Menopause, Perimenopause and Postmenopause
What is menopause?
Menopause is a stage in life when you stop having your monthly period. It’s a normal part of aging and marks the end of your reproductive years. Menopause typically occurs in your late 40s to early 50s. However, women who have their ovaries surgically removed undergo "sudden" surgical menopause.
Why does menopause happen?
Natural menopause — menopause that happens in your early 50s and is not caused by surgery or another medical condition — is a normal part of aging. Menopause is defined as a complete year without menstrual bleeding, in the absence of any surgery or medical condition that may cause bleeding to artificially stop (use of hormonal birth control, overactive thyroid, etc.) As you age, the reproductive cycle begins to slow down and prepares to stop. This cycle has been continuously functioning since puberty. As menopause nears, the ovaries make less of a hormone called estrogen. When this decrease occurs, your menstrual cycle (period) starts to change. It can become irregular and then stop. Physical changes can also happen as your body adapts to different levels of hormones. The symptoms you experience during each stage of menopause (perimenopause, menopause and postmenopause) are all part of your body’s adjustment to these changes.
What are the hormonal changes during menopause?
The traditional changes we think of as "menopause" happen when the ovaries no longer produce high levels of hormones. The ovaries are the reproductive glands that store eggs and release them into the fallopian tubes. They also produce the female hormones estrogen and progesterone as well as testosterone. Together, estrogen and progesterone control menstruation. Estrogen also influences how the body uses calcium and maintains cholesterol levels in the blood.
As menopause nears, the ovaries no longer release eggs into the fallopian tubes, and you’ll have your last menstrual cycle.
How does natural menopause occur?
Natural menopause is the permanent ending of menstruation that is not brought on by any type of medical treatment. For women undergoing natural menopause, the process is gradual and is described in three stages:
- Perimenopause or "menopause transition": Perimenopause can begin eight to 10 years before menopause, when the ovaries gradually produce less estrogen. It usually starts in a woman's 40s, but can start in the 30s as well. Perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. In the last one to two years of perimenopause, the drop in estrogen accelerates. At this stage, many women may experience menopause symptoms. Women are still having menstrual cycles during this time, and can get pregnant.
- Menopause: Menopause is the point when a woman no longer has menstrual periods. At this stage, the ovaries have stopped releasing eggs and producing most of their estrogen. Menopause is diagnosed when a woman has gone without a menstrual period for 12 consecutive months.
- Postmenopause: This is the name given to the period of time after a woman has not bled for an entire year (the rest of your life after going through menopause). During this stage, menopausal symptoms, such as hot flashes, may ease for many women. However, some women continue to experience menopausal symptoms for a decade or longer after the menopause transition. As a result of a lower level of estrogen, postmenopausal women are at increased risk for a number of health conditions, such as osteoporosis and heart disease. Medication, such as hormone therapy and/or healthy lifestyle changes, may reduce the risk of some of these conditions. Since every woman's risk is different, talk to your doctor to learn what steps you can take to reduce your individual risk.
How long does perimenopause (the menopause transition) last?
The length of each stage of the menopause transition can vary for each individual. The average length of perimenopause is about four years. Some women may only be in this stage for a few months, while others will be in this transition phase for more than four years. If you have gone more than 12 months without having a period, you are no longer perimenopausal. However, if there are medications or medical conditions that may affect periods, it can be more difficult to know the specific stage of the menopause transition.
What is premature menopause?
Menopause, when it occurs between the ages of 45 and 55, is considered "natural" and is a normal part of aging. But, some women can experience menopause early, either as a result of a surgical intervention (such as removal of the ovaries) or damage to the ovaries (such as from chemotherapy). Menopause that occurs before the age of 45, regardless of the cause, is called early menopause. Menopause that occurs at 40 or younger is considered premature menopause.
Symptoms and Causes
What are the symptoms of menopause?
You may be transitioning into menopause if you begin experiencing some or all of the following symptoms:
- Hot flashes (a sudden feeling of warmth that spreads over the body).
- Night sweats and/or cold flashes.
- Vaginal dryness; discomfort during sex.
- Urinary urgency (a pressing need to urinate more frequently).
