Menopause

Menopause marks a natural turning point in a woman’s life when menstrual periods stop permanently. While this transition brings hormonal changes that can affect physical and emotional well-being, understanding what happens and knowing your options can help you navigate this stage with confidence.

Table of contents

• What is menopause?
• The three stages of the menopausal journey
• When does menopause occur?
• Signs and symptoms
• What causes menopause?
• How is menopause diagnosed?
• Treatment options
• Lifestyle changes that can help
• Long-term health considerations

What is menopause?

Menopause is a point in time when a woman has gone 12 consecutive months without a menstrual period. It is not a disease or disorder—it is a normal part of aging for women.^[1] After menopause, a woman can no longer become pregnant naturally, except in rare cases when specialized fertility treatments are used.^[5]

Menopause happens when the ovaries stop producing reproductive hormones (substances made by the body that control various functions). This process occurs when the ovaries stop releasing eggs for fertilization.^[1][5]

The three stages of the menopausal journey

The menopausal process is gradual and happens in three distinct stages:^[1]

Perimenopause (also called the “menopause transition”) is the time leading up to your last period. This stage can begin eight to 10 years before menopause when your ovaries gradually produce less and less estrogen (a key hormone made by the ovaries). It usually starts when you’re in your 40s. You can be in perimenopause for several months or several years. During this time, the amount of hormones your ovaries make varies, which can cause symptoms.^[1][3] Perimenopause can last two to eight years, with an average of about four years.^[2][3]

Menopause is the specific point when you no longer have menstrual periods. At this stage, your ovaries don’t release eggs, and your body doesn’t produce much estrogen. A healthcare provider diagnoses menopause when you’ve gone without a period for 12 consecutive months. Unlike the other stages, menopause itself is a defined moment, so you don’t stay in this stage.^[1] You have reached menopause only after it has been a full year since your last period, meaning you have not had any bleeding, including spotting, for 12 months in a row.^[4]

Postmenopause is the time after menopause. You stay in postmenopause for the rest of your life. While most symptoms of menopause ease up in postmenopause, you can continue to have mild symptoms for several years. People in the postmenopausal phase are at an increased risk for osteoporosis (a condition where bones become weak) and heart disease due to low estrogen levels.^[1]

When does menopause occur?

Most women experience menopause between the ages of 45 and 55 years as a natural part of biological aging.^[5] The average age of menopause in the United States is 52 years old, but the transition to menopause usually begins in your mid-40s.^[1][4] The average age is 51 in the United States.^[3]

Menopause that occurs before the age of 45 is called early menopause. Menopause that occurs at 40 or younger is considered premature menopause.^[1] Some women experience premature menopause because of certain chromosomal abnormalities, autoimmune disorders or other unknown causes.^[5] When there’s no medical or surgical cause for premature menopause, it’s called primary ovarian insufficiency.^[1]

Menopause can also be induced, meaning it happens as a consequence of surgical procedures that involve removal of both ovaries or medical interventions that cause cessation of ovarian function, such as radiation therapy or chemotherapy.^[1][5]

Signs and symptoms

The menopausal transition can bring various symptoms, including hot flashes, night sweats, trouble sleeping, joint and muscle discomfort, pain during sex, moodiness and irritability, forgetfulness, difficulty concentrating, or a combination of these.^[2] Some women have no or mild menopausal symptoms and may even feel relieved when they no longer need to worry about periods or getting pregnant. For other women, the menopausal transition can bring uncomfortable symptoms.^[2]

You may be transitioning into menopause if you begin experiencing some or all of the following symptoms:^[1]

• Irregular periods or periods that are heavier or lighter than usual
• Hot flashes, also known as vasomotor symptoms (a sudden feeling of warmth that spreads over your body)
• Night sweats and/or cold flashes
• Vaginal dryness that causes discomfort during sex
• Urinary urgency (a pressing need to urinate more frequently)
• Difficulty sleeping (insomnia)
• Emotional changes (irritability, mood swings or depression)
• Dry skin, dry eyes or dry mouth
• Trouble finding words and remembering, often called brain fog

Most often, periods are not regular before they end. Skipped periods during perimenopause are common and expected. Often, menstrual periods skip a month and return, or they skip a few months and then start monthly cycles again for a few months. Period cycles tend to get shorter in early perimenopause, so periods are closer together. As menopause gets closer, periods get farther apart for months before they end.^[3]

Symptoms related to menopause can last for between two and eight years, though the timing and symptoms are highly variable.^[2] Vasomotor symptoms may affect as many as 80% of women worldwide and last, on average, a total of seven to eight years, including four to five years after the final menstrual period.^[15]

Genitourinary syndrome of menopause (symptoms affecting the vaginal and urinary areas) affects up to 50% of women worldwide. Unlike vasomotor symptoms, it is progressive without treatment.^[15]

What causes menopause?

