Lifestyle Medicine and Vasomotor Symptoms: An Analytic Review

Abstract

This paper is an literature evaluation of the treatments based on the 6 pillars of Lifestyle Medicine (nutrition, physical activity, restorative sleep, stress management, positive social connection, and avoidance of risky substances) to improve vasomotor symptoms. Main findings were: (1) the Mediterranean diet and other plant-forward approaches may effectively reduce vasomotor symptoms; (2) stress can directly impact menopausal symptoms by increasing the frequency and intensity of hot flashes and other symptoms; (3) the incidence of sleep disturbances are high during the menopause transition; (4) evidence on the impact of physical activity and exercise on vasomotor symptoms is mixed, although moderate activity and strength training may be better for vasomotor symptom optimization than vigorous exercise and part of a healthy aging process; (5) evidence on the impact of social support on VMS is mixed with some studies suggesting benefit; and (6) evidence on the impact of risky substances is mixed but appears stronger for the effects of tobacco cessation than for alcohol cessation. In summary, while there is a variety of quality of evidence depending on the pillar, lifestyle medicine may be generally considered to improve vasomotor symptoms for patients that cannot use or decline hormone therapy.

“Evidence exists most strongly for stress reduction via cognitive-behavioral therapy, and clinical hypnosis, with mixed evidence for mindfulness-based stress reduction and other mind-body techniques.”

Introduction

While hormone therapy is the most effective treatment for vasomotor symptoms (VMS), ¹ health care providers should still remain informed on evidence-based non-hormonal options to treat vasomotor symptoms in women that cannot use or may decline hormone therapy. The recent North American Menopause Society (NAMS) 2023 position statement covered non-hormonal therapies in detail; however, much of the review was focused on non-hormonal pharmaceuticals. This paper examines the evidence for the 6 pillars of Lifestyle Medicine—nutrition, physical activity, restorative sleep, stress management, positive social connection, and avoidance of risky substances—as a detailed analytic review on the topic of lifestyle elements and adjustments to improve vasomotor symptoms of menopause as a supplement to the recent NAMS position statement.

Methods

A comprehensive search was performed using PubMed, Auraria and Northwestern libraries’ website search function to search for articles pertaining to the pillars of Lifestyle Medicine and vasomotor symptoms. The search was conducted between 2021 and 2023, with articles from 2002-2023, and research published within the last 5 years prioritized for inclusion. Search words, including “vasomotor symptoms, menopause, menopausal, premenopausal, postmenopausal, hot flashes, night sweats, transition, flushes, and lifestyle medicine,” were used. In addition, words specific to each lifestyle medicine pillar helped narrow down the literature as follows.

• Nutrition: nutrition, diet, soy, isoflavones, healthy eating, nutrient, Mediterranean, whole food, plant-based, DASH, vegan, vegetarian

• Physical Activity: exercise, movement, yoga, aerobic, anaerobic, resistance, balance, sedentary, cardiometabolic, walking, moderate, vigorous

• Sleep: sleep disturbances, sleep problems, insomnia, sleep disorder, sleep apnea, sleep quality, sleep efficiency, fatigue

• Stress: psychological, oxidative stress, change, stressor, resilience, mindfulness, relaxation, perceived stress, cognitive-behavioral therapy, hypnotherapy

• Social Connection: partner, spouse, relationship, social support, interpersonal, friend, community

• Risky Substances: alcohol, tobacco, illicit drug

Mendeley reference management software was used to organize the literature. Paperpile was used to compile the reference list. Research articles published in the last 5 years were prioritized, unless there was a paucity of literature in the area of interest or if the study had a strong research cohort, prospective or randomized control trial, that was done prior to the five-year window. Randomized controlled trials, meta-analyses, and well-designed prospective studies were prioritized in the analytical review, although less robust studies were considered in the event of a paucity of available data.

Results

Each of six pillars of Lifestyle Medicine was examined for improvement in vasomotor symptoms in this analytic review.

Nutrition (Diet)

Recent studies have examined the potential benefits of specific dietary patterns and nutrients, as well as the impact of resultant weight change, in alleviating VMS. While many studies of natural products for VMS exist, this review focuses only on natural food sources.

