for genitourinary symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative. Menopause 28, 859–866 (2021).

    Article  PubMed  Google Scholar 

  144. Paramanandam, V. S. et al. Recommended measurement instruments for genitourinary symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) consortium. Menopause 31, 591–599 (2024).

    Article  PubMed  Google Scholar 

  145. Burgin, J., Pyne, Y. & Hickey, M. Helping women prepare for menopause. BMJ 386, q1512 (2024).

    Article  PubMed  Google Scholar 

  146. Williams, R. E. et al. Healthcare seeking and treatment for menopausal symptoms in the United States. Maturitas 58, 348–358 (2007).

    Article  PubMed  Google Scholar 

  147. Santoro, N. Perimenopause: from research to practice. J. Womens Health 25, 332–339 (2016).

    Article  Google Scholar 

  148. Davis, S. R. et al. The 2023 practitioner’s toolkit for managing menopause. Climacteric 26, 517–536 (2023).

    Article  CAS  PubMed  Google Scholar 

  149. Manson, J. E. et al. The Women’s Health Initiative randomized trials and clinical practice: a review. JAMA 331, 1748–1760 (2024).

    Article  PubMed  Google Scholar 

  150. Peate, M., Johnson, T. L., Avis, N. E. & Hickey, M. Addressing sociodemographic, socioeconomic, and gendered disparities for equity in menopause care. Cell Rep. Med. 5, 101616 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  151. Carpenter, J. S. et al. Validity, cut-points, and minimally important differences for two hot flash-related daily interference scales. Menopause 24, 877–885 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Victoria, Australia

    Martha Hickey & Annabelle Huguenin

  2. Royal Women’s Hospital, Melbourne, Victoria, Australia

    Martha Hickey & Annabelle Huguenin

  3. Australian Women and Girls’ Health Research Centre, School of Public Health, University of Queensland, Brisbane, Queensland, Australia

    Hsin-Fang Chung & Gita D. Mishra

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  1. Martha Hickey
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  2. Annabelle Huguenin
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The authors contributed equally to all aspects of the article.

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Correspondence to Martha Hickey.

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Competing interests

M.H. was topic expert for the 2024 NICE UK menopause guidelines and is an unpaid board member of BreastScreen Victoria, and editor for the Cochrane Collaboration. All other authors declare no competing interests.

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Review criteria

We searched PubMed for all articles published up to 19 February 2026. The search terms included the following keywords in the title and/or abstract: (“vasomotor symptoms” or “VMS” or “hot flashes/flushes” or “night/cold sweats”) AND (“severity/severe” or “frequency/frequent” or “intensity/intense” or “duration” or “bothersome”) AND (“cardiovascular disease” or “diabetes” or “metabolic syndrome” or “osteoporosis” or “quality of life” or “chronic health” or “non-communicable disease” or “breast cancer” or “cancer” or “genitourinary symptoms” or “risk factors” or “demographic” or “socioeconomic” or “race” or “ethnicity” or “stress” or “physiological” or “lifestyle” or “reproductive” or “obesity” or “body mass index” or “weight gain” or “smoking” or “diet” or “exercise” or “physical activity” or “sedentary behaviour” or “type of menopause” or “age at menopause” or “surgical menopause” or “oophorectomy” or “hysterectomy”). This returned 2,011 results. Titles and abstracts were screened, and 298 articles were included for full-text review. We summarized evidence from systematic reviews, meta-analyses and large population-based studies (n > 500) where possible.

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Hickey, M., Huguenin, A., Chung, HF. et al. Risk factors, management and consequences of severe menopausal vasomotor symptoms. Nat Rev Endocrinol (2026). https://doi.org/10.1038/s41574-026-01245-w

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