It’s hard to believe that a routine stage of life half the planet goes through is so rife with misinformation and unanswered questions, but that pretty much defines menopause.
Thankfully, women are talking more and more about this natural process, which has been brought into the open in part by the proliferation of books on the topic, free-speaking celebrities, “Femtech” apps, pricey diets and “cures” pitched to menopausal women and more. “But it’s still not something every woman hears about from her mother or sister,” says Jackie Thielen, M.D., director of the women’s health specialty clinic at the Mayo Clinic in Jacksonville, Florida.
The term itself can be confusing — even to doctors, says Stephanie Faubion, M.D., medical director of the North American Menopause Society (NAMS) and director of the Mayo Clinic Center for Women’s Health in Rochester, Minnesota. People generally use the word “menopause” to mean everything from a first skipped period to the decades after bleeding has stopped. But that’s not exactly accurate.
The three stages of menopause:
A big piece of the confusion is that the thing we all say — that we’re “in menopause” —actually has no scientific meaning. The stage when your ovaries start producing less hormones and your periods become less regular is commonly called perimenopause. The term menopause refers to one year after your last menstrual flow — which you can’t know you’ve hit until those 12 months have passed. Menopause itself is really more of a line in the sand — something you’ve passed — as opposed to a phase you can be “in.” Everything else — the months and years following the one-year mark? That’s postmenopause.
In the U.S., the menopause milestone occurs at an average age of 51. But some women are more than a decade younger and others closer to 60. Meanwhile, perimenopause can start as much as eight years before that.
In most women, the body makes this transition naturally. But menopause can also be artificially induced by the surgical removal of the ovaries, suppressive medications or chemotherapy.
Because the hormones that are shifting during this time are powerful (remember puberty?), perimenopause can be a bumpy ride for some women. But it’s important to remember that even though symptoms can range from barely noticeable to disruptive to the point where you need help managing them, menopause is a normal process designed to move the body from one stage of life to another, not an illness or sign that something is going wrong.
What is the main cause of menopause?
In a word, hormones.
Babies assigned female at birth are born with all the egg cells they will ever produce. When they enter puberty, those eggs get ready to help form new life, and the ovaries begin making the hormone estrogen. Along with its sister hormone progesterone, this starts the years of monthly ovulation followed by menstruation (not to mention mad rushes to the ladies’ room, pregnancy scares when periods are missed and all that other fun stuff.)
So what exactly happens during the menopause transition? Those once-fresh eggs are no longer as viable. And since estrogen is made by cells surrounding each egg, the ovaries start putting out much less of it, says Nanette Santoro, M.D., chair of obstetrics and gynecology at the University of Colorado School of Medicine and a longtime menopause researcher.
Another result of having fewer and less responsive eggs: a hormone known as follicle stimulating hormone (FSH), which helps trigger ovulation, ramps up. Levels of FSH rise as it works hard to push the ovaries to pop out an egg every month like they used to, Dr. Santoro says. Ovulation and a surge of estrogen is what tells the FSH to calm down, but with fewer or no eggs left, and so no estrogen surge, FSH remains high. That’s why some doctors measure FSH to tell whether a person is in perimenopause or menopause, although it’s not considered a good test to diagnose it (we’ll get to that later).
But the process does not go in a straight line. During perimenopause, levels of estrogen go up and down like a roller coaster, and it’s these fluctuations that cause most symptoms, Dr. Santoro says. Naturally, the hormonal fluctuations also affect your periods, which can become irregular. You might go months between some periods and then weeks between others. Bleeding can also be heavier (keep those super tampons at the ready), or sometimes lighter, according to the Cleveland Clinic.
Exactly how and when each person goes through their menopause transition is impacted by many things, including genetics (if your mom or sister had an early menopause, you’re six times more likely to as well, Dr. Santoro says), social stress, adverse childhood experiences and smoking history. According to NAMS, smokers hit menopause an average of two years earlier than nonsmokers.
Race may also be a factor, although that’s still unclear. An analysis of data from the landmark 25-year menopause research known as the Study of Women’s Health Across the Nation (SWAN) found that Black women enter menopause at an average earlier age than white women and report more bothersome hot flashes and other symptoms. But the Black women in the study were more likely to have had difficult childhoods, adult life stresses and to be smokers, the researchers found, all things that can affect menopause. “There are so many socio-cultural influences on menopause that it’s hard to tease out the influence of race,” Dr. Thielen says.
What are the symptoms of menopause?
