Does cervical spine instability worsen menopausal symptoms?

Ross Hauser, MD

How does cervical spine instability worsen menopausal symptoms? Let’s look at the nervous system. Your natural balance between stress and calm or “homeostasis” is under the control of the autonomic nervous system. The autonomic nervous system is divided into two parts, a stress part, and a calm part. The first part is the sympathetic nervous system which relays messages of danger, conflict, and demands and allows us to handle stress (fight-flight). The second part is the counterpart nervous system, the parasympathetic nervous system which winds the body down from danger, conflict, and stress to a state of rest and digestion. The energy required to digest food requires the body to divert resources to digestion. The parasympathetic nervous system is the domain of its “cellular network” the vagus nerves. In the illustration below we see the vast reach of the vagus nerve in managing body systems.

What has this to do with menopausal symptoms? According to research and clinical evidence, the vagus nerve may have a lot to do with it, but a lot is still unknown.

Now let’s remind ourselves that part of the nervous system helps us cope with stress and part of the nervous system winds us down. That part of the nervous system that winds us down with a calming effect is dominated by the vagus nerve. To be clear there are two vagus nerves, a left side of the body and a right side of the body vagus nerve.

The illustration below depicts the extreme reach of the vagus nerve. While the vagus nerve starts in the brainstem and its headquarters or command center the nodose ganglion sits near the top of the neck at C1, the functional impact throughout the human body is clear. It may be easy to understand that if the vagus nerve suffers from an impingement, it may cause a multitude of symptoms.

Is there a connection between vagus nerve dysfunction and menopausal symptoms?

What then is the impact on menopausal symptoms? Surprisingly there is not by way of research exploring this subject. We often see premenopausal, menopausal, and post-menopausal women who suffer from a constellation of dozens of symptoms and conditions. In my article Vagus nerve compression in the neck: Symptoms and treatments, I discuss Neurological-like problems, emotional stress: anxiety, depression, and panic attacks, cardiovascular-like attacks, gastrointestinal-like and digestive issues, headaches, immune disorders, urinary and bladder problems, POTS, and respiratory disorders. In my articles, I point to neck instability and nerve compression as a culprit if not the main culprit in many of these symptoms and conditions. Let’s examine the research and clinical observation.

A composite view of what women tell us.

A woman will contact us and they will describe problems of feeling faint or being lightheaded when they eat, get up from a chair or bed or suddenly become dizzy for no apparent reason. They will have problems with heat, skin temperature regulation, problems of tremors, and anxiety. They will be sent to an endocrinologist for hormonal or menopausal symptoms but they get bounced from specialist to specialist because little is resolving their problems. They will also be seeing chiropractors for neck pain.

Other women may report that have suffered from hot flashes for decades, but they never shut off. They have been on hormonal therapy for just as long for “menopausal and post-mesopause problems). But there is more to the story. Anxiety, depression, panic attacks, allergy, digestive disorders, chronic sinus pain, balance problems caused by inner ear fluids, (please see my article Neck Pain Chronic Sinusitis and Eustachian Tube Dysfunction,) and cough. They also report that they are on many medications. Here menopausal symptoms are just part of the many problems women face.

The severity of these symptoms from woman to woman varies greatly. Some women will have headaches and hot flashes along with some neck pain. They will find relief from simple medical care or at least manage their symptoms to a tolerable level. Even at this level, however, many can make a whole-body connection to their symptoms, which means that somehow these symptoms are connected to each other and may have a common cause. It may not be just a poor diet as being on a healthy diet has not helped as much as one would have helped. It should never be a medication deficiency in that they are not taking enough medication.

One aspect that most of the medical community can agree on in treating these women is that in many of their problems, “little is known” about connections and treatments.

Little is known about the connection between hot flashes on cardiac autonomic regulation (the control of the heart rate).

The vagus nerve controls heart rate and heart function. I discuss this subject at length in my article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?

A 2013 paper in the journal Menopause (1) looked at the connection between the vagus nerve and hot flashes. The researchers wrote: “Little is known about the impact of hot flashes on cardiac autonomic regulation (the control of the heart rate), particularly vagal (vagus nerve) control.” The researchers then assessed if a connection existed between this heart function and hot flashes occurring when perimenopausal women slept.

