Menopause and Perimenopause, Symptoms, Age, Treatment

Understanding Menopause and Perimenopause, Symptoms, Age, Treatment

Menopause is a natural phase in a woman’s life when she stops having periods and can no longer conceive. This natural process occurs due to the decline in ovarian follicular function. Its clinical manifestations often include hot flushes, night sweats, disrupted sleep patterns, and genitourinary syndrome of menopause.

Diagnosing menopause primarily relies on clinical evaluation, specifically the absence of menses for 12 consecutive months. Typically, blood tests are unnecessary for confirmation. During the years leading up to and immediately following menopause, estrogen levels undergo significant fluctuations, resulting in irregular periods and the onset of symptoms such as hot flushes.

Throughout a woman’s reproductive years, menstrual cycles typically occur in approximately monthly intervals, with ovulation taking place in the middle of the cycle, around two weeks after the onset of the previous period. For this cycle to function regularly, the ovaries must produce adequate levels of the hormones estrogen and progesterone.

When Does Menopause Start ?

Menopause unfolds as women age, marking the gradual cessation of estrogen and progesterone production by the ovaries. In the years preceding menopause, estrogen and progesterone production starts to wane, leading to less frequent menstrual periods and ovulation. Ultimately, menstrual periods and ovulation cease entirely, and natural pregnancy becomes impossible. The conclusive identification of a woman’s final menstrual period can only occur retrospectively, after she has experienced a full year without any periods.

The average age at which menopause occurs is around 51. Nevertheless, it can be considered normal for women to experience menopause anywhere from the age of 45 (or even 40) to 55 or older. When menopause transpires before the age of 40, it is referred to as premature menopause, also known as premature ovarian failure or primary ovarian insufficiency.

Menopause Stages

The aging process of the female reproductive system, both before and after menopause, can be categorized into three stages:Menopause and Perimenopause, stages Age

  1. Perimenopause or “Menopause Transition”: Perimenopause typically begins eight to ten years prior to menopause when the ovaries gradually produce reduced amounts of estrogen. It commonly initiates in a woman’s 40s and persists until menopause, which is marked by the cessation of egg release from the ovaries. In the final one to two years of perimenopause, estrogen levels decline more rapidly, leading to the onset of menopausal symptoms. It’s crucial to note that menstrual cycles still occur during this stage, and pregnancy remains possible.
  2. Menopause. Menopause is defined as the moment when a woman no longer experiences menstrual periods. During this phase, the ovaries halt the release of eggs and significantly decrease estrogen production. Healthcare providers diagnose menopause when a woman has gone an entire year without a menstrual period.
  3. Post menopause. denotes the period following a full year without a menstrual period (or the remainder of a woman’s life after menopause). Although some menopausal symptoms, such as hot flushes, may improve during this phase, certain individuals continue to experience these symptoms for a decade or more after the menopause transition. Due to reduced estrogen levels, individuals in the postmenopausal stage face an increased risk of various health conditions, including osteoporosis and heart disease.

Menopause Causes

Menopause can result from:

