One of the most bothersome and common symptoms experienced by patients going through the menopausal transition is hot flashes (Freedman 2015). Vasomotor symptoms can vary in intensity from mild to debilitating (Gold et al., 2000), and patients can suffer from a flushed face up to a full sweat with the removal of clothing and a brisk fan required for relief. Hot flashes can affect a patient’s focus, sleep, and activity tolerance. These pesky flashes are also associated with several medical disorders including heart disease, dementia, and osteoporosis (Biglia et al, 2017).

What causes hot flashes isn’t entirely known. A variety of factors can be at play including genetics, personal experience, cultural influences, and medications (Biglia et.al, 2017), however, one of the predominant factors contributing to these flushes is decreasing or fluctuating estrogen levels. Declining estrogen is linked with the KnDy (kisspeptin-neurokinin B-dynorphin neurons) located in the hypothalamus. These neurons project to the thermoneutral zone also located in the hypothalamus. This zone regulates the temperature in the body. As estrogen levels diminish, these neurons hypertrophy. This causes an increase in activity to the thermoneutral zone making the patient more sensitive to temperature changes (Rance et al, 2013). A small shift in temperature causes a greater physiological response triggering the hot flash.

In their 2022 position statement on hormone therapy, the North American Menopause Society recommends estrogen as one of the most effective treatments for this symptom. It is cited as a safe and effective option which many choose for relief. For some patients, this is not an option due to either personal choice or contraindications from their medical history.

An adjunct or alternative treatment for hot flashes is cognitive behavioral therapy (CBT). It has been proven as an effective diminisher of hot flashes and can be utilized by patients through this transition (The Non-Hormonal Position Statement of the North American Menopause Society 2023). In the book Living Well Through the Menopause, authors Hunter and Smith describe the importance of utilizing cognitive behavioral therapy as a tool for diminishing the intensity and bother of hot flashes.

One of the tools specifically mentioned in their recommendations is diaphragmatic breathing. This is a common skill that can be taught to patients by providers to help manage pain and urinary urgency symptoms. By tapping into the parasympathetic or “rest and digest” aspect of the autonomic nervous system, it facilitates the body to chill out and calm. This can also be recommended to patients in the menopausal transition as one method of hot flash management. Quieting the nervous system throughout the day can aid in stress management and decrease the intensity of hot flashes.

Another tool for management is self-care (Hunter and Smith 2021). Perimenopause can be a time of great stress for many. Busy work schedules, aging parents, and active teenagers can cause patients to forget about prioritizing time for themselves to reflect, recharge, and pause. Patients' lives are often constant caregiving and chaos. With this flurry of activity, the importance of their own health and well-being can be forgotten. Clinicians are integral in reminding patients that taking time for themselves will ensure they are capable of handling the circus of activities they are juggling. Giving the patient permission for self-care can be invaluable. Encouraging exercise, friendships, and taking a rest can help with stress management and in turn can help with sleep and the severity of symptoms (Hunter and Smith 2021).

Ahhhhh sleep, so often disrupted in this phase of life. Hot flashes certainly play a role with this as does stress. Both can play off the other. Educating our patients about the effects of alcohol, caffeine, and bright light bombardment before bed can help them on the road to better rest. Teaching meditation or diaphragmatic breathing before bed can also provide benefits (Hunter and Smith 2021). With better sleep comes less stress and with less stress comes reduced symptoms.

When patients experience vasomotor symptoms, the pelvic health provider has several tools in their toolbox to help with management. There are non-hormonal options out there that can make a difference. Clinicians can help patients navigate through the menopausal transition with tools for decreasing the intensity of symptoms and improving quality of life.

To learn more, sign up for Menopause Transitions and Pelvic Rehab scheduled for February 1-2, 2025. This course is an excellent opportunity to understand the physiological consequences to the body as hormones decline, in order to assist our patients in lifestyle habits for successful aging. Course topics include cardiovascular changes, metabolic syndrome, bone loss and sarcopenia, neurological changes (headache, brain fog, sleeplessness), Alzheimer’s risk, and urogenital changes. Symptoms and treatment options will also be discussed, including hormone replacement, non-hormonal options, dietary choices, and exercise considerations. 