Dietary Patterns

A limited body of evidence suggests that the Mediterranean diet and other plant-forward approaches may effectively reduce VMS [Table 1]. Existing studies support a diet characterized by high intakes of fruits, vegetables, whole grains, pulses and legumes, and having a higher proportion of healthier fats from foods such as oily fish, nuts and seeds, while limiting the intake of sugar and unhealthy fats. While plant-based diets may help to reduce the prevalence and severity of hot flushes, the greatest benefit appears to be with accompanying weight loss. Future studies should aim to separate the impact of weight and body composition from dietary patterns.

Table 1.

Studies on the Effect of Diet Patterns on VMS in Postmenopausal Women.

Authors/Reference	Study Type	Diet Pattern/Intervention	Participants
Kroenke et al, 2012 2	RCT	Low-fat dietary pattern with high plant intake similar to the MedDiet	6014 post-men. women
	Results: In women with mild VMS, the likelihood of elimination of VMS within 12 months increased by 14% with intervention (OR = 1.14; 95 % CI: 1.01-1.28; P = .04); however, there was no significant improvement for women with moderate to severe VMS. Symptom resolution was more likely among those who lost more than 10 lbs (OR = 1.23; 95% CI:1.05, 1.46) or lost 10% or more of baseline bodyweight (OR = 1.56; 95% CI: 1.21, 2.02) compared to women who maintained weight over the year. Large wt. loss (>22 lbs), but not dietary changes, was also related to eliminating moderate/severe VMS.
Rotolo et al, 2019 3	RCT	Lacto-ovo-vegetarian diet rich in omega-3 fats from flaxseed oil, walnuts and almonds (26 g/day) vs lacto-ovo-vegetarian diet rich in extra virgin olive oil (EVOO)	54 post-men. women
	Results: Women randomized to the omega-3 group showed significant improvement compared to the EVOO group in hot flashes (Δ = −3.3 ± 3.4 vs −1.3 ± 2.6; P = .04)
Barnard et al, 2022 4	RCT	Low-fat, vegan diet (including ½ cup [86g] of cooked soybeans daily) vs control	84 post-men. women
	Results: Total hot flash frequency in the intervention group decreased by 78% (P < .001) and 39% (P < .001) for the control group (between-group P = .003). The decrease in moderate to severe hot flashes in the intervention group was 88% (from 5.0 to .6 per day, P < .001), compared with 34% (from 4.4 to 2.9 per day, P < .001) among controls (between-group P < .001). Bodyweight also decreased in the intervention group, although the correlation between weight loss and symptom change was weak
Gold et al, 2006 5	RCT	High-vegetable, high-fiber, reduced-fat diet vs control	2198 women with early-stage breast cancer
	Results: Daily fiber intake >30 g was associated with a 35% greater chance of decreased symptom severity; low fat intake was associated with less likelihood of decreased symptom severity at 12 months
Herber-Gast et al, 2013 6	Prospective cohort study	Six dietary patterns identified from factor analysis: Cooked vegetables, fruit, Mediterranean-style, meat and processed meat, dairy, and high fat and sugar	6040 post-men. women
	Results: Med diet: significantly decreased the risk (OR = .80; 95% CI: .69-.92). Increased fruit intake: Significantly decreased the risk (OR = .81; 95% CI: .71-.93). High fat and sugar: Significantly increased the risk of VMS (OR = 1.23; 95% CI: 1.05-1.44)
Flor-Alemany et al, 2020 7	Cross-sect. study	Mediterranean diet adherence	172 post-men. women
	Results: Worse VMS symptomatology associated with greater consumption of poultry (bb: .18, P = .02) and skimmed dairy products (P < .05). Soy milk consumption associated with fewer vasomotor symptoms (bb: −.15, P = .04)
Soleymani et al, 2018 8	Cross-sect. study	Three major dietary patterns: Vegetables and fruits (VF); mayonnaise, liquid oils, sweets, and desserts (MLSD); and solid fats and snacks (SFS)	400 post-men. women
	Results: VF dietary pattern inversely associated with physical symptoms (b ¼ 1.54; SE ¼ 1.09; P for trend <.001). SFS dietary pattern directly related to physical symptoms (b ¼ 1.24; SE ¼ 1.09; P for trend = .04)

Insulin resistance (IR) and metabolic syndrome have been correlated with VMS.^9,10 Dietary strategies such as low carbohydrate diets, intermittent fasting, and fasting mimicking diets may counter IR, ¹¹ and theoretically relieve VMS; however, only anecdotal data for this indication exists. A study comparing 4 dietary patterns from the Women’s Health Initiative Observational Study: low-fat; reduced-carbohydrate; Mediterranean-style; and a diet consistent with the USDA’s Dietary Guidelines for Americans found that a reduced-carbohydrate diet, with moderate fat and high protein intake, may decrease the risk of weight gain in postmenopausal women, whereas a low-fat diet was associated with increased risk of weight gain. ¹² While this study did not examine VMS, the link between weight, metabolic syndrome, and VMS postmenopause suggests a plausible benefit to lower carbohydrate diets.