  • Natural Decline in Reproductive Hormones. Natural menopause occurs as a result of the gradual decline in reproductive hormones.
  • Ovary Removal Surgery (Oophorectomy). Surgical removal of the ovaries, known as oophorectomy, leads to immediate menopause. The ovaries play a pivotal role in hormone production, including estrogen and progesterone, which regulate the menstrual cycle. Consequently, surgery of this nature halts menstruation abruptly, giving rise to symptoms such as hot flushes and other typical menopausal signs. These symptoms can be quite intense since hormonal changes manifest abruptly rather than gradually over several years.
  • Hysterectomy (Uterus Removal Surgery). A hysterectomy that leaves the ovaries intact typically does not result in immediate menopause but can expedite its onset by a few years. Despite the cessation of menstrual periods, the ovaries continue to release eggs and produce estrogen and progesterone.
  • Chemotherapy and Radiation Therapy. Certain cancer treatments, such as chemotherapy and radiation therapy, can trigger menopause, leading to symptoms like hot flushes during or immediately following treatment. However, the cessation of menstruation and fertility following chemotherapy isn’t always permanent. Therefore, contraceptive measures may still be advisable. Radiation therapy exclusively affects ovarian function if the treatment is specifically directed at the ovaries. Radiation to other parts of the body, such as breast tissue or the head and neck, does not impact menopause.
  • Primary Ovarian Insufficiency (POI). Approximately 1% of women encounter menopause before reaching the age of 40, referred to as premature menopause. Premature menopause may result from primary ovarian insufficiency, where the ovaries fail to produce adequate levels of reproductive hormones. This insufficiency may stem from genetic factors or autoimmune diseases. In many cases, the cause of premature menopause remains unidentified. For women facing this situation, hormone therapy is often recommended at least until the typical age of natural menopause. This approach is aimed at safeguarding the health of vital organs such as the brain, heart, and bones.

Symptoms of Menopause and Perimenopause

Menopausal and perimenopausal symptoms can vary in intensity, ranging from mild to severe, or may even be absent altogether. These symptoms may persist for a period of 6 months to approximately 10 years, and sometimes, they can extend even longer. It’s worth noting that certain symptoms presumed to be linked to menopause may actually be caused by other underlying medical conditions. If symptoms manifest outside the expected timeframe for menopause or fail to improve with conventional menopause symptom management approaches, it’s advisable for a woman to consult a healthcare professional to explore alternative causes.

Irregular Menstrual Periods. Perimenopause often begins with irregular menstrual periods. Typically, these periods become more frequent and then less so, although any pattern is plausible. Periods may become shorter or longer, lighter or heavier, and they might even cease for several months before resuming a regular pattern. Some women maintain regular periods until the onset of menopause.

Hot Flushes. Hot flushes affect approximately 75 to 85% of women during perimenopause and menopause. They often commence before menstrual periods cease and can persist for an average of nearly 7.5 years or even longer. Research indicates that Black women tend to experience hot flushes more frequently and over a more extended duration compared to Asian, Hispanic, or White women. The precise cause of hot flushes remains unknown, but it may involve the resetting of the brain’s temperature control center, the hypothalamus. This reset can cause women to feel hot even with slight temperature increases. Hot flushes might be linked to hormonal fluctuations. During a hot flash, blood vessels near the skin’s surface dilate, increasing blood flow. This results in flushing, particularly on the head and neck, and women feel warm or hot, often accompanied by profuse perspiration. These episodes, sometimes referred to as hot flushes, can last anywhere from 30 seconds to 5 minutes and may be followed by chills. Night sweats, which are essentially hot flushes occurring at night, are a common occurrence as well.

Additional Symptoms. A variety of other symptoms may emerge during perimenopause and menopause due to hormonal shifts:

  • Breast Tenderness
  • Mood Swings
  • Exacerbation of Menstrual Migraines
  • Depression, Irritability, Anxiety, Nervousness
  • Sleep Disturbances (Including Insomnia)
  • Difficulty Concentrating
  • Headaches
  • Fatigue

Many women experience these symptoms during perimenopause. While these symptoms can be influenced by various factors such as aging or underlying medical conditions, the hormonal fluctuations and estrogen decrease that accompany perimenopause can often exacerbate them. Night sweats, in particular, may disrupt sleep patterns, leading to fatigue, irritability, difficulty concentrating, and mood swings. Although these symptoms may be indirectly related to menopause due to their connection with night sweats, sleep disturbances are prevalent during menopause even in the absence of hot flushes. Various midlife stresses, such as challenges with adolescents, concerns about aging, caregiving responsibilities for aging parents, and shifts in marital dynamics, can also contribute to sleep disruptions. Consequently, the association between fatigue, irritability, concentration difficulties, and mood changes with menopause remains less straightforward.