What they found was: “Heart rate increased by, on average, 4 beats/minute with the occurrence of a hot flash . . .Physiological hot flashes per se, recorded during undisturbed sleep periods and independent of any arousals, are associated with increased heart rate and decreased cardiac autonomic vagal activity. These data support the hypothesis that the parasympathetic (the rest and digest governing body) of the autonomic nervous system is involved in the cardiac response to a hot flash.”

What does this mean? The vagus nerve is involved in hot flashes. A dysfunctional vagus nerve can make hot flashes worse.

Menopause or cervical spine instability?

Here is another person’s profile. Let’s be clear that not all menopausal-like symptoms are caused by cervical spine instability and dysfunction of the vagus nerve / nervous symptoms. However, research is showing us that there are common problems.

Moderate cervical spondylosis, cervical stenosis, and spinal cord compression.
Pain management (medications, cervical steroid injections, and ablations – nerve burning).
Diagnosed with autonomic dysregulation, symptoms include:
- Postural tachycardia syndrome (POTS),
  - Menopausal, cervical instability, and vagus nerve dysfunction are common symptoms:
    - Lightheadedness, feeling feint, cognitive dysfunction, chronic fatigue, headache, vision problems, digestive problems, increased heart rate.
- Gastrointestinal symptoms are common symptoms in menopause, cervical spine instability, and vagus nerve dysfunction.
- Visual changes (Nystagmus – Oscillopsia),
  - Menopausal, cervical instability, and vagus nerve dysfunction are common symptoms:
    - Light sensitivity, blurred vision, and changes in the shape of the eyeball.
- voice hoarseness, common symptoms in menopause, cervical spine instability, and vagus nerve dysfunction
- Swallowing problems common symptoms in menopause, cervical spine instability, and vagus nerve dysfunction
- Hot flashes
- Tinnitus and ear fullness are common symptoms in menopause, cervical spine instability, and vagus nerve dysfunction
- TMJ (See my article TMJ, cervical neck instability, neck muscle spasms, myofascial pain, breathing problems, digestive disorders, and dizziness).
- Mood swings

Metabolic parameters affecting menopausal symptoms include body mass index, waist circumference, cholesterol levels, blood pressure, glucose levels, and insulin resistance.

We are going to briefly talk about the heart, heart rate, and blood pressure.

A February 2021 paper in the Clinical and Experimental Hypertension (2) studied the link between decreased baroreflex sensitivity to cardiometabolic risks and prehypertension status in postmenopausal women during their early menopausal phase.

Explanatory note for the image below: Baroreceptors, which are blood pressure sensors located in the aortic arch and internal carotid arteries contribute to short-term HRV. When a person inhales, heart rate increases and blood pressure rises about 4-5 seconds later. Baroreceptors detect this rise and fire more rapidly. When you exhale, the HR decreases, and blood pressure falls 4-5 seconds later. The baroreflex makes this acceleration and deceleration of the heart, or sinus arrhythmia possible. Simply put, the baroreflex links heart rate, blood pressure, and vascular tone.

Fifty-five premenopausal women and fifty early-postmenopausal women between 40 and 55 years were recruited for the study, and a complete battery of autonomic function tests (AFT), baroreflex reflex, hormone levels, and cardiometabolic risk parameters was measured and compared between two groups.

Results: There was a significant difference in autonomic function tests and metabolic parameters between premenopausal and postmenopausal women.

Explanatory note: Metabolic parameters are weight, body mass index, waist circumference, cholesterol levels, blood pressure, glucose levels, and insulin resistance.

Sympathovagal imbalance (increased sympathetic and decreased parasympathetic) was prominent in early-postmenopausal women. Decreased baroreflex reflex, the marker of cardiovascular risk was found to be significant and correlated with various cardiometabolic parameters in early-postmenopausal subjects. The analysis demonstrated that decreased baroreflex reflex is independently linked to parameters of decreased vagal activity, inflammation, and oxidative stress in the early-postmenopausal group. Decreased baroreflex reflexes could predict prehypertension status in early-postmenopausal subjects.

Hot flashes, hormones, and psychosocial factors contribute to insomnia risk in the context of the menopausal transition

A 2015 study wrote (3): “Hot flashes, hormones, and psychosocial factors contribute to insomnia risk in the context of the menopausal transition. Stress is a well-recognized factor implicated in the pathophysiology of insomnia; however, the impact of stress on sleep and sleep-related processes in perimenopausal women remains largely unknown.”