- Difficulty sleeping (insomnia).
- Emotional changes (irritability, mood swings, mild depression).
- Dry skin, dry eyes or dry mouth.
Women who are still in the menopause transition (perimenopause) may also experience:
- Breast tenderness.
- Worsening of premenstrual syndrome (PMS).
- Irregular periods or skipping periods.
- Periods that are heavier or lighter than usual.
Some women might also experience:
- Racing heart.
- Joint and muscle aches and pains.
- Changes in libido (sex drive).
- Difficulty concentrating, memory lapses (often temporary).
- Weight gain.
- Hair loss or thinning.
These symptoms can be a sign that the ovaries are producing less estrogen, or a sign of increased fluctuation (ups and downs) in hormone levels. Not all women get all of these symptoms. However, women affected with new symptoms of racing heart, urinary changes, headaches, or other new medical problems should see a doctor to make sure there is no other cause for these symptoms.
What are hot flashes and how long will I have them?
Hot flashes are one of the most frequent symptoms of menopause. It is a brief sensation of heat. Hot flashes aren’t the same for everyone and there’s no definitive reason that they happen. Aside from the heat, hot flashes can also come with:
- A red, flushed face.
- A chilled feeling after the heat.
Hot flashes not only feel different for each person — they also can last for various amounts of time. Some women only have hot flashes for a short period of time during menopause. Others can have some kind of hot flash for the rest of their life. Typically, hot flashes are less severe as time goes on.
What triggers a hot flash?
There are quite a few normal things in your daily life that could set off a hot flash. Some things to look out for include:
- Spicy foods.
- Tight clothing.
- Stress and anxiety.
Heat, including hot weather, can also trigger a hot flash. Be careful when working out in hot weather — this could cause a hot flash.
Can menopause cause facial hair growth?
Yes, increased facial hair growth can be a change related to menopause. The hormonal change your body goes through during menopause can result in several physical changes to your body, including more facial hair than you may have had in the past. If facial hair becomes a problem for you, waxing or using other hair removers may be options. Talk to your healthcare provider about your options to make sure you don’t pick a product that could harm your skin.
Is having a hard time concentrating and being forgetful a normal part of menopause?
Unfortunately, concentration and minor memory problems can be a normal part of menopause. Though this doesn’t happen to everyone, it can happen. Doctors aren’t sure why this happens. If you’re having memory problems during menopause, call your healthcare provider. There are several activities that have been shown to stimulate the brain and help rejuvenate your memory. These activities can include:
- Doing crossword puzzles and other mentally stimulating activities like reading and doing math problems.
- Cutting back on passive activities like watching TV.
- Getting plenty of exercise.
Keep in mind that depression and anxiety can also impact your memory. These conditions can be linked to menopause.
Can menopause cause depression?
Your body goes through a lot of changes during menopause. There are extreme shifts in your hormone levels, you may not be sleeping well because of hot flashes and you may be experiencing mood swings. Anxiety and fear could also be at play during this time. All of these factors can lead to depression.
If you are experiencing any of the symptoms of depression, talk to your healthcare provider. During your conversation, your provider will tell you about different types of treatment and check to make sure there isn’t another medical condition causing your depression. Thyroid problems can sometimes be the cause of depression.
Are there any other emotional changes that can happen during menopause?
Menopause can cause a variety of emotional changes, including:
- A loss of energy and insomnia.
- A lack of motivation and difficulty concentrating.
- Anxiety, depression, mood changes and tension.
- Aggressiveness and irritability.
All of these emotional changes can happen outside of menopause. You have probably experienced some of them throughout your life. Managing emotional changes during menopause can be difficult, but it is possible. Your healthcare provider may be able to prescribe a medication to help you (hormone therapy or an antidepressant). It may also help to just know that there is a name to the feeling you are experiencing. Support groups and counseling are useful tools when dealing with these emotional changes during menopause.
How does menopause affect my bladder control?
Unfortunately, bladder control issues (also called urinary incontinence) are common for women going through menopause. There are several reasons why this happens, including:
- Estrogen. This hormone plays several roles in your body. It not only controls your period and promotes changes in your body during pregnancy, estrogen also keeps the lining of your bladder and urethra healthy.