Symptoms After Menopause

Following menopause, many of the symptoms experienced during perimenopause tend to become less frequent and less intense. Nevertheless, the decline in estrogen levels triggers changes that can persist and have ongoing implications for a woman’s health, potentially increasing the risk of conditions like osteoporosis. Without preventative measures, these changes may worsen over time. The following areas may be affected:

Reproductive Tract. Postmenopausal changes in the reproductive tract include vaginal thinning, dryness, and reduced elasticity, medically referred to as vaginal atrophy. These alterations can lead to discomfort or pain during sexual intercourse. Additionally, various components of female anatomy, including the labia minora, clitoris, uterus, and ovaries, may decrease in size. It’s common for a decrease in sex drive (libido) to accompany aging. While most women can still experience orgasm, some may require more time to reach it or perceive that their orgasms are less intense.

Urinary Tract. The term “genitourinary syndrome of menopause” accurately describes symptoms affecting both the vaginal and urinary tracts, resulting from menopause. These symptoms encompass vaginal dryness, painful sexual intercourse, urinary urgency, and urinary tract infections (UTIs). The lining of the urethra becomes thinner, and the urethra itself shortens. These changes can make it easier for microorganisms to enter the body, potentially leading to more frequent UTIs. Women with UTIs may experience a burning sensation during urination. Postmenopausal women may also encounter episodes of sudden, urgent urination, occasionally resulting in urge urinary incontinence, which involves the inadvertent leakage of small or larger amounts of urine. Age-related urinary incontinence becomes more common and severe, though it’s uncertain to what extent menopause contributes to this issue. Various factors, including the effects of childbirth, obesity, and hormone therapy usage, can play a role in urinary incontinence.

Skin. Estrogen reduction, combined with the natural aging process, leads to a decrease in collagen (a protein that fortifies skin) and elastin (a protein that confers elasticity to the skin). Consequently, the skin may become thinner, drier, less elastic, and more susceptible to injury.

Bone. The decline in estrogen levels often results in reduced bone density and, in some cases, osteoporosis. Estrogen plays a vital role in maintaining bone health, so its decrease can lead to weaker, less dense bones, making fractures more likely. Bone density experiences rapid decline during the initial 5 years of post-menopause, followed by a subsequent rate of decrease similar to that seen in men (approximately 1 to 3% annually).

Cholesterol (Lipid) Levels. After menopause, women typically see an increase in low-density lipoprotein (LDL) cholesterol, commonly known as “unhealthy” cholesterol. Conversely, high-density lipoprotein (HDL) cholesterol levels, often referred to as “good” cholesterol, remain relatively consistent compared to pre-menopausal levels. The shift in LDL levels may partially explain the increased prevalence of atherosclerosis and coronary artery disease among women post-menopause. However, whether these changes stem from the aging process or the estrogen reduction following menopause remains unclear. Estrogen’s high levels leading up to menopause may offer some protection against coronary artery disease.

Diagnosing Menopause

Menopause is typically diagnosed based on the recent pattern of menstrual periods and, in rare cases, through blood tests to measure hormone levels. In the majority of women, a diagnosis of menopause can be confidently established when they have experienced a full year without any menstrual periods. Consequently, laboratory tests are often considered unnecessary.

The timing of menopause cessation is categorized by age as follows:

  • Premature Menopause. Occurring at 39 years old or younger.
  • Early Menopause. Developing between the ages of 40 and 45.
  • Menopause (Usual Age Range). Taking place at 46 years old or older.

In instances where menopause transpires before the age of 45 or when the menstrual pattern is ambiguous (e.g., periods cease for several months but then resume), medical tests may be conducted to investigate potential underlying conditions that could disrupt menstrual cycles. Should blood tests become necessary to confirm menopause, these evaluations will focus on measuring the levels of follicle-stimulating hormone (FSH), a hormone that stimulates the ovaries to produce estrogen and progesterone.