Specific Dietary Components

Phytoestrogens are a group of plant-based compounds that have been found to have a similar chemical structure to estrogen and may weakly stimulate estrogen receptors. Conflicting evidence suggests that dietary consumption of phytoestrogens, specifically isoflavones, may demonstrate improvement in the incidence and severity of vasomotor symptoms in postmenopausal women (Table 2); however, the NAMS 2023 position statement states that soy foods and extracts are not recommended for the treatment of vasomotor symptoms. Lignans, another studied phytoestrogen, has not demonstrated efficacy in this regard as compared to placebo.^18,19 In contrast, other dietary components, including alcohol and spicy foods, have demonstrated a positive association with vasomotor symptoms. ²⁰

Table 2.

Studies on the Effect of Dietary Phytoestrogens on Vasomotor Symptoms (VMS).

Authors/Reference	Subjects	Intervention	Study Length	Findings
Carmignani et al, 2010 13	Double blind RCT	90 mg soy isoflavone compared v. HRT v. placebo	16 weeks	Both soy and HRT groups had signif. reduced hot flashes and vaginal dryness comp. with plac. gp; no signif. diff. in endometrial thickness
Chen et al, 2015 14	Meta-analysis of 10 studies	Phytoestrogen intake and hot flash frequency	n/a	Phytoestrogens significantly reduced VMS frequency
Hanachi, 2008 15	37 postmen. women	Group 1: Soy milk product (12.5 g spy protein with 13 mg genistein and 4.13 mg daidzein	12 weeks	Hot flushes significantly improved with both soy interventions compared with control group
		Group 2: Soy milk product plus exercise
Lewis et al, 2006 16	99 postmen. women	Group 1: Soy flour muffins (42 mg/d isoflavones)	16 weeks	No significant difference noted in vasomotor score, number of flushes per day, or severity of flushes for either group compared with control group
		Group 2: Flaxseed muffins (50 mg/d lignans)
Nagata et al, 2001 17	Cohort study of 1106 postmen. women	Soy intake dietary intake (44-116 g/day) and hot flash severity and frequency	6 years	Hot flashes were significantly inversely associated with consumption of soy products

Summary

Many potential mechanisms of diet on VMS exist, including the role of the gut microbiome in estrogen metabolism, insulin resistance, estrogen production in adipose tissue, hormone receptor modulation, and vasodilation. Given the correlation of VMS with cardiovascular disease risk, ²¹ a plant-based diet is an appropriate option to both improve quality of life for women with VMS and prevent CVD, with consideration of reduced-carbohydrate diets in women at risk for weight gain and metabolic syndrome.

Avoidance of Risky Substances

The lifestyle medicine pillar of avoiding risky substances, such as alcohol and tobacco, may help decrease the occurrence of vasomotor symptoms. ²² Beyond this, refraining from these substances results in known risk reduction of cardiovascular, cancer-related, and general health risks. The data appears stronger for tobacco cessation’s effects compared to those from alcohol cessation for reduction of VMS. (Table 3).

Table 3.

Studies on the Effect of Alcohol and Cigarette Smoking (Risky Substances) on Vasomotor Symptoms (VMS).

