Acta Oto-Laryngologica. 2014; 134: 146–150

ORIGINAL ARTICLE

The relationship between vasomotor symptomsand menopause-associated dizziness

SATOKO OWADA & MITSUYA SUZUKI

Department of Otolaryngology, Sakura Medical Center, Toho University, Chiba, Japan

AbstractConclusion: Vasomotor symptoms (VMS) and especially hot flushes are negatively associated with recovery from menopause-related dizziness. A further study is justified to determine whether hormone replacement therapy (HRT) can shorten thisrecovery time.Objectives: This study aimed to compare the rate of recovery from dizziness between patients who had VMS andthose who did not. We also evaluated the effect of HRT on recovery from dizziness.Methods:Themedical records of 85 womenaged between 40 and 59 years were analyzed retrospectively. The patients were asked detailed questions about theirmenopausal symptoms as well as any episodes of dizziness, which were diagnosed on the basis of neuro-otological examinationsand were treated appropriately. All patients were followed up until dizziness improved. Results:Over a 2-month period, the rateof recovery from vertigo was significantly higher in patients without VMS (no-VMS group, n = 38) than in those with VMS(VMS group, n = 29). In the VMS group, patients treated with HRT (n = 7) recovered from dizziness more quickly than thosewho were not treated with HRT (n = 22), although this difference was not statistically significant.

Keywords: Hot flushes, hot flashes, hormone replacement therapy, HRT

Introduction

Data from the National Institutes of Health (NIH)suggest that in the United States, most women expe-riencemenopause between 40 and 58 years of age, witha median age of 52 years [1]. Other studies havereported a universal age of menopause of approxi-mately 50 years [2–5]. TheWorld Health Organizationand the Stage of Reproductive Aging Workshop(STRAW) working group have defined menopauseas the permanent cessation of menstrual periods thatoccurs naturally or is induced by surgery, chemother-apy, or radiation. Menopausal transition often beginswith a variation in the length of the menstrual cycle [1].Some women who transit menopause have no

symptoms at all, but most experience some symp-toms, often beginning several years before the finalmenstrual period [1]. Menopausal symptoms includevasomotor symptoms (VMS; hot flushes (hot flashes)and night sweats), dizziness, palpitations, headache,

stiff shoulder, insomnia, depression, nervousness,anxiety, fatigue, and irritability [5,6]. Of the manysymptoms of menopause that may affect a women’squality of life, the most common are those related tothermoregulation, specifically hot flushes and nightsweats [2]. Hot flushes (a sudden sensation of intenseheat with sweating and flushing, typically lasting5–10 min) and night sweats are reported to occurfrequently in perimenopausal women (i.e. those inmenstrual transition and in the first year after theirlast menses) [3]. Longitudinal and cross-sectionalobservational studies have provided strong evidenceshowing that the menopausal transition causes VMS[1], of which dizziness is one of the most commonmanifestations during perimenopause and especiallyduring the late stage of menopausal transition [7].Previous studies have suggested a causal relationshipbetween VMS and balance disturbances on the basisof epidemiologic investigations of the general popu-lation conducted using a questionnaire [8].

Correspondence: Mitsuya Suzuki, Department of Otolaryngology, SakuraMedical Center, Toho University, 564-1 Shimo-shizu, Sakura, Chiba 285-0841, Japan.Tel: +81 043 462 8811. Fax: +81 043 462 8820. E-mail: misuzuki-tky@umin.ac.jp

(Received 22 July 2013; accepted 23 August 2013)

ISSN 0001-6489 print/ISSN 1651-2251 online � 2014 Informa HealthcareDOI: 10.3109/00016489.2013.841991

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The present study aimed to assess whether there isan association between VMS and menopause-relateddizziness. In addition, we compared the periodrequired to recover from dizziness between patientswho had VMS and those who did not. Hormonereplacement therapy (HRT), using estrogen aloneor estrogen combined with progestin, is the mostconsistently effective therapy for hot flushes and nightsweats [1,4]. Therefore, we also investigated whetherHRT is effective in reducing dizziness in patients withVMS symptoms, including hot flushes.

Material and methods

We retrospectively analyzed the outpatient and inpa-tient records of 85 women aged 40–59 years who hadboth menopausal symptoms and dizziness betweenApril 2008 and March 2012. In our department,dizziness in each patient was treated with medicationincluding betahistine and steroid therapy or physicalexercise. In addition, 52 of the 85 patients visited thegynecology department for treatment of menopausalsymptoms. The patients were asked detailed ques-tions about their menopausal symptoms as well asdizziness, and were diagnosed based on clinical symp-toms and neuro-otological examinations. The latterconsisted of a pure-tone audiogram and vestibularfunctional tests, including gaze nystagmus, positionaland positioning nystagmus using an infrared CCDcamera, and/or electronystagmography (ENG). Inaddition, eye tracking, optokinetic nystagmus, andcaloric tests (with a cold air temperature of 24�Cand a warm air temperature of 46�C, for 1 min)were recorded using ENG.Magnetic resonance imag-ing (MRI) was performed to rule out intracraniallesions such as infarction, hemorrhage, or vestibularschwannoma.We checked for menopausal symptoms, especially