- Pelvic floor muscles. Supporting the organs in your pelvis — your bladder and uterus — are called the pelvic floor muscles. Throughout your life, these muscles can weaken. This can happen during pregnancy, childbirth and from weight gain. When the muscles weaken, you can experience urinary incontinence (leakage).
Specific bladder control problems that you might have can include:
- Stress incontinence (leakage when you cough, sneeze or lift something heavy).
- Urge incontinence (leakage because your bladder squeezes at the wrong time).
- Painful urination (discomfort each time you urinate).
- Nocturia (feeling the need to get up in the night to urinate).
Will I start menopause if I have a hysterectomy?
During a hysterectomy, your uterus is removed. You won’t have a period after this procedure. However, if you kept your ovaries — removal of your ovaries is called an oophorectomy — you may not have symptoms of menopause right away. If your ovaries are also removed, you will have symptoms of menopause immediately.
Diagnosis and Tests
How is menopause diagnosed?
There are several ways your healthcare provider can diagnose menopause. The first is discussing your menstrual cycle over the last year. If you have gone a full year (12 straight months) without a period, you may be postmenopausal. Another way your provider can check if you are going through menopause is a blood test that checks your follicle stimulating hormone (FSH) level. FSH is a hormone produced by the pituitary gland — this gland is located at the base of your brain. However, this test can be misleading during the beginning of menopause when your body is transitioning and your hormone levels are fluctuating up and down. Hormone testing always need to be interpreted in the context of what is happening with the menstrual period.
For many women, a blood test is not necessary. If you are having the symptoms of menopause and your periods have been irregular, talk to your healthcare provider. Your provider may be able to diagnose menopause after your conversation.
Management and Treatment
Can menopause be treated?
Menopause is a natural process that your body goes through. In some cases, you may not need any treatment for menopause. When treatment for menopause is discussed, it’s about treating the symptoms of menopause that disrupt your life. There are many different types of treatments for the symptoms of menopause. The main types of treatment for menopause are:
It is important to talk to your healthcare provider while you are going through menopause to craft a treatment plan that works for you. Every person is different and has unique needs.
What is hormone therapy?
During menopause, your body goes through major hormonal changes, decreasing the amount of hormones it makes — particularly estrogen and progesterone. Estrogen and progesterone are produced by the ovaries. When your ovaries no longer make enough estrogen and progesterone, hormone therapy can be used as a supplement. Hormone therapy boosts your hormone levels and can help relieve some symptoms of menopause. It’s also used as a preventative measure for osteoporosis.
There are two main types of hormone therapy:
- Estrogen therapy (ET): In this treatment, estrogen is taken alone. It’s typically prescribed in a low dose and can be taken as a pill or patch. ET can also be given to you as a cream, vaginal ring, gel or spray. This type of treatment is used after a hysterectomy. Estrogen alone can’t be used if a woman still has a uterus.
- Estrogen Progesterone/Progestin Hormone Therapy (EPT): This treatment is also called combination therapy because it uses doses of estrogen and progesterone. Progesterone is available in its natural form, or also as a progestin (a synthetic form of progesterone). This type of hormone therapy is used if you still have your uterus.
Hormone therapy can relieve many of the symptoms of menopause, including:
- Hot flashes and night sweats.
- Vaginal dryness.
- Irritability and mood swings.
- Hair loss.
Are there any risks related to hormone therapy?
Like most prescribed medications, there are risks for hormone therapy. Some known health risks include:
- Endometrial cancer (only increased if you still have your uterus and are not taking progestin together with the estrogen).
- Gallstones and gallbladder issues.
- Blood clots.
Going on hormone therapy is an individualized decision. Discuss all past medical conditions and your family history with your healthcare provider to understand the risks versus benefits of hormone therapy for you.
What are non-hormonal therapies for menopause?
Though hormone therapy is a very effective method for relieving menopause symptoms, it’s not the perfect treatment for everyone. Non-hormonal treatments include changes to your diet, lifestyle and using over-the-counter options. These treatments are often good options for women who have other medical conditions or have recently been treated for breast cancer. The main non-hormonal treatments that your provider may recommend include:
- Changing your diet.