Menopause is caused by the loss of ovarian follicular function and a decline in circulating blood oestrogen levels.^[5] During the menopausal transition, the body’s production of estrogen and progesterone (two hormones made by the ovaries) declines greatly. Changes in these hormones may explain the symptoms that some women experience during this time.^[2]

After menopause, your ovaries make very low levels of the hormones called estrogen and progesterone. These low hormone levels can raise your risk for certain health problems.^[4]

How is menopause diagnosed?

Most people can tell by the symptoms that they’ve started menopause. Tests most often aren’t needed to diagnose menopause.^[8] The regularity and length of the menstrual cycle varies across a woman’s reproductive life span, but you will only know that you’ve reached menopause when you have not had a period or spotting for a full year.^[5][4]

If you have worries about irregular periods or hot flashes, talk with your healthcare professional. Sometimes, your healthcare professional may suggest blood tests to check your levels of:^[8]

• Follicle-stimulating hormone (FSH) and estrogen (estradiol). FSH goes up and estrogen goes down during menopause. Because hormones go up and down during perimenopause, it can be hard to tell from these tests whether you’re in menopause.
• Thyroid-stimulating hormone (TSH). Overactive thyroid, called hyperthyroidism, can cause symptoms like those of menopause.

You can get home tests to check FSH levels in your urine without a prescription. The tests show whether you have higher FSH levels. This might mean that you’re in perimenopause or menopause. But FSH levels rise and fall during your menstrual cycle, so home FSH tests can’t really tell you whether you’re in menopause.^[8]

Treatment options

Menopause needs no treatment. Treatments aim to ease symptoms and prevent or manage ongoing conditions that may happen with aging.^[8] If you experience menopause symptoms, they may go away without treatment. Or you may not find the symptoms uncomfortable. If you are bothered by your symptoms, talk to your health care provider. You can work together to find a treatment that is right for you.^[10]

A variety of non-hormonal and hormonal interventions can help alleviate perimenopausal symptoms.^[5] Treatment recommendations depend on a holistic evaluation by your health care provider and your choice of the options offered to you. All medicines have risks, and your health care provider can help you figure out which medicines are best for you.^[10]

Hormone therapy

Hormone therapy (HT), also called menopausal hormone therapy (MHT) or hormone replacement therapy (HRT), is a safe and effective treatment for most going through menopause and perimenopause. Your healthcare provider will discuss any risks with you.^[9] HRT involves using oestrogen to replace your body’s own levels around the time of the menopause.^[9]

Estrogen therapy works best for easing menopausal hot flashes. It also eases other menopause symptoms and slows bone loss. Your healthcare professional may suggest estrogen in the lowest dose and for the time needed to relieve your symptoms. It’s best used by people who are younger than 60 and within 10 years of the onset of menopause.^[8]

If you still have your uterus, you’ll need progestin with estrogen. Estrogen also helps prevent bone loss. Long-term use of hormone therapy may have some heart disease and breast cancer risks. But starting hormones around the time of menopause has shown benefits.^[8]

There are different types and doses of HRT. Using the right dose and type usually means your symptoms improve. Oestrogen comes as skin patches, a gel or spray to put on the skin, implants, and tablets. If you have a womb (uterus) you also need to take progesterone to protect your womb lining from the effects of oestrogen. Progesterone comes as patches (as part of a combined patch with oestrogen), IUS (intrauterine system, or coil), and tablets.^[9]

The main benefit of HRT is that it can help relieve most menopause and perimenopause symptoms, including hot flushes, brain fog, joint pains, mood swings and vaginal dryness. Hot flushes or night sweats often improve within a few weeks. Other symptoms like mood changes and vaginal dryness can take a few months to improve. Taking HRT can also reduce your risk of hormone-related health problems including osteoporosis and heart disease.^[9]

Testosterone for reduced sex drive

If HRT does not help restore your sex drive, you might be offered a testosterone gel or cream. It can help improve sex drive, mood and energy levels. You can safely use this at the same time as HRT. Side effects of using testosterone are not common but include acne and unwanted hair growth.^[9]