Authors/Reference	Study Type	Intervention	Participants
Wilsnack et al, 2016 23	Review	Alcohol use and menopause
	Results: Clinicians should periodically assess their menopausal patients’ alcohol use. Specific health hazards from excessive alcohol consumption, as well as potential benefits of low-level consumption (for cardiovascular disease, bone health, and type 2 diabetes), should be discussed with their patients who drink. Alcohol consumption is correlated with worsening VMS.
Anderson et al, 2020 24	Meta-analysis	Cross-sectional analysis of midlife women from 8 pooled studies, to investigate associations between smoking, body mass index, and VMS	21,460 midlife women
	Results: Higher body mass index and smoking more cigarettes with longer duration and earlier initiation were associated with more frequent or severe vasomotor symptoms. Smokers who were also obese had the highest risk of VMS, (RR 3.02; CI 95%, 2.41-3.78)
Zhang et al, 2020 25	RCT	To investigate association of alcohol with menopausal symptoms	4595 Chinese women
	Results: Alcohol consumption, greater than or equal to 3 times/week, was significantly associated with VMS aggravation (OR 3.051 (2.61-3.56, 95% CI), P < 00.1)

There are conflicting studies regarding positive, negative, or no association between the effects of alcohol and vasomotor symptoms. ²³ Avoiding alcohol, along with other environmental triggers, is one lifestyle recommendation that may be helpful in the management of mild hot flashes. ²⁶ However, the 2023 Non-hormonal Therapy position statement of the North American Menopause Society cites a 2020 Clinical Interventions in Aging study, which showed that menopausal women had a significant increase in vasomotor symptoms with alcohol consumption,^24,25 but also observed that other studies did not show this association. ¹ For those who do not drink alcohol, there is no recommendation to start, especially due to other health risks associated with excessive alcohol. ²³

Current smoking and past smoking are associated with an increased risk of vasomotor symptoms, possibly due to the anti-estrogenic effects of smoking. ²⁷ Smoking has been associated consistently with an increased incidence of hot flashes. ²⁶ A pooled analysis of eight observational studies looking at the associations between body mass index, smoking, and potential effects on vasomotor symptoms noted significant interactions between BMI and smoking status for increased risk of vasomotor symptoms (P < .001), especially among those who were obese. Smoking cessation before age 40 or quitting for more than 5 years may decrease the excess risk of vasomotor symptoms to similar levels as nonsmokers. ²⁴

Restorative Sleep

The incidence of sleep disturbances (SD) a high during the menopause transition, around 43%-47%. ²⁸ Poor sleep can lead to dysfunction both in the short term resulting in memory loss, attention deficits and decreased quality of life; and long term with more serious effects including a higher prevalence of diabetes, obesity, depression and increased mortality due to cardiovascular disease. ²⁹ The causes of SD in menopause are still not fully known; however, a five-year retrospective follow-up study found risk factors including but not limited to vasomotor symptoms (80%), CNS medications, personal crises, anxiety, and depression. ³⁰ Women who experienced surgical menopause compared to those who develop naturally were found to be more affected. ³¹

Hormone replacement therapy is the standard of care for evidence-based improvement of vasomotor symptoms, which can impair sleep quality; however, there is no direct evidence for treatment of sleep disorders. ³² Sleep apnea and sleep-disordered breathing increases in the perimenopause transition.

It is important for patients to work with their clinical team to exclude underlying sleep pathology, including treatment of associated anxiety, depression, or psychosis.^33,34 Sleep hygiene is important which includes consistent bedtimes, early light exposure, and cooling bedding. ³⁵ In addition, high fiber intake, especially in morning, ³⁶ regular exercise, ³⁷ and stress and mood management ³⁸ have been shown to improve vasomotor symptoms and sleep in the menopausal transition, although causation should not be inferred. The addition of cognitive-behavioral therapy and maintaining healthy relationships also has a positive impact on quality sleep. In addition, avoidance of late-night meals, eating less processed foods, ³⁹ and minimizing overall alcohol consumption has been shown to decrease sleep disturbances, but not VMS per se.^40,41

Stress Management

Stress can directly impact menopausal symptoms by increasing the frequency and intensity of hot flashes and other symptoms, making the menopausal transition more challenging. ⁴² Managing stress is crucial as part of a comprehensive approach to menopausal symptom management, and many stress management techniques are available to help women cope with the physical and emotional challenges of menopause.

Menopausal symptoms can be managed through various mind-body approaches, including cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and clinical hypnosis. CBT aims to identify and change negative thought patterns and behaviors contributing to stress. A study published in the journal Menopause demonstrated the effectiveness of CBT in reducing the frequency and severity of hot flashes in menopausal women. ⁴³ In addition, a randomized controlled trial involving 187 postmenopausal women found that clinical hypnosis significantly reduced the frequency and severity of hot flashes (74.2%) compared to a structured attention control group (Table 4). ⁴⁴

Table 4.

