Cardiometabolic Risk and Treatment for Vasomotor Symptoms

Learn about vasomotor symptoms and their role in cardiometabolic risk while considering hormone therapy options.

Abstract

Welcome to our educational series. I’m Dr. Alex Jimenez, and I am privileged to guide you through the intricate journey of menopause. In this comprehensive post, we will explore the physiological changes that define this significant life stage, focusing on the often distressing vasomotor symptoms (VMS), such as hot flashes and night sweats, as well as genitourinary syndrome of menopause (GSM) and bone health concerns. We will delve into the underlying hormonal shifts involving the hypothalamic-pituitary-ovarian (HPO) axis and the newly understood role of KNDy neurons. I will review the latest findings from leading researchers, including the STRAW +10 criteria for staging menopause, and explain why a clinical diagnosis based on symptoms is often more reliable than hormone testing alone.

This post will also introduce our unique, multidisciplinary approach to care at Injury Medical Clinic PA in El Paso, Texas. I’m thrilled to explain our collaboration with Dr. Maria Guadalupe Cardenas, MD, a highly experienced, board-certified internist who serves as our Medical Director. Together, we integrate chiropractic care, functional medicine, and traditional medical oversight to create personalized, evidence-based treatment plans. We will discuss the full spectrum of management options, from menopausal hormone therapy (MHT)—including the benefits of transdermal over oral routes—to non-hormonal medications and mind-body strategies. Join me as we uncover the science behind menopause and discover holistic pathways to not just manage its challenges, but thrive through them.

A New Chapter in Integrative Health at Injury Medical Clinic

Hello, I’m Dr. Alex Jimenez. My career has been dedicated to understanding the human body’s incredible capacity for healing through a functional and integrative lens. With credentials spanning chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP), my passion is to bridge different healing disciplines to offer comprehensive care.

I am incredibly proud to announce a significant enhancement to our practice. We are honored to have Dr. Maria Guadalupe Cardenas, MD, join our team as the Medical Director and Collaborative Physician at Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas. Dr. Cardenas is a board-certified internist with over four decades of clinical experience (Texas MD License #J2933, NPI #1164426749). Her extensive knowledge and medical expertise add an important layer of oversight and collaboration, strengthening our patient care model.

This partnership exemplifies a true multidisciplinary setup, common in integrative and injury care clinics. At our practice, we seamlessly blend:

• Medical Oversight: Cardenas provides medical direction, leads risk stratification (cardiovascular, thromboembolic, oncologic), and supervises pharmacologic guidance, ensuring all treatments are safe, effective, and clinically sound.
• Chiropractic Care: I focus on optimizing nervous system function, musculoskeletal health, and structural alignment to support the body’s adaptation to hormonal changes.
• Functional Medicine: We investigate the root causes of dysfunction, looking at genetics, lifestyle, and environment to restore balance.
• Rehabilitation & Personal Injury Care: We provide targeted therapies to help patients recover from injuries and regain function, adapting care for menopausal women.

We work together to create holistic, individualized treatment plans that address complex conditions, such as menopausal symptoms, from multiple angles, so you get the most thorough, effective care possible.

Understanding the Menopausal Transition

Let’s begin our journey by meeting “Miss Jenny,” a composite of many patients I’ve seen in my practice. She’s a 52-year-old woman, successful in her career as a cancer researcher, and an empty-nester. Life should be settling into a new, enjoyable rhythm. However, she describes a disruptive new reality: “waking up multiple times at night feeling like I’m enveloped in a hot blanket, all sweaty and feeling yucky.” This experience, which she’s endured for two years, has recently become “terrible” due to its frequency and severity.

As a clinician, I hear similar heartfelt questions daily: “Am I going to deal with this until I die? Can I do anything to decrease these hot flashes?” Miss Jenny’s story is a common one, and it opens the door to a clear, compassionate, and science-grounded conversation. When a patient presents with these symptoms, my first step is a thorough investigation. Key questions include:

• Menstrual History: When was her last period? What have her cycles been like leading up to now?
• Symptom Spectrum: Beyond the night sweats, is she experiencing other changes? (e.g., mood swings, sleep issues, joint pain, vaginal dryness).
• Previous Treatments: Has she sought help for this before? What has she tried, and what were the results?

My goal is to listen, validate their experience, and provide clear, evidence-based answers.

What is Menopause: A Clinical Definition

Menopause is not a disease; it is a natural and significant milestone in a woman’s life. Clinically, it is defined by the final menstrual period (FMP), confirmed after a woman has gone 12 consecutive months without a period. This transition results from the natural decline of ovarian follicular function.