- Avoiding triggers to hot flashes.
- Prescription medications, which have been shown to help.
Sometimes changing your diet can help relieve menopause symptoms. Limiting the amount of caffeine you consume every day and cutting back on spicy foods can make your hot flashes less severe. You can also add foods that contain plant estrogen into your diet. Plant estrogen (isoflavones) isn’t a replacement for the estrogen made in your body before menopause. Foods to try include:
Avoiding triggers to hot flashes
Certain things in your daily life could be triggers for hot flashes. To help relieve your symptoms, try and identify these triggers and work around them. This could include keeping your bedroom cool at night, wearing layers of clothing, or quitting smoking. Weight loss can also help with hot flashes.
Working out can be difficult if you are dealing with hot flashes, but exercising can help relieve several other symptoms of menopause. Exercise can help you sleep through the night and is recommended if you have insomnia. Calm, tranquil types of exercise like yoga can also help with your mood and relieve any fears or anxiety you may be feeling.
Joining support groups
Talking to other women who are also going through menopause can be a great relief for many. Joining a support group can not only give you an outlet for the many emotions running through your head, but also help you answer questions you may not even know you have.
Can my doctor prescribe non-hormonal medications?
There are several non-hormonal medications that your doctor can prescribe. These are typically used to treat hot flashes. Speak to your doctor about what specific non-hormonal medications might work best for you.
Outlook / Prognosis
Can I get pregnant during menopause?
The possibility of pregnancy disappears once you are postmenopausal, you have been without your period for an entire year (assuming there is no other medical condition for the lack of menstrual bleeding). However, you can actually get pregnant during the menopause transition (perimenopause). If you don’t want to become pregnant, you should continue to use some form of birth control until you have gone fully through menopause. Ask your healthcare provider before you stop using contraception.
For some women, getting pregnant can be difficult once they’re in their late 30s and 40s because of a decline in fertility. However, if becoming pregnant is the goal, there are fertility-enhancing treatments and techniques that can help you get pregnant. Make sure to speak to your healthcare provider about these options.
What are the long-term health risks associated with menopause?
There are several conditions that you could be at a higher risk of after menopause. Your risk for any condition depends on many things like your family history, your health before menopause and lifestyle factors (smoking). Two conditions that affect your health after menopause are osteoporosis and coronary artery disease.
Osteoporosis, a "brittle-bone" disease, occurs when the inside of bones become less dense, making them more fragile and likely to fracture. Estrogen plays an important role in preserving bone mass. Estrogen signals cells in the bones to stop breaking down.
Women lose an average of 25% of their bone mass from the time of menopause to age 60. This is largely because of the loss of estrogen. Over time, this loss of bone can lead to bone fractures. Your healthcare provider may want to test the strength of your bones over time. Bone mineral density testing, also called bone densitometry, is a quick way to see how much calcium you have in certain parts of your bones. The test is used to detect osteoporosis and osteopenia. Osteopenia is a disease where bone density is decreased and this can be a precursor to later osteoporosis.
If you have osteoporosis or osteopenia, your treatment options could include estrogen therapy.
Coronary artery disease
Coronary artery disease is the narrowing or blockage of arteries that surround the heart muscle. This happens when fatty plaque builds up in the artery walls (known as atherosclerosis). This buildup is associated with high levels of cholesterol in the blood. After menopause, your risk for coronary artery disease increases because of several things, including:
- The loss of estrogen (this hormone also contributes to healthy arteries).
- Increased blood pressure.
- A decrease in physical activity.
- Bad habits from your past catching up with you (smoking or excessive drinking).
A healthy diet, not smoking and getting regular exercise are your best options to prevent heart disease. Treating elevated blood pressure and diabetes as well as maintaining cholesterol levels with medications for selected at-risk people are the standards of care.
Will hormone therapy help prevent long-term health risks?
The benefits and risks of hormone therapy vary depending on a woman’s age and her individual history. In general, younger women in their 50s tend to get more benefits from hormone therapy as compared to postmenopausal women in their 60s. Women who undergo premature menopause are often treated with hormone therapy until age 50 to avoid the increased risk that comes from the extra years of estrogen loss.