References:

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022. 29(7): p. 767-794.
2. Biglia, N., et al., Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases? Climacteric, 2017. 20(4): p. 306-312.
3. Freedman, R.R., Menopausal hot flashes: mechanisms, endocrinology, treatment. J Steroid Biochem Mol Biol, 2014. 142: p. 115-20.
4. Gold, E.B., 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(5): p. 463-73.
5. Hunter, M.a.S., Melanie, Living Well Through the Menopause: An Evidenced Based Cognitive Behavioural Guide 2021, Great Britain: Robinson.
6. Rance, N.E., et al., 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, 2013. 34(3): p. 211-27.
7. The Nonhormone Therapy Position Statement of The North American Menopause Society" Advisory, P., The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 2023. 30(6): p. 573-590.

Author Bio
Christine Stewart, PT, CMPT

Christine Stewart, PT, CMPT (she/her) graduated from Kansas State University in 1992 and went on to pursue her master’s degree in physical therapy from the University of Kansas Medical Center graduating in 1994. She began her career specializing in orthopedics and manual therapy then became interested in women’s health after the birth of her second child.

Christine developed her pelvic health practice in a local hospital with a focus on urinary incontinence and prolapse. She left the practice in 2010 to work at Olathe Health to further focus on pelvic rehabilitation for all genders and obtain her CMPT from the North American Institute of Manual Therapy. She completed Diane Lee’s Integrated Systems Model education series in 2018. Her passion is empowering patients through education and treatment options for the betterment of their health throughout their lifespan. She enjoys speaking to physicians and to community-based organizations on pelvic health physical therapy.

Aparna Rajagopal, co-author of the Breathing and the Diaphragm: Orthopedic Therapists remote course, shares "I have used breathing and evaluation of the diaphragm as a part of pelvic care for several years now...Through my interactions, I have come to realize that although many of the therapists are aware that the diaphragm and breathing are important, they are unsure of how to assess for dysfunctions and address those dysfunctions."

Pelvic floor patients who may benefit from diaphragmatic breathing exercises include those who present with pelvic pain, incontinence, prolapse, and cervical/thoracic/scapular/lumbar pain. The Breathing and the Diaphragm: Orthopedic Therapists remote course will expand the participant's knowledge of the diaphragm and breathing mechanics. This course offers a different perspective on back pain and alignment, along with the ability to assess and connect breathing and the diaphragm to core stability, continence issues, and the autonomic nervous system.

The autonomic nervous system is in charge of those bodily processes that do not require conscious thought. These include digestion, temperature, blood pressure, and breathing. The autonomic nervous system can be hacked or manipulated with deep breathing exercises such as diaphragmatic breathing.

Diaphragmatic breathing involves fully engaging the abdominal muscles and diaphragm when breathing by actively pulling the diaphragm down with each inward breath, allowing the lungs to fill more efficiently. The benefits of diaphragmatic breathing can include lowered heart rate and blood pressure regulation. Patients may also see a decrease in cortisol (a stress hormone), allowing them to relax better (1).

The effects of stress can show as emotional, cognitive, behavioral, or physical symptoms in different people. Pelvic pain can be connected to stress through the pelvic floor stress reflex response. This response is a reaction where the pelvic floor muscles actively contract from a stress trigger, either mental or physical. In such cases, increased muscle contractions can lead to tightness and weakness in the affected muscles. Visualize an agitated, tightened muscle to understand how stress can lead to hypertonic muscles, diarrhea, bladder, and sexual issues

Now let's back up to tie in the stress hormone cortisol. Normal cortisol levels rise and fall in a rhythmic pattern throughout the day, allowing for circadian rhythms. Cortisol also helps immune functions and cell repair. When the body is under stress, cortisol is produced in abnormal levels, leading to compromised immune function, pain, exhaustion, and many other issues. Pelvic conditions connected to abnormal cortisol levels include endometriosis(2), interstitial cystitis (3), vulvovaginal candidiasis, and vulvodynia. If a patient has a high cortisol-related diagnosis, intervention can include diaphragmatic breathing for stress management.

The course Breathing and the Diaphragm: Orthopedic Therapists is curated and taught by Aparna Rajagopal and Leeann Taptich. To learn how to incorporate breathing and the diaphragm into your practice, join the next scheduled remote course on October 23-24, 2021.

1. Hopper S, Murray S, Ferrara L, Singleton J. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep. 2019 Sep;17(9):1855-1876. doi:10.11124/JBISRIR-2017-003848.
2. Friggi Sebe Petrelluzzi K, Garcia M, Petta C et al. Physical therapy and psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):191-198. doi:10.3109/0167482x.2012.729625.
3. Schrepf A, O’Donnell M, Luo Y, Bradley C, Kreder K, Lutgendorf S. Inflammation and Symptom Change in Interstitial Cystitis or Bladder Pain Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study. Urology. 2016;90:56-61. doi:10.1016/j.urology.2015.12.040.