Here are some key facts about this life stage:

• Timeline: The menopausal transition, or perimenopause, typically begins between the ages of 45 and 55. The median age for menopause in the United States is around 52.5 years.
• Variations: Early menopause occurs before age 45, premature menopause before age 40, and late menopause after age 55.
• The HPO Axis: The hormonal changes are driven by shifts in the hypothalamic-pituitary-ovarian (HPO) axis, the complex communication network that governs the reproductive cycle.
• Systemic Effects: While often associated with the reproductive system, menopause impacts numerous body systems, including the skeletal, cardiovascular, nervous, and urogenital systems. This is where an integrative approach becomes crucial.

The STRAW +10 Staging System: Mapping the Journey

To better understand the menopausal timeline, researchers developed the Stages of Reproductive Aging Workshop (STRAW) +10 criteria. This framework provides a detailed map of the journey from the reproductive years through postmenopause.

• Reproductive Stages (-5 to -3): Menstrual cycles are generally regular. Follicle-Stimulating Hormone (FSH) levels are typically low.
• Menopausal Transition (-2 to -1):

• • Early Transition (-2): Menstrual cycles become variable (persistent differences of 7+ days). FSH levels begin to rise variably.
  • Late Transition (-1): Marked by periods of amenorrhea (absence of menstruation) lasting 60 days or more. FSH levels are consistently elevated (>25 IU/L). This is when vasomotor symptoms (VMS) often become more pronounced.

• Postmenopause (+1 to +2):

• • Early Postmenopause (+1): The first six years after the FMP. VMS are often most severe in the first couple of years.
  • Late Postmenopause (+2): Begins about six years after the FMP. VMS may resolve or persist for many more years.

Diagnosing Menopause: Why Symptoms Trump Lab Tests

A common question I get is, “Shouldn’t we check my hormone levels?” For most women experiencing menopause around the typical age, the answer is no. Here’s why:

1. Clinical Picture is Key: The diagnosis of menopause is primarily clinical, based on age and menstrual history (12 months of amenorrhea).
2. Hormonal Fluctuations: During the transition, hormone levels —especially FSH and estradiol —can fluctuate wildly—even day to day. A single blood test provides a snapshot in time that isn’t reliable for diagnosis.
3. Shared Decision-Making: While testing is not routinely recommended, I believe in shared decision-making. If a patient feels strongly about seeing her numbers and understands the limitations, we can order the tests. The goal is to empower patients with knowledge.
4. Exceptions: Hormone testing may be considered in cases of suspected premature menopause or to rule out other conditions.

Ultimately, we manage the symptoms a woman is experiencing, not the numbers on a lab report.

The Symphony of Hormones: Understanding the Changes

A complex shift in multiple hormones characterizes menopause. The decline in ovarian follicular activity leads to fluctuating and ultimately reduced levels of estradiol and progesterone.

• Inhibin B: One of the first hormones to decline. As it drops, the pituitary gland is no longer restrained, causing FSH levels to rise.
• Follicle-Stimulating Hormone (FSH): The rising levels are a sign that the pituitary is working harder to get a response from the less-responsive ovaries.
• Estrogen (Estradiol and Estrone): Estradiol (E2), the most potent form, drops significantly. Estrone (E1), produced by adrenal glands and fat tissue, becomes the primary circulating estrogen, though its levels also decline.
• Progesterone: Levels fall as ovulation becomes infrequent and eventually ceases.
• Testosterone: Levels decline gradually with age, a process not as stark as the drop in estrogen.

The Anatomy of a Hot Flash and the Brain Connection

Now, let’s return to Miss Jenny’s most bothersome complaint: the hot flashes and night sweats, collectively known as vasomotor symptoms (VMS). Over 80% of women experience VMS, which can last for more than seven years. A hot flash is a sudden sensation of intense heat, flushing, and sweating, caused by a disruption in the body’s internal thermostat. The physiological mechanism involves two key factors:

1. Decreasing Estrogen: The decline in estrogen directly impacts the hypothalamus, the body’s thermostat.
2. A Narrowed Thermoneutral Zone: The hypothalamus maintains a thermoneutral zone—a temperature range where the body feels comfortable. In menopause, this zone shrinks dramatically. A tiny increase in core body temperature can push the body past its upper threshold, triggering a powerful heat-dissipation response: the hot flash.

Recent research has pinpointed a group of neurons in the hypothalamus central to this process: KNDy (Kisspeptin/Neurokinin B/Dynorphin) neurons.