VMS such as hot flushes and night sweats, in eachpatient. We first subjectively compared the time torecover from dizziness between patients who had

VMS and those who did not. Seven patients in theVMS group were administered HRT orally or withtransdermal patches or as a gel. We compared thetime taken to recover from dizziness between patientswho received HRT (HRT group) and those who didnot (no-HRT group).We obtained informed consent from all patients.

This study was approved by the Institutional ReviewBoard of Toho University Sakura Medical Center(no. 2012-080, on January 9, 2013) and was con-ducted in full accordance with the Declaration ofHelsinki. A statistical analysis was performed usingFisher’s exact test. A value of p < 0.05 was consideredstatistically significant.

Results

Neuro-otological diagnoses

Neuro-otological examinations revealed 44 cases(51.8%) of benign paroxysmal positional vertigo(BPPV), 15 cases (17.6%) of peripheral vestibulopa-thy, and 14 cases (16.5%) of Meniere’s disease. Inaddition, two patients were diagnosed as having sud-den deafness with vertigo, and there was a single caseeach of vestibular schwannoma, vasomotor angina,and mitochondrial encephalomyopathy.

Neuro-otological diagnoses in the VMS andno-VMS groups

The presence or absence of VMS was not recorded inthe medical records of 6 of the 85 patients. Further-more, 12 patients did not come back to our hospitalfor the 1-month follow-up; therefore, the effects ofVMS were analized in 67 of 85 cases. We were able tocompare 29 cases in the VMS group with 38 cases inthe no-VMS group. No significant difference wasfound between the two groups with respect to diseasedistribution, as diagnosed by neuro-otological exam-ination (Table I).

Table I. Neuro-otological diagnoses for patients with or without vasomotor symptoms (VMS).

Diagnosis VMS (n = 29) No-VMS (n = 38) p Value

BPPV 13 (44.8%) 19 (50.0%) NS

Peripheral vestibulopathy 7 (24.1%) 8 (21.1%) NS

Meniere’s disease 5 (17.2%) 7 (18.4%) NS

Sudden deafness 0 (0.0%) 2 (5.3%) NS

Vestibular schwannoma 1 (3.4%) 0 (0.0%) NS

Cardiac disorder 1 (3.4%) 0 (0.0%) NS

Unknown etiology 2 (6.9%) 2 (5.3%) NS

NS, not significant; BPPV, benign paroxysmal positional vertigo.

Dizziness and vasomotor symptoms 147

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Comparison of the VMS and no-VMS groups

The rate of recovery from dizziness was significantlyhigher in the no-VMS group than in the VMS group,when measured at the end of a 2-month period(Figure 1). However, no significant differences werefound if this rate was measured after only 1 month, orbeyond 2 months.

Comparison of the HRT and no-HRT groups

Seven patients in the VMS group received HRT.These patients recovered more quickly from dizzinessthan patients who were not treated with HRT; how-ever, this difference was not statistically significant(Figure 2).

Discussion

In this study, we found a negative association betweenthe time needed to recover from dizziness and thepresence of VMS in middle-aged women consideredto be in menopausal transition. These women recov-ered from dizziness more slowly compared with thosewho did not have VMS.When assessed after 2months,the rate of recovery from dizziness was significantlyhigher in the no-VMS group than in the VMS group;however, no significant difference was observedbetween the two groups beyond 2 months (Figure 1).Although the occurrence of VMS may be associatedwith an early recovery from menopause-related dizzi-ness, it may not affect the final rate of recovery.Another possibility is that the therapeutic effect ofVMS treatment may occur over a 3-month period.Vertigo, dizziness, unsteadiness, and a fainting sen-

sation are common menopausal symptoms. A studyconducted in Nagano, Japan found that 41.7% of thefemale population aged between 45 and 60 years hadfelt dizzy or faint at some point [9]. In general,middle-aged women visit their gynecologist for both-ersome symptoms, including dizziness, when theythink that these symptoms may be related to meno-pause [3]. Dizziness and vertigo, which occur duringperimenopause, are frequently misclassified as non-specific climacteric symptoms or are mistakenlythought to have a psychological cause [7]. In thepresent study, 75 of the 85 patients who reportedmenopause-related vertigo or dizziness also hadperipheral vestibular symptoms. Therefore, we sug-gest that middle-aged women suffering from dizzinessshould be assessed by both a gynecologist and anotolaryngologist.We found that 44 of 85 patients who experienced

