Hot flashes are reported nearly as often in the late stages of reproductive years and transition phase as in early postmenopause [2]. The precise pathophysiology of hot flashes remains puzzling, but they are thought to be associated with low estradiol levels and narrowing of the thermoregulatory zone system that resides in the hypothalamus [51]. The racial and ethnic variation in prevalence, severity, and total duration of VMS is interesting and suggests multifactorial etiology with contributing environmental and genetic factors.

While these symptoms may occur in the early stage of the menopausal transition, symptoms of GUSM dominate the late stage of postmenopausal years and once apparent can become progressive and chronic over time if left untreated [52, 53]. A large survey of women 55–65 years of age found that only 30 % of women with vaginal discomfort had spoken to their providers about their symptoms [54], emphasizing the importance for providers to prompt discussion and question their postmenopausal patients about vulvovaginal and urinary symptoms. In the VIVA study, 50 % of women identified their primary care doctor as a primary source they had or would use for information on vulvovaginal symptoms, whereas 46 % of women had or would consults their gynecologist about these symptoms [8]. These survey findings indicate that both primary care physicians and gynecologists are central in providing diagnostic and therapeutic assistance in the care of menopausal women suffering from genitourinary symptoms.

Although the association of sexual function, aging, and menopausal changes is complex, the Menopause Epidemiology Study found that women with VVA were at fourfold increased risk of experiencing sexual dysfunction [55]. Decreased vaginal lubrication and symptoms of vaginal dryness become manifest for many in years predating the menopause transition and worsen in the years postmenopause.

Severity and prevalence of sleep disturbances appear to peak during the late menopausal transition when women are undergoing prolonged amenorrhea [18]. Self-reported measures of sleep quality including sleep latency, sleep duration, and wakefulness all worsen as women traverse the menopause [18]. In a longitudinal study of midlife that followed women over a 16-year period, the annualized prevalence of moderate-to-severe poor sleep ranged between 25 and 38 % and did not vary significantly by menopausal status [19]. Notably in this study premenopausal sleep pattern strongly predicted the likelihood for sleep disturbances around the time of the final menstrual period. Those reporting moderate/severe poor sleep premenopausally were at a threefold higher risk of experiencing poor sleep of similar severity during the menopausal transition and in menopause, whereas women without sleep-related issues in the premenopausal phase of life generally continued to sleep well as they negotiated the menopausal transition into postmenopausal period. While the relationship between poor sleep, aging, and menopausal symptoms is complex and currently not completely understood, sleep quality and quantity are nonetheless influenced by both frequency and severity of vasomotor symptoms [19].