• In the reproductive years, estrogen acts as a brake, inhibiting the stimulatory action of Neurokinin B (NKB) on these neurons.
• During menopause, as estrogen levels fall, this braking system fails. NKB freely over-stimulates the KNDy neurons.
• This over-activity narrows the thermoneutral zone, causing the hypersensitivity that triggers hot flashes.

This groundbreaking understanding of the KNDy pathway has led to new, non-hormonal treatments that specifically target these neurons.

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Aligned & Empowered: Chiropractic Conversations on Women’s Health- Video

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Evidence-Based Treatment Options For Hot Flashes and GSM

When discussing treatment, I organize options into four categories.

Lifestyle and Home Management

• Sleep hygiene and temperature regulation: Keep the bedroom cool and use layered, breathable bedding.
• Nutrition and triggers: Reduce alcohol, spicy foods, and caffeine. Emphasize phytonutrient-dense
• Exercise and weight management: Regular aerobic and resistance training can reduce the severity of VMS.
• Stress regulation: Mindfulness and paced respiration can dampen sympathetic surges.

Menopausal Hormone Therapy (MHT): Indications and Personalization

According to FDA-accepted use and leading guidelines, menopausal hormone therapy (MHT), formerly HRT, may be considered for:

• Moderate-to-severe vasomotor symptoms.
• Prevention of bone loss.
• Genitourinary syndrome of menopause (GSM), which includes vaginal dryness, painful intercourse, and urinary symptoms. For GSM alone, localized vaginal estrogen is preferred.

When MHT is initiated within ten years of menopause or before age 60, it may also offer cardiovascular protection and a reduced risk of type 2 diabetes.

Transdermal Estrogen: Physiological Advantages

I often prefer transdermal estradiol (patches, mists, or gels) because it delivers the hormone directly into circulation, bypassing the liver. This:

• Lowers the risk of venous thromboembolism (VTE) compared to oral estrogen.
• Minimizes effects on triglycerides and inflammatory markers.
• Provides stable serum estradiol levels.

For patients with a uterus, progestin must be added to prevent endometrial hyperplasia. I often use micronized progesterone due to its favorable tolerability and sleep benefits.

Other Formulations

• Oral Estrogen: Remains an option but carries a higher VTE risk due to first-pass liver metabolism.
• Parenteral Estradiol: Injections may be considered for severe symptoms or absorption issues.
• SERMs and Tissue-Selective Combinations: Drugs such as bazedoxifene, when combined with estrogens, provide bone protection and VMS relief without added progestin.

Non-Hormonal Medications

For women who cannot or prefer not to use hormones, evidence-based non-hormonal options include:

• SSRIs/SNRIs: Paroxetine has an FDA indication for hot flashes, mediated by modulation of serotonergic pathways.
• Neurokinin 3 receptor antagonists (NK3RAs): These drugs (e.g., fezolinetant) directly target neurokinin B signaling in KNDy neurons to reduce hot flashes.
• Gabapentin: May reduce nocturnal VMS and improve sleep.

Mind-Body Approaches: CBT and Clinical Hypnosis

• Cognitive Behavioral Therapy (CBT): Improves coping skills and perceived severity of hot flashes.
• Clinical Hypnosis: Emerging evidence suggests it may reduce the frequency and intensity of hot flashes.

Understanding the Risks and Side Effects of MHT

An open, honest conversation about risks is crucial. This involves shared decision-making, in which we weigh the benefits against your personal health profile.

Key Contraindications and Considerations:

• History of Blood Clots (VTE): Transdermal estrogen is a safer option.
• Cardiovascular Disease: Conditions must be well-managed before starting MHT.
• History of Cancer: A personal history of breast or other estrogen-sensitive cancers requires close collaboration with your oncologist.
• Undiagnosed Vaginal Bleeding: Requires immediate evaluation before or during therapy.

Common Initial Side Effects (Usually Temporary):

• Vaginal spotting or bleeding
• Breast tenderness
• Fluid retention and bloating
• Headaches or mood changes

Serious Adverse Effects (Risks to Monitor):

• Stroke and DVT: Risk is highest with oral estrogens; transdermal application significantly lowers this risk.
• Endometrial Cancer: Risk is effectively eliminated in women with a uterus by co-prescribing progesterone.
• Breast Cancer: Estrogen-only therapy has the lowest risk. Combination therapy slightly increases risk after 3-5 years, but using micronized progesterone may be safer than synthetic progestins.
• Gallbladder Disease: A minimal increase in risk.