Studies on Stress Management and Vasomotor Symptoms (VMS).

Authors/reference	Study Type	Intervention	Participants
Elkins et al, 2013 44	RCT	Evaluate impact of clinical hypnosis for hot flashes	187 women reporting >50 hot flashes/week
	Results: Participants reported a mean reduction of 74.16% hot flashes for the clinical hypnosis intervention vs a mean reduction of 17.13% hot flashes for controls (P < .001; 95% CI, 36.15-49.67) over a 12 week period
Ayers et al, 2012 45	RCT	Examine effectiveness of group and self-help cognitive-behavioral therapy in reducing VMS	140 women
	Results: Group (adjusted mean difference, 2.12; 95% CI, 1.36-2.88; P < .001) and self-help (adjusted mean difference, 2.08; 95% CI, 1.29-2.86; P < .001) CBT significantly reduced night sweat frequency at 6 and 26 weeks
Carmody et al, 2011 46	RCT	To analyze the effect of participation in a mindfulness training program (MBSR) on the degree of bother from hot flashes/night sweats	110 perimenopausal women
	Results: At 20 weeks, total reduction in bother for MBSR was 21.62% and 10.50% for controls (P = .04). In addition, the MBSR group made clinically significant improvements in quality of life (P = .022), subjective sleep quality (P = .009), anxiety (P = .005), and perceived stress (P = .001)

Structured stress management programs, which can effectively reduce stress and menopausal symptoms, should also be considered when creating a menopause management plan. While the NAMS 2023 position statement did not recommend yoga, relaxation, or mindfulness-based interventions, limited evidence exists for supporting mind-body therapies such as these overall during the menopause transition. One study found that a program combining mindfulness meditation, relaxation techniques, cognitive-behavioral therapy, and social support was effective in reducing perceived stress and menopausal symptoms in peri- and postmenopausal women. ⁴⁵ In addition, a study examining the effect of mindfulness-based stress reduction for VMS demonstrated a 21.6% reduction in bothersome VMS vs 10.50% for controls. In addition, the MBSR group made clinically significant improvements in quality of life, subjective sleep quality, anxiety, and perceived stress. ⁴⁶ These results suggest that a comprehensive approach to menopausal symptom management that includes structured stress management programs may significantly improve women’s well-being and quality of life during the menopausal transition beyond vasomotor symptoms alone.

Social Connection

The interaction between menopausal vasomotor symptoms and social connectedness is difficult to study and has little data, but is likely bidirectional. Menopause can be a time of social isolation for some women; moreover, negative attitudes towards menopause can lead to underreporting. In one study, 25% of women reported that vasomotor symptoms impacted quality of life through social embarrassment, physical discomfort, and disturbed sleep. ⁴⁷ Not only can menopause lead to social disconnection, but lack or presence of social connectedness may also shape a woman’s experience of this period. For example, Asian women living in the UK attributed more symptoms to menopause compared with Asian women living in Delhi. In cultures where older women are held in high respect, generally fewer symptoms are reported. ⁴⁸ There is evidence that strong social networks and higher social support may reduce symptom severity and frequency.^49,50 Exactly how this happens is not well understood but may be hypothesized to be secondary to better health behaviors, less depression, and less stress. Conversely, other studies have not found that increased social support leads to reduced VMS or moderates the relationship between stress and its impact on such symptoms. ⁵¹

Physical Activity

Physical activity and exercise are part of a healthy lifestyle and have accepted benefits for many menopausal concerns including cardiovascular risk, blood pressure control, osteoporosis, and mood. ⁵² Evidence on physical activity and exercise for vasomotor symptoms, however, is mixed.^53–55 While there are some trials showing that aerobic and strength training exercise programs can decrease the frequency of hot flashes, other studies have linked higher levels of vigorous physical activity to a greater risk of hot flashes.^52,54–56

There is also research that shows that separate from formal exercise, reducing levels of sedentary behavior may help prevent vasomotor symptoms.^54,55 One confounding factor appears to be the difference between reported hot flashes and ones that are measured via skin temperature changes, as several studies showed higher levels of physical activity increase objective but not subjective symptoms.^47,54,55,57 Another is fitness level, as increases in physical activity appear to precipitate hot flashes in women with lower baseline fitness.^55,57,58 Currently, there is not enough evidence to recommend physical activity for vasomotor menopause symptoms specifically, although moderate activity and strength training may be better for vasomotor symptom optimization than is vigorous exercise. (Table 5).