How do I know if changes in my periods are normal perimenopausal symptoms or something to be concerned about?
Irregular periods are common and normal during perimenopause (the menopause transition). But other conditions can cause abnormalities in menstrual bleeding. If any of the following situations apply to you, see a doctor to rule out other causes.
- Your periods are changing to become very heavy, or accompanied by blood clots.
- Your periods last several days longer than usual.
- You spot or bleed after your period.
- You experience spotting after sex.
- Your periods occur closer together.
Potential causes of abnormal bleeding include hormonal imbalances, hormonal treatments, pregnancy, fibroids, blood-clotting problems or, rarely, cancer.
Can menopause affect sleep?
Some women may experience trouble sleeping through the night and insomnia during menopause. Insomnia is an inability to fall asleep or stay asleep at night. This can be a normal side effect of menopause itself, or it could be due to another symptom of menopause. Hot flashes are a common culprit of sleepless nights during menopause.
If hot flashes keep you awake at night, try:
- Staying cool at night by wearing loose clothing.
- Keeping your bedroom well-ventilated.
Avoiding certain foods and behaviors that trigger your hot flashes. If spicy food typically sets off a hot flash, avoid eating anything spicy before bed.
Can menopause affect my sex life?
After menopause, your body has less estrogen. This major change in your hormonal balance can affect your sex life. Many menopausal women may notice that they’re not as easily aroused as before. Sometimes, women also may be less sensitive to touch and other physical contact than before menopause.
These feelings, coupled with the other emotional changes you may be experiencing, can all lead to a decreased interest in sex. Keep in mind that your body is going through a lot of change during menopause. Some of the other factors that can play a role in a decreased sex drive can include:
- Having bladder control problems.
- Having trouble sleeping through the night.
- Experiencing stress, anxiety or depression.
- Coping with other medical conditions and medications.
All of these factors can disrupt your life and even cause tension in your relationship. In addition to these changes, the lower levels of estrogen in your body can actually cause a decrease in the blood supply to the vagina. This can cause dryness. When you don’t have the right amount of lubrication in the vagina, it can be thin, pale and dry. This can lead to painful intercourse.
Don’t be afraid to talk to your healthcare provider about any decreases you are experiencing in your sex drive. Your provider will discuss options to help you feel better. For example, vaginal dryness can be treated with over-the-counter, water-soluble or silicone lubricants. Your healthcare provider can also prescribe estrogen or nonestrogen hormones to treat the vaginal tissue. This may be prescribed in a low-dose cream, pill or vaginal ring.
Do all menopausal women experience a decrease in sexual desire?
Not all women experience a decreased sexual desire. In some cases, it’s just the opposite. This could be because there’s no longer any fear of getting pregnant. For many women, this allows them to enjoy sex without worrying about family planning.
However, it is still important to use protection (condoms) during sex if not in a monogamous relationship. Once your doctor makes the diagnosis of menopause, you can no longer become pregnant. However, when you are in the menopause transition (perimenopause), you can still become pregnant. You also need to protect yourself from sexually transmitted infections (STIs). You can get an STI at any time in your life.
Will I still enjoy sex after menopause?
You should still be able to enjoy sex after menopause. Sometimes, decreased sex drive is related to discomfort and painful intercourse. After treating the source of this pain (vaginal dryness), many women are able to enjoy intimacy again. Hormone therapy can also help many women. If you are having difficulties enjoying sex after menopause, talk to your healthcare provider.
Can menopause be a positive time of life?
Menopause can certainly be a positive time of life. Too often, myths foster misconceptions about this normal process of aging. Although menopause can cause some noticeable and uncomfortable changes, these can be effectively managed.
Alliance for Aging Research
American College of Obstetricians and Gynecologists (ACOG)
American Society for Reproductive Medicine
National Cancer Institute
National Heart, Lung, and Blood Institute (NHLBI) Information Center
National Institute on Aging
National Library of Medicine's MEDLINEplus
National Osteoporosis Foundation
US Department of Health and Human Services, Office on Women’s Health
National Women's Health Resource Center
The Hormone Foundation
The North American Menopause Society
U.S. Food and Drug Administration
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