The wild up-and-down ride of estrogen during perimenopause is known to cause a variety of symptoms, much more so than the typically stable, low levels of estrogen that follow in the postmenopause years. Of course, having sweat pour out of you in the middle of an important meeting is never fun, but experts emphasize that these and other effects are not a sign that anything is medically wrong. In other words, whatever you may need to do to ease your discomfort, it’s the symptoms you’re treating, rather than trying to “cure” menopause, which is not an illness.
And most symptoms — phew! — have effective treatments, and most of them also go away on their own. And while most women do experience symptoms, some manage to skate by with nothing more than some irregular periods, Dr. Faubion says.
Dr. Santoro has termed the most commonly documented symptoms of menopause the “core four.” They include:
- Hot flashes. This feels like a sudden wave of heat lasting from one to five minutes, which women describe as an internal oven suddenly turning on. The sensation may come along with sweating, flushing skin and a rapid heartbeat, followed by a cold chill. At least 85% of women report having flashes, according to the Journal of Midlife Health, and about a third of menopausal women describe them as moderately or severely bothersome, Dr. Santoro says. Hot flashes that happen when you’re sleeping are called night sweats, where you might wake up in your bed to find yourself drenched.
- Sleep problems. About half of women going through their transition complain of broken sleep, although experts aren’t sure how much is caused by hormonal shifts vs the natural processes of aging.
- Changes in mood. Some women become mildly irritable. But others suddenly feel sad, anxious or even experience full-blown depression, in some cases even if they’ve never had problems before. Studies have found mood changes are relatively common: For example, up to 68% of perimenopausal women report heightened depressive symptoms, compared with around a third of women who are premenopausal, NAMS reports in its guidelines for depression. Mood issues are most likely to come up during the late transition stage, Dr. Santoro says.
- Vaginal dryness. Estrogen lines the walls of the vagina, so when it drops, vaginal tissue thins and dries. The result: pain, soreness or burning during sex. Unlike other perimenopause symptoms, this one won’t improve without treatment, Dr. Santoro says.
These four symptoms can all exacerbate one another. For example, night sweats might make it harder to sleep, while trouble sleeping can heighten mood changes, Dr. Santoro says.
Women may also experience other symptoms that have not been captured in research. This includes everything from thinning hair to heart palpitations, dizziness, itching, brain fog and even a metallic taste in their mouth or the sensation of ants crawling under the skin. Dr. Santoro says she herself experienced heart palpitations during her transition, a symptom that stopped once she reached menopause.
Surprisingly, some menopausal symptoms can pop up even before your first period changes, researchers found in 2021. “This study validated so many women’s senses that something is happening even though they’re still regularly menstruating,” Dr. Faubion says.
How long does menopause last?
The answer depends on what you mean by “menopause.”
If you mean perimenopause, the stage leading up to that final period, that typically lasts from four to eight years, but in some women it’s longer, according to NAMS. Somewhere in there, you stop bleeding. When you’ve gone a full year without a single period, you’ve reached menopause. Then you’re postmenopausal (which some people refer to as “in menopause”) every day of your life after. It’s worth celebrating: no more tampons, no more menstrual cramps, no more need for birth control!
Can tests show if you’re in menopause?
Not accurately. Some doctors do a blood test measuring a woman’s level of follicle-stimulating hormone (FSH) — remember, that’s the hormone that rises to try to get your winding-down ovaries to perk up — to determine whether someone is perimenopausal. The reason why this isn’t a good way to pinpoint menopause, NAMS warns, is because a single FSH level can be misleading. Like estrogen, FSH goes up and down during this stage. Same goes for drugstore urine tests that clock FSH. Saliva testing to assess menopause status? Another bad (and expensive) idea, NAMS says, because this isn’t accurate either.
The only way to know for sure you’ve reached menopause? When you look back at your last documented period and realize it’s been a whole year.
And anyway, tests aren’t necessary, Dr. Faubion says. If you have symptoms that get in the way of your life, they need to be treated, regardless of what a test might show.
When you’re in perimenopause, can you stop using birth control?
If only. You know those “change of life” babies we’ve all heard about? They arrived because women figured they couldn’t get pregnant once their periods stopped being regular. It is true that you’re less likely to conceive, Dr. Thielen says, but less likely doesn’t mean never. During perimenopause you may think you’re done, and then your period shows up after four or five months … this means you ovulated a couple of weeks before that.
That’s why if you don’t want to get pregnant, you must use effective birth control during perimenopause. Especially good methods for women in this stage include oral contraceptives and hormonal rings, because they can also reduce menopause symptoms like hot flashes. Another is an intrauterine device, Dr. Thielen says.
What are the treatments for menopause?
One more time, with feeling! Perimenopause and menopause are natural stages of life, so it’s not menopause you’re treating, but rather any symptoms that bother you.