Treatment for vaginal dryness

Your vagina may become dry, painful or itchy as a result of the menopause and perimenopause. A healthcare provider can prescribe oestrogen treatments you can insert into your vagina, as a tablet, cream or ring. This can also improve any urinary symptoms caused by menopause and perimenopause, like pain when you urinate. These vaginal oestrogen treatments do not get into your bloodstream and only work on the area where you put them. You can use them for the rest of your life. It’s safe to use vaginal oestrogen with HRT.^[9]

Hormone-free vaginal moisturizers are also available and have been shown to be as effective as estrogen-based therapies for treating genitourinary syndrome of menopause.^[15] You can use vaginal moisturisers or lubricants that you can get without a prescription at a pharmacy.^[9]

Non-hormone medicines

There are non-hormone treatments if your symptoms are having a big impact on your life and you cannot, or choose not to, have HRT.^[9] Nonhormonal medications for vasomotor symptoms include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and gabapentin (a medicine originally used for epilepsy).^[15]

Some medicines that can help with hot flushes and night sweats include a blood pressure medicine called clonidine and an epilepsy medicine called gabapentin. Talk with a healthcare provider about these medicines and their side effects, and if they might be suitable for you.^[9]

Antidepressants can help with mood symptoms if you’ve been diagnosed with depression or anxiety.^[9]

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a talking therapy which can help with low mood and anxiety caused by menopause and perimenopause, some physical symptoms like hot flushes and joint pain, and sleep problems. You can get NHS talking therapies, including CBT, without seeing a healthcare provider.^[9] Clinical hypnosis is also effective for short-term reduction of vasomotor symptoms and associated sleep disturbances.^[15]

Lifestyle changes that can help

You may find that you can manage your symptoms with lifestyle changes.^[7] Eating well, exercising and looking after your mental wellbeing can help with symptoms during perimenopause and menopause. It can also help you keep as well as possible in the future.^[16]

For hot flashes and night sweats

If you have hot flashes, here are some changes that might help:^[7][16]

• Dress in layers that can be removed at the start of a hot flash
• Carry a portable fan to use when you get a hot flash
• Wear light clothing
• Keep your bedroom cool at night
• Take a cool shower, use a fan or have a cold drink
• Try to reduce your stress level
• Avoid or reduce potential triggers, such as spicy food, caffeine, hot drinks, smoking and alcohol

General healthy habits

Here are healthy lifestyle changes that can help during menopause:^[16]

• Get plenty of rest, including keeping to regular sleep routines
• Eat a healthy diet
• Have calcium-rich food like milk, yoghurt and kale to keep bones healthy
• Exercise regularly, including weight-bearing activities where your feet and legs support your weight like walking, running or dancing, and resistance exercises (for example, using weights)
• Do relaxing things like yoga, tai chi or meditation
• Talk to other people going through the same thing, like family, friends or colleagues
• Maintain a healthy weight. Being overweight or having obesity can make hot flashes worse

If you smoke, try to quit, not only for hot flashes, but for your overall health. Avoid alcohol, spicy foods, and caffeine, as they can make your menopause symptoms worse.^[7] Do not drink more than the recommended alcohol limit.^[16]

Lower stress, for example by using relaxation techniques such as meditation, deep breathing, and muscle relaxation exercises.^[7] Have good sleep habits. Keep your bedroom dark, quiet, and cool. Get regular exercise. It can help you sleep better, improve your mood, and help lower your risk for many age-related diseases.^[7]

What about supplements?

Talk to a doctor before taking herbal supplements or complementary medicines.^[16] Data are lacking to support the effectiveness of herbal or botanical supplements, exercise, and acupuncture for menopause symptoms.^[15]

Long-term health considerations

During the menopause transition and afterwards, hormone changes can raise your risk for certain health problems, such as cardiovascular disease and osteoporosis.^[19]

The loss of estrogen can cause you to lose bone density. This can lead to osteoporosis, a condition that causes bones to become weak and break easily. It can also raise your cholesterol levels and increase your risk of heart disease and stroke.^[7]

To help protect against weak bones, you can try to exercise regularly, including weight-bearing exercises and resistance exercises, eat a healthy diet that includes plenty of fruit, vegetables and sources of calcium, get some sunlight on your skin as this triggers the production of vitamin D which can help keep your bones healthy, take vitamin D supplements, and stop smoking and cut down on alcohol.^[16]

If lifestyle changes are not enough to improve your symptoms, you may want to contact your health care provider. They will talk to you about your symptoms, family and medical history, and preferences. They also can explain the risks and benefits of different treatment options.^[7]