In this study, researchers investigated the effect of an acute experimental (artificially created stress) on pre-sleep measures of cortisol and autonomic (chronic) arousal in perimenopausal women with and without insomnia that developed in the context of the menopausal transition.

Twenty-two women average age of about 50 and eighteen women (age about 48) without insomnia were assessed. Anticipation of the task (the artificially created stress) resulted in higher pre-sleep salivary cortisol levels (adrenal function in a stress state) and perceived tension, faster heart rate, and lower vagal activity (the vagus nerves are not calming the women down), based on heart rate variability measures, in both groups of women.

Here is where the inner conflict occurs:

The effect of the stress manipulation on the autonomic nervous system extended into the first 4 hours of the night in both groups. However, vagal tone recovered 4-6 hours into the stress night in controls but not in the insomnia group. (Suggesting the vagus nerve was not calming these patients down). Hot flash frequency remained similar on both nights for both groups. These results show that pre-sleep stress impacts autonomic nervous system functioning before and during sleep in perimenopausal women with and without insomnia. Findings also indicate that women with insomnia had increased EEG (electroencephalogram (EEG) is a test that measures electrical activity in the brain) arousal and lacked recovery in vagal activity across the stress night suggesting a greater sensitivity to stress in this group.

In simplest terms, insomnia women had greater stress less and the vagus nerve could convince the parasympathetic nervous system to calm them down.

The controversy of nerve blocks in treating hot flashes.

We are going to take another brief, two-decade-long journey to understand the research connecting a nerve block to the stellate ganglion. The stellate ganglion is a nerve bundle located in your lower neck, specifically in the front of the C7 vertebra and the first rib. The stellate ganglion provides branches or nerve highways into the C7 and T1 spinal nerves, vertebral artery, and the heart via the inferior cardiac nerves. Injections into this nerve bundle (given at C6 levels) are used to treat pain in the head, neck, arm, and chest. The stellate ganglion injection is also considered a Vagal Nerve Stimulation technique. Doctors are trying to get the vagus nerve to function better.

Let’s start in 2005, here researchers writing in the Journal of Women’s Health (4) investigated whether standard C6 stellate ganglion blockade (nerve block) might provide relief from hot flashes associated with menopause. Six women were involved in this study with severe menopausal hot flashes.

Results: Initial stellate ganglion block was successful in all 6 subjects. The successful treatment caused complete alleviation of hot flashes for times ranging from 2 to 5 weeks. Patients returned for follow-up nerve block after mild hot flashes returned. A second nerve block produced additional asymptomatic periods of relief ranging from 4 to 18 weeks. In each case, repeated block provided hot flash relief equal to or greater than the initial block. Two patients who submitted for a third SGB reported 15 and 48 weeks of relief.

As evidenced by this small study the nerve block into the nerve center that is connected to the vagus seemed very successful.

Another intriguing connection – successful treatment of hot flashes seems to improve brain and cognitive health

It is important to understand that researchers are just now exploring the connections between hot flashes and cognitive health. Let’s look at a September 2020 study in the journal Frontiers in Neurology (5). It comes to us from researchers at the University of Illinois and the University of Pittsburgh.

“Most studies of menopause and brain aging have focused on the role of the sex steroid hormone, estradiol, as key mechanisms contributing to cognitive and brain aging in women. Emerging literature demonstrates that beyond endogenous estradiol levels, menopausal symptoms, particularly vasomotor symptoms (hot flashes), are also key determinants of menopause-related changes in cognition and brain function. . . .Currently, it is premature to make a causal claim about vasomotor symptoms (hot flashes) and memory dysfunction, but initial findings raise the possibility that women with vasomotor symptoms might experience an improvement in cognition with vasomotor symptoms (hot flashes) treatment. More generally, these findings underscore the utility of investigating female-specific risk factors for cognitive decline.”

As these researchers point out, it is premature to suggest a connection between hot flashes and cognitive function and memory. However, one connection is clear. Cervical spine instability can cause symptoms of both.

Heart Rate Variability (HRV) and Menopause

There are also suggestions in research that cervical spine instability can be a factor in heart rate variability. Heart rate variability is the variation in the time between heartbeats. Variability is typically these variations or fluctuations are very small, measured in fractions of a second. A high heart rate variable is a good thing. It shows your body can control the acceleration of heart rate and deceleration of heart rate. In other words, it demonstrates the resiliency of your body to cope with “fight-flight” or danger, stress, and anxiety and have the ability to calm yourself down quickly.