menopausal-related dizziness were also diagnosedwith BPPV during neuro-otological examinations.Studies using mice have demonstrated that the rapiddecline of estrogen during menopause causes a reduc-tion in the number of estrogen receptors, inducing adisturbance in otoconial metabolism; this may explainthe high prevalence of BPPV [10]. We did not find asignificant difference in the prevalence of BPPVbetween the VMS and no-VMS groups. This findingsuggests that the occurrence of VMS in BPPV maynot be associated with disturbed otoconial metabo-lism. Physical activity may improve VMS throughincreased production of endogenous opioids [11].Given that BPPV can be cured with vestibular reha-bilitation [12], physical rehabilitation may be usefulfor treating menopausal women suffering from bothdizziness and VMS.Menopausal signs and symptoms are generally

attributed to three main causes: reduced estrogen

Months

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1 2 3 6 12* : P < 0.05

VMS group (n = 29)

44.7%

20.7%

41.4%

55.2%

68.4%78.9%

62.1%

84.2% 88.8%

72.4%

*No-VMS group (n = 38)

0

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25

30

35

40

Figure 1. The rate of recovery from dizziness was significantlyhigher in patients without vasomotor symptoms (VMS) (no-VMS group, n = 38) than in patients with VMS (VMS group,n = 29), over 2 months.

Months

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1 2 3 6 12Not significant

HRT group (n = 7)

28.5%18.1%

71.4% 71.4%31.8%

50.0%59.1%

85.7%

68.1%

85.7%

No-HRT group (n = 22)

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5

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Figure 2. There was no significant difference in the time needed torecover from dizziness between patients treated with hormonereplacement therapy (HRT group, n = 7) and those who did notreceive HRT (no-HRT group, n = 22) among patients with vaso-motor symptoms (VMS).

148 S. Owada & M. Suzuki

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production (giving rise to VMS and vaginitis), socio-cultural changes, and psychological changes [6].Sociocultural factors include a lack of support byintimate friends and a low socioeconomic status[13]. Psychological factors include a feeling of poorhealth, low self-esteem, a perceived lack of respectfrom people, dissatisfaction with present life, anxietyabout the future, and a feeling of being a burden toone’s family and/or community [13]. In the currentstudy, 14 of 85 patients with menopause-related diz-ziness also had Meniere’s disease. Because vertigi-nous attacks in Meniere’s disease may also beinfluenced by psychological and sociocultural factors[14], a psychological approach using anxiolytic andantidepressants drugs may be an effective strategy fortreating menopause-related dizziness.An additional finding in this study was that sig-

nificantly more patients recovered from vertigowithin 2 months in the no-VMS group comparedwith the VMS group. Ekblad et al. also described arelationship between balance disturbances and hotflushes [8]. In agreement with their observation, wefound that the recovery period for dizziness waslonger in the VMS group than in the no-VMS group.Among women with VMS who were also experienc-ing postural imbalance, hot flushes and sweating mayaffect the quality of night-time sleep, which in turnmay influence concentration and balance function[8]. In addition, VMS may negatively affect thecentral integration of balance impulses in the centralnervous system [8].Recently, the incidence of hot flushes has increased

in Japanese menopausal women and is approachingthat for menopausal women in Europe and America[9]. Estrogen therapy is one of the most effectivetreatments for VMS [2,15], and postural balance inpostmenopausal women with VMS is significantlyimproved by HRT [16]. In addition, older womenwho are prescribed estrogen over a prolonged periodhave better postural balance than women of a similarage who are not prescribed estrogen [17]. However,several studies have reported results that conflict withthese findings; in these studies, HRT did not reducevertigo and balance disturbances [8,15,18]. Estrogenis thought to act on the hearing and vestibular func-tions of the inner ear [10]. Menopausal womenreceiving HRT have slightly better hearing comparedwith those not being treated with HRT [19]. In Japan,middle-aged women with menopausal symptoms areoften treated not only with HRT but also with atraditional herbal medicine known as kampo [20].In the current study, HRT was associated with anearlier recovery from dizziness, although this associ-ation was not statistically significant. However, as thisstudy only included seven patients who received

HRT, a further study that includes more patientsreceiving HRT is needed to assess the effectivenessof HRT in reducing menopausal-related dizziness.In conclusion, VMS, especially hot flushes, are

negatively associated with an early recovery frommenopause-related dizziness. HRT was ineffectivein reducing the recovery time after dizziness.

Acknowledgments

The authors thank Professor T. Kinoshita of theDepartment of Obstetrics and Gynecology of TohoUniversity and Emeritus Professor M. Yamamoto ofToho University for their valuable suggestions. Theauthors also thank Mr Yukio Fukuda for his valuableadvice regarding the statistical analysis.

Declaration of interest: The authors report noconflicts of interest. The authors alone are responsiblefor the content and writing of the paper.

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