Background     Vasomotor symptoms (VMS), such as hot flashes and night sweats, are among the most common and distressing manifestations of menopause. Many individuals’ undergoing cancer treatment (including men), experience VMS. Despite their significant impact on quality of life, VMS and other menopause-related symptoms are often under-assessed and undertreated in clinical practice. This is the first in a three-part series focused on improving recognition and management of these symptoms.

Physiology of natural menopause    Natural menopause in women occurs at a mean age of 51 years and is determined retrospectively after 12 months of amenorrhea. This is preceded by a period called perimenopause in which symptoms related to changes in sex hormones begin to occur. VMS (e.g., hot flashes or hot flushes), are the most common menopausal symptoms. Greater than 70% of postmenopausal women who do not receive hormone replacement therapy (HRT) experience VMS (1). Although their pathophysiology is incompletely understood, they are thought to result from hypothalamic thermoregulatory dysfunction, causing sudden vasodilation and sensations of heat, often followed by sweating, shivering, and anxiety. Hot flashes can result in significant sleep disturbance and reduction in quality of life (2). There are several other common symptoms associated with natural menopause including depression, cognitive changes, arthritis, dry mucous membranes, decreased libido, hair thinning.  Many of these can be confused with side effects of cancer treatments or cancer itself.  Genitourinary syndrome of menopause (GSM) describes a collection of symptoms (GU discomfort, sexual symptoms, frequent UTIs) associated with changes of the vulva, vagina, and lower urinary tract associated estrogen deficiency (3). See Fast Fact # 511.

Reproductive hormone deficiency and cancer   Reproductive hormone deficiency related to cancer treatment can occur as a primary treatment goal (e.g. endocrine therapies such as selective estrogen receptor modulators, aromatase inhibitors, anti-androgens), as an unwanted side effect of cancer treatment (e.g., chemotherapy, oophorectomy), or because of the cancer itself. Notably, cancer treatment-related VMS may be more abrupt in onset, more prevalent, and more severe than those experienced as part of natural menopause (4).  In men, most of their circulating estrogen is derived from peripheral aromatization of testosterone. Therefore, changes in testosterone levels related to prostate cancer treatment can induce VMS like that seen in menopause. Approximately 60% of patients receiving ADT for prostate cancer experience hot flashes (5).

Assessment   Qualitative studies suggest many patients are dissatisfied with counseling about reproductive and menopausal health, reflecting misconceptions about treatment options and discomfort discussing these issues among both patients and clinicians (6,7). Only about one-third of breast cancer survivors receiving endocrine therapy reported being asked about menopausal symptoms by their health care provider (8).  The absence of consensus guidelines contributes to gaps in care. Experiences of VMS vary widely. Clinicians should consider the influence of biological, cultural, and psychosocial factors and recognize that gender-binary approaches to menopause may create barriers to care for intersex, transgender, and gender-diverse individuals (9). Important components of VMS assessment include: 

• Inquire about not just the physical symptoms of VMS but the emotional impact as well.
• Ask about the impact of VMS on sleep and other daily activities.
• Identify potential triggers and patterns of occurrence (e.g. stress, alcohol, caffeine, spicy food, hot showers, hot weather, smoking and overheated bedrooms).
• Ask the patient to complete a one-week diary recording VMS frequency, duration, triggers, and severity.  See reference 10 for an example (10).
• Integrate the patient’s perspective by asking, “What aspect of this is most bothersome for you?”
• Acknowledge, validate, and normalize patient experiences with regards to VMS.

References 

1. Casper RF. Menopause: Clinical features and diagnosis. In: Robert L Barbieri MKAM, MD, ed.UpToDate. 2025.
2. Blumel JE, Chedraui P, Baron G, et al. A large multinational study of vasomotor symptom prevalence, duration, and impact on quality of life in middle-aged women.Menopause. Jul 2011;18(7):778-85. doi:10.1097/gme.0b013e318207851d
3. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference P. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society.Maturitas. Nov 2014;79(3):349-54. doi:10.1016/j.maturitas.2014.07.013
4. Zhu L, Hshieh TT, Iyer TK, Morgans AK, Hamnvik OR. Management of vasomotor symptoms in cancer patients.Oncologist. Feb 6 2025;30(2)doi:10.1093/oncolo/oyaf002
5. Raychaudhuri R, Lin DW, Montgomery RB. Prostate Cancer: A Review.JAMA. 2025;333(16):1433-1446. doi:10.1001/jama.2025.0228
6. Scanlon M, Blaes A, Geller M, Majhail NS, Lindgren B, Haddad T. Patient Satisfaction with Physician Discussions of Treatment Impact on Fertility, Menopause and Sexual Health among Pre-menopausal Women with Cancer.J Cancer. 2012;3:217-25. doi:10.7150/jca.4408
7. Kapoor E, Safwan N, Chaudhry R, et al. Addressing Menopause Symptoms: Barriers and Opportunities for Improvement.Mayo Clinic Proceedings. 2025;100(11):1897-1907. doi:10.1016/j.mayocp.2025.02.018
8. Tharani AR, Townsley C, Smith J, et al. Sexual health and therapy adherence of hormone-sensitive breast cancer survivors on maintenance endocrine therapy: The SHE-CAN project in Toronto, Canada.Journal of Clinical Oncology. 2024;42(16_suppl):536-536. doi:10.1200/JCO.2024.42.16_suppl.536
9. Toze M, Westwood S. Experiences of menopause among non-binary and trans people.Int J Transgend Health. 2025;26(2):447-458. doi:10.1080/26895269.2024.2389924
10. Guttuso T, Jr., DiGrazio WJ, Reddy SY. Review of hot flash diaries.Maturitas. Mar 2012;71(3):213-6. doi:10.1016/j.maturitas.2011.12.003

Version History:  First electronically published in 2012; reviewed and updated in 2024 by Laura Minikel MD; reviewed and updated again in July 2026.
Conflicts of Interest: none to report.
Author Affiliations: 1Icahn School of Medicine; New York, NY; 2University of Colorado, Denver CO; 3Lund University, Lund Sweden; 4Harvard Medical School, Boston MA.