Occasionally, physicians may perform a pelvic examination to assess the presence of typical changes in the vagina, which can serve as supporting evidence for a menopause diagnosis. These examinations may also be included in the evaluation process for women experiencing discomforting symptoms like vaginal dryness or pain during sexual intercourse.

Menopause Treatment Options

Menopause and its associated symptoms can be managed through a variety of approaches, including nonhormonal treatments, hormone therapy, lifestyle adjustments, and even complementary therapies. Here are some considerations for addressing the challenges of menopause:

  1. Cognitive-Behavioral Therapy and Clinical Hypnosis. Cognitive-behavioral therapy techniques and clinical hypnosis can be valuable tools in managing menopausal symptoms like hot flushes and night sweats.
  2. Nonhormonal Medications. Several nonhormonal medications can offer relief from menopausal symptoms. These include specific antidepressants like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), neurokinin receptor antagonists, the overactive bladder medication oxybutynin, and the antiseizure medication gabapentin.
  3. Hormone Therapy. In cases where nonhormonal treatments do not provide adequate relief, hormone therapy may be considered. This therapy typically involves the use of estrogen, progestogen, or a combination of both. It aims to alleviate symptoms such as hot flushes, mood changes, sleep disturbances, and vaginal dryness. However, it’s important to weigh the potential benefits against the risks and consult with a healthcare provider to determine the most suitable approach.
  4. General Measures and Lifestyle Adjustments. Several lifestyle changes can help manage menopausal symptoms. These include:
    • Utilizing cooling methods like fans and wearing lightweight clothing to combat hot flushes.
    • Avoiding triggers like alcohol or spicy foods that may exacerbate symptoms.
    • Dietary modifications for symptom relief.
    • Ensuring sufficient sleep by reducing caffeine intake and limiting alcohol consumption before bedtime.
    • Regular exercise during the day (avoid intense workouts right before bedtime).
    • Practicing relaxation techniques such as deep breathing, guided imagery, and progressive muscle relaxation.
    • Exploring mindfulness, exercise, or yoga for improved sleep and overall well-being.
    • Adhering to a bladder-friendly diet (avoiding caffeine-containing beverages, spicy, or salty foods).
    • Engaging in Kegel exercises to improve bladder control.
    • Using over-the-counter vaginal lubricants or moisturizers to address vaginal dryness.
    • Staying sexually active to promote blood flow to the genital area and maintain tissue flexibility.
    • Maintaining a balanced diet rich in fruits, vegetables, and whole grains while limiting saturated fats, oils, and sugars.
    • Avoiding smoking, which poses multiple health risks and may exacerbate menopausal symptoms, including hot flushes.
  5. Nonhormonal Medications. Certain FDA-approved medications like paroxetine salt (an antidepressant) and fezolinetant (a neurokinin receptor antagonist) are effective in alleviating hot flushes. Additionally, other antidepressants, such as desvenlafaxine, fluoxetine, sertraline, or venlafaxine, and oxybutynin (used to treat overactive bladder) may provide some relief. Gabapentin, often prescribed for epilepsy and chronic pain, can also help with certain menopausal symptoms, particularly hot flushes. However, it’s important to note that hormone therapy is generally more effective than these medications.
  6. Herbal or Dietary Supplements. Some women turn to herbal and dietary supplements like soy products, soy metabolite equol, black cohosh, dong quai, evening primrose, ginseng, and cannabinoids to manage symptoms. However, research results on the effectiveness of these supplements have been mixed, and many menopause experts do not recommend them due to a lack of consistent evidence and regulation.
  7. Bioidentical Hormones. Bioidentical hormones, derived from plant sources such as yams and soy, are similar in molecular structure to hormones naturally produced by the body. While some women may opt for compounded bioidentical hormones, it’s important to exercise caution, as these products lack standardization and rigorous regulation. They should be discussed with a healthcare professional.

When considering any treatment approach for menopause, it’s essential to consult with a healthcare provider to determine the most appropriate and safe options tailored to individual needs and health considerations.