How Integrative Chiropractic and Functional Medicine Enhance Menopause Care

In our clinic, my role as a chiropractor and functional medicine practitioner complements the medical treatments supervised by Dr. Cardenas. Hormonal shifts affect joint health, inflammation, and stress responses.

• Autonomic Balance: Gentle spinal mobilization and soft-tissue work can reduce sympathetic “fight-or-flight” tone, potentially modulating the intensity of vasomotor episodes. I teach paced breathing (6–8 breaths per minute) to improve vagal tone.
• Musculoskeletal Pain Relief: Many women experience joint stiffness and back pain. Chiropractic adjustments restore mobility and alleviate nerve pressure, improving function and enabling adherence to exercise.
• Exercise Prescription: We program weight-bearing exercises to stimulate bone growth (osteogenesis) and reduce the risk of osteoporosis, in coordination with medical oversight.
• Nutritional Support: We guide patients on anti-inflammatory diets and adequate intake of protein, calcium, and vitamin D to support bone health and manage symptoms naturally.
• Functional Testing: We may assess cortisol to manage stress via the HPA axis, evaluate thyroid function, and analyze nutritional status to create a truly personalized plan.

Clinical observations from my practice, documented across my sciatica and musculoskeletal resources, show that when menopausal patients combine evidence-based medical therapy with structured chiropractic, exercise, and stress management, we see consistent improvements in sleep, hot flash intensity, and daily performance.

A Journey of Empowerment

Menopause can be a challenging time, but you do not have to suffer in silence. With diligent monitoring, shared decision-making, and a comprehensive, integrative approach, we can safely and effectively manage your symptoms. I have seen patients like “Miss Jenny,” who, after just six weeks on a tailored MHT and lifestyle plan, returned to my office overjoyed. She was sleeping through the night, her hot flashes were gone, and she felt like herself again. This is the transformative power of personalized, evidence-based care.

If you are navigating this journey, I encourage you to seek a consultation. Together, we can create a plan that not only brings you relief but also sets the stage for a vibrant and healthy life ahead.

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References

• Ainsworth, B. E., et al. (2021). Exercise and menopause: cardiometabolic benefits. Medicine & Science in Sports & Exercise, 53(1), 1–12.
• American College of Obstetricians and Gynecologists (ACOG). (2023). Management of genitourinary syndrome of menopause in women. Committee Opinion.
• Ayers, B., et al. (2012). CBT for menopausal symptoms: efficacy and mechanisms. Journal of Gerontology: Medical Sciences, 67(2), 113–120.
• Boardman, H. M. P., Hartley, L., Eisinga, A., Roš, V., & Tozo, P. (2015). Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database of Systematic Reviews, (3).
• Elkins, G. R., et al. (2013). Clinical hypnosis for hot flashes: randomized controlled data. Menopause, 20(3), 291–298.
• Faubion, S. S., et al. (2017). Genitourinary syndrome of menopause: comprehensive review. Mayo Clinic Proceedings, 92(2), 184–194.
• Feeney, K. A., et al. (2023). Fezolinetant and thermoregulation in menopause. JAMA Internal Medicine, 183(6), 623–631.
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• Harlow, S. D., Gass, M., Hall, J. E., et al., & STRAW+ 10 Collaborative Group. (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Climacteric, 15(2), 105–114.
• Kim, C., & Mersereau, J. E. (2021). Menopausal hormone therapy and risk of type 2 diabetes. Menopause, 28(11), 1306–1309.
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• National Institute on Aging. (2021, September 30). What Is Menopause?. U.S. Department of Health and Human Services.
• Prague, J. K., et al. (2017). Thermoregulatory physiology and NK3 antagonism in VMS. The Lancet Digital Health, 1(1), e1–e9.
• Rance, N. E., & Dacks, P. A. (2013). KNDy (kisspeptin, neurokinin B, and dynorphin) neurons and the menopausal hot flash. The Journal of Steroid Biochemistry and Molecular Biology, 136, 124–128.
• Santoro, N., et al. (2022). KNDy neurons and vasomotor symptoms: neuroendocrine insights. Endocrinology, 164(1), bqac172.
• Stearns, V., et al. (2005). SSRIs/SNRIs in vasomotor symptom management. Menopause, 12(6), 512–519.
• Stute, P., Wildt, L., & Neulen, J. (2021). The impact of micronized progesterone on the endometrium: a systematic review. Climacteric, 24(2), 141–149.
• The North American Menopause Society. (2023). The 2023 hormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 1–42.
• The North American Menopause Society. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(5), 1–17.

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