Table 5.

Studies on Physical Activity and Vasomotor Symptoms (VMS).

Authors/Reference	Study Type	Intervention	Participants
Haimov-Kochman et al, 2013 47	Cross-sectional	To assess the association between lifestyle parameters and climacteric syndrome severity	151
	Results: Exercise was the lifestyle parameter most significantly correlated with reduced climacteric scores (Greene score) (17.0 ± 11.0 vs 22.6 ± 11.3) (P = .01)
Daley et al, 2014 59	Meta-analysis	Cochrane review: 5 RCTs comparing exercise with no treatment, exercise with yoga, and exercise with hormone therapy	733 women
	Results: Evidence was low quality, with limitations in study design. Available evidence showed no difference between groups in frequency or intensity of vasomotor symptoms between exercise and sedentary activity (SMD -.10, 95% CI -.33 to .13, three RCTs, 454 women); nor was any evidence found when exercise was compared with yoga (SMD -.03, 95% CI -.45 to .38, two studies, n = 279 women)
Zhang et al, 2020 25	RCT	To investigate association of exercise with menopausal symptoms	4595 Chinese women
	Results: VMS varied based on daily exercise intensity. Heavy exercise with associated with increased VMS (OR 1.22), while mild exercise was associated with decreased VMS (OR .233). Regular exercise improved other symptoms of menopause, including sleep quality and mood

Discussion

This analytic review examined the evidence of the pillars of Lifestyle Medicine’s impact on vasomotor symptoms (Table 6).

Table 6.

Lifestyle Pillars and Effects on Vasomotor Symptoms Recommendations.

Lifestyle Medicine Pillar	Recommendations
Nutrition (Diet)	Diet characterized by high intakes of fruits, vegetables, whole grains, pulses, and legumes, and having a higher proportion of healthier fats from foods such as oily fish, nuts and seeds, while limiting the intake of sugar and unhealthy fats, reduce VMS.
Physical activity/exercise	Reducing levels of sedentary behavior may reduce VMS. Moderate exercise may reduce VMS. Vigorous exercise may increase VMS.
Restorative sleep	No current data to conclusively link reductions in VMS and sleep. Clinical team may consider excluding underlying sleep pathology
Stress management	Structured stress management programs may reduce stress and menopausal symptoms. Clinical hypnosis and CBT associated with lower VMS.
Positive social connection	Maintaining strong social networks and higher social support may reduce VMS; low quality evidence available
Avoidance of risky substances	Smoking cessation and lowering alcohol intake is associated with reduction of VMS.

There was strong support for the reduction and/or avoidance of risky substances, particularly tobacco products, in reducing VMS. There was evidence that a Mediterranean-style plant-forward dietary pattern may effectively reduce vasomotor symptoms, specifically as it relates to weight loss (Table 1). There was a linear correlation observed for an increasing fiber and reduction in VMS, with the best results observed for a WFPB diet. Hot flushes were significantly inversely associated with consumption of soy products, and phytoestrogens reduced hot flash frequency compared to placebo (Table 2).^{14,17,60–62} Evidence exists most strongly for stress reduction via cognitive-behavioral therapy, and clinical hypnosis, with mixed evidence for mindfulness-based stress reduction and other mind-body techniques. While restorative sleep and positive social connections have been associated with longevity and successful aging, the evidence could not support specific recommendations regarding vasomotor symptom relief.

Conclusion

Vasomotor symptoms are a common feature of the menopause transition, and while hormone therapy is the first-line recommendation, women may not utilize this form of treatment due to medical contraindications or personal preference. This review found evidence that utilizing the pillars of Lifestyle Medicine may be an effective strategy to improving vasomotor symptoms in a nonpharmacologic approach. It should be explicitly stated that the scope of this paper is for vasomotor symptoms alone; all pillars of Lifestyle Medicine should be re-evaluated for other elements of menopause, including cardiovascular health, bone health, and longevity. Follow-up systematic reviews on a broader scope of health after the menopause transition using the pillars of Lifestyle Medicine would be an area of future interest for clinical practice and patient education. ⁶³

ORCID iD

Anne Kennard https://orcid.org/0009-0005-9129-591X