Therefore a high heart rate variable indicates an ability to manage stressful situations and calm down quickly. A low heart rate variability demonstrates the lack of resiliency of your body to cope with “fight-flight” or danger, stress, and anxiety.

A January 2020 paper (6) suggested that HRV was decreased (low) in the menopausal transition and post-menopausal women with more intense symptoms. The findings suggest that somatic symptoms (anxiety, depression, hot flashes, sweating) have a close relationship with HRV. Moreover, HRV presented significant association with menopausal transition and post-menopausal symptoms.” One more thing. It was not clear whether the women in this study actually suffered from severe menopausal symptoms or they thought they did.

This was also alluded to in a June 2017 paper in the journal Menopause (7). Here researchers wrote: “Among perimenopausal and postmenopausal women with hot flashes, variations in hot flash frequency and severity were not explained by variations in resting (slowing) sympathetic activation (the body’s heart rate ). Greater parasympathetic activation was associated with more frequent moderate-to-severe hot flashes, which may reflect increased sensitivity to perceiving hot flashes.”

Now what does all this mean?

This article is about cervical spine instability intensifying menopausal symptoms. In this section of the heart rate variable, we see that something is off in the networking that can make symptoms worse or perception of symptoms being worse. In other words, the individual’s ability to adapt effectively to changing demands and stressors.

Summary

We will get an email where someone will describe symptoms of dizziness, lightheadedness, heat intolerance, tremors, skin temperature fluctuations, and anxiety. Despite having neck pain, back pain, and sciatica-like symptoms, this woman will have menopausal problems singled out as a cause. In many it is cervical spine instability worsening the menopausal and not vice-versa, menopause making the neck pain worse.

The importance of the vagus nerve as related to overall health cannot be overstated. While researchers continue to explore the many symptoms and conditions related to cervical spine instability including those of more severe or long-lasting hot flashes and other menopausal symptoms, structural deficiencies in the neck should be addressed with treatments aimed at restoring the structural alignment and integrity of the cervical spine. It is possible in some that these treatments may be able to reverse many of the chronic symptoms menopausal women suffer from.

Do you have a question about this article or need help?
Get help and information from our Caring Medical staff

1 Subhashri S, Pal P, Pal GK, Papa D, Nanda N. Decreased baroreflex sensitivity is associated with cardiometabolic risks and prehypertension status in early-postmenopausal women. Clinical and Experimental Hypertension. 2021 Feb 17;43(2):112-9. [Google Scholar]
2 de Zambotti M, Colrain IM, Sassoon SA, Nicholas CL, Trinder J, Baker FC. Vagal withdrawal during hot flashes occurring in undisturbed sleep: Hot flashes and autonomic activity. Menopause (New York, NY). 2013 Nov;20(11). [Google Scholar]
3 de Zambotti M, Sugarbaker D, Trinder J, Colrain IM, Baker FC. Acute stress alters autonomic modulation during sleep in women approaching menopause. Psychoneuroendocrinology. 2016 Apr 1;66:1-0. [Google Scholar]
4 Lipov E, Lipov S, Stark JT. Stellate ganglion blockade provides relief from menopausal hot flashes: a case report series. Journal of Women’s Health. 2005 Oct 1;14(8):737-41. [Google Scholar]
5 Maki PM, Thurston RC. Menopause and brain health: hormonal changes are only part of the story. Frontiers in Neurology. 2020 Sep 23;11:562275. [Google Scholar]
6 Martinelli PM, Sorpreso IC, Raimundo RD, Junior OD, Zangirolami-Raimundo J, Malveira de Lima MV, Pérez-Riera A, Pereira VX, Elmusharaf K, Valenti VE, de Abreu LC. Correction: Heart rate variability helps to distinguish the intensity of menopausal symptoms: A prospective, observational and transversal study. Plos one. 2020 Feb 6;15(2):e0229094. [Google Scholar]
7 Gibson CJ, Mendes WB, Schembri M, Grady D, Huang AJ. Cardiac autonomic function and hot flashes among perimenopausal and postmenopausal women. Menopause (New York, NY). 2017 Jul;24(7):756. [Google Scholar]