Sometimes simple fixes are enough. Wear layers that you can shed when the internal heat turns up. Find a relaxing meditation app to play during nighttime wake ups. Seek out cooling bedding. You can also try reducing caffeine, which has been shown to help with hot flashes, according to the Mayo Clinic. And if you’re feeling depressed or anxious, talk to your doctor about it; the NAMS depression guidelines call for using psychotherapy and/or antidepressants as first-line therapy.
The most widely used and most effective treatment for many perimenopause and menopause symptoms for most women is hormones, says Dr. Santoro. While it’s not for everybody, hormone therapy (HT) got an undeserved black eye after a big study, the Women’s Health Initiative, found in 2002 that postmenopausal women taking a combination of estrogen and progestin hormone therapy for many years had an increased risk of breast cancer, heart disease, and strokes. Many perimenopausal women began shunning the treatment, even though the findings did not pertain to them; perimenopausal women generally take hormones for a shorter period of time , and what’s more, experts who’ve looked at that study in the years since say it also doesn’t mean all postmenopausal women face these risks.
If you’re unsure if HT will help you, says Dr. Santoro, talk to your doctor about starting a three-month trial course, either pills or patches (assuming you have no medical contraindications). If the treatment is helping by the end of that time, you can continue, she advises. If it isn’t helping, simply stop. If you’re perimenopausal and may still get pregnant, you may prefer hormonal birth control over HT, Dr. Faubion says. Because birth control pills need to prevent pregnancy, they offer a much stronger dose of hormones than HT does.
And what about all those supplements marketed for menopause symptoms that you see in drugstores and health food shops? They often contain ingredients like evening primrose oil or omega-3 oils. Alas, large, well-constructed clinical trials have not found these supplements to be effective, Dr. Santoro says. There is some evidence that black cohosh may help some women, though the studies have been mixed – and because the supplement can interact with certain prescription meds, it’s important to consult your doctor before taking it. (Also, with any supplements, keep in mind that the supplement industry isn’t well-regulated by the FDA.)
Can menopause cause any other health problems?
Once you have passed through menopause, you no longer have the protective effects of estrogen. This can lead to a number of health issues you may not have had to think about before. They include:
- Heart disease. Postmenopausal women are much more vulnerable to heart disease and stroke than premenopausal women. That’s because estrogen protects the heart in a woman’s younger years. During perimenopause, women also experience higher risks for rising cholesterol levels, thickening arteries and others, according to a scientific statement published by the American Heart Association in 2020. The AHA stresses that women should see their doctor while still in perimenopause to be treated for other heart-disease risks, like high blood pressure or high cholesterol, to better prevent later problems.
- Another reason heart issues increase during menopause is due to the body changes many women experience. When women (and men) gain weight as they get older, much of that fat accumulates in the abdomen, which is riskier for your heart than fat around the butt and thighs. “If you look at women across the menopause transition, there really isn’t a change on the scale, but there is change in body composition and where we have fat,” says Dr. Faubion.
- Urinary incontinence. Some 16 to 18% of women complain of urinary incontinence after menopause, especially stress incontinence (when you pee during exercise or laughing). This happens because the tissues of the bladder and urinary tubes lose tone once estrogen declines.
- Osteoporosis. This weakening of bones, to the point where they can easily break, affects both women and men and is linked to aging more than to menopause. But according to the National Institutes of Aging, bone loss occurs most quickly in women the first few years after menopause.
- All these changes that happen during and after the menopause transition make it especially crucial that you take extra care of your health during this time, doing the things that generally priority wellness: eating a healthy diet, staying physically active and reducing stress as much as possible.
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How can you find a menopause doctor?
Gynecologists and gynecological nurse practitioners are the healthcare pros who tend to know the most about changes during the menopausal transition. Not all of them specialize in this stage of life, however; some deal more with the reproductive years. To find a healthcare practitioner with a specific focus on menopause, check out NAMS’ directory .
A growing number of menopause-focused healthcare practitioners now offer their services by telehealth. The website Midi, for example, lets you see experts specializing in midlife women’s health from your living room couch (PJs perfectly acceptable) and is covered by many insurance plans.
Is menopause support available online?
Some women find it valuable to share concerns and get tips online from other women going through the same experience. Facebook groups for women in perimenopause include the Menopause Support Group, Early Menopause and Perimenopause Support (for women hitting this stage before the national average) and Menopausing So Hard (for those finding their symptoms more challenging).
Online sources of in-depth, quality information about menopause include the North American Menopause Society, the National Institute of Aging and the American College of Obstetricians and Gynecologists.
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