Hormone Therapy for Menopause

Hormone therapy is a viable option for addressing moderate to severe menopausal symptoms like hot flushes, night sweats, and vaginal dryness. Additionally, for some women, it can help prevent or manage osteoporosis. However, it’s essential to recognize that hormone therapy carries certain risks.

Benefits of Hormone Therapy

  • Improved quality of life by relieving menopausal symptoms.
  • Potential prevention or treatment of osteoporosis.

Decision-Making Considerations

  • Hormone therapy is recommended primarily for women experiencing bothersome menopausal symptoms, such as hot flushes, vaginal dryness, or recurrent urinary tract infections.
  • It is most likely to be beneficial for women under the age of 60 or those diagnosed with menopause within the last 10 years.
  • The decision to pursue hormone therapy should be made in consultation with a healthcare provider, considering the individual’s specific circumstances.
  • Women should discuss both the advantages and disadvantages of hormone therapy with their doctor before initiating treatment.
  • For many women, the risks associated with hormone therapy outweigh the potential benefits, leading to non-recommendation.

Dosage and Types

  • Hormone therapy aims to use the lowest effective dose to manage symptoms for the shortest duration necessary.
  • Treatment typically includes estrogen, progestogen (such as progesterone or medroxyprogesterone acetate), or a combination of both.
  • For general menopausal symptoms, such as hot flushes and mood changes, oral estrogen and progestogen are often prescribed for short durations to target the entire body.
  • Vaginal medications may be used when symptoms primarily affect the vaginal or urinary tract.

Estrogen Alone and Combination Therapy

  • Estrogen alone is typically administered to women who have undergone a hysterectomy to prevent endometrial cancer, as taking estrogen without a progestogen can increase this risk.
  • Very low-dose vaginal estrogen therapy (used for genitourinary syndrome of menopause) may be given without a progestogen.
  • Estrogen along with a progestogen should be given to women with the uterus intact in order to protect from endometrial cancer.

Osteoporosis Considerations

  • Women at risk of osteoporosis with bone loss or fractures may receive hormone therapy if they are under 60 years old, were diagnosed with menopause fewer than 10 years ago, and cannot take alternative medications like bisphosphonates.
  • Hormone therapy can help reduce bone loss and fracture risk in this group.

Risks of Hormone Therapy

  • Hormone therapy carries certain risks, including:
    • Increased risk of breast cancer.
    • Elevated risk of stroke.
    • Higher likelihood of blood clots in the legs and lungs (deep vein thrombosis and pulmonary embolism).
    • Potential gallbladder disorders, such as gallstones.
    • Coronary artery disease risk, particularly in women starting therapy after age 65.

Risk Mitigation

  • Lower doses of estrogen may reduce risks associated with hormone therapy.
  • Vaginal forms of estrogen are generally administered at lower doses than oral pills or skin patches.
  • Transdermal estrogen or vaginal rings may offer lower risk of blood clots, stroke, and gallbladder disorders compared to oral estrogen.
  • Women with specific medical conditions or risk factors should avoid estrogen therapy, including those with a history of breast cancer, coronary artery disease, blood clots, stroke, or who are at risk for these conditions.
  • High doses of estrogen and progestogens may lead to side effects such as nausea, breast tenderness, headaches, fluid retention, and mood changes.

Routes and Formulations of Hormone Replacement Therapy (HRT)

  • Estrogen and/or progestogen can be administered through various means, including oral tablets, topical lotions, sprays, gels, skin patches, intrauterine devices, and vaginal creams, tablets, rings, or suppositories.
  • Selective estrogen receptor modulators (SERMs) may be used to treat osteoporosis and relieve vaginal dryness, albeit with potential temporary worsening of hot flushes.
  • Dehydroepiandrosterone (DHEA), available as a suppository, can alleviate vaginal dryness and related discomfort during intercourse.

It’s crucial for women considering hormone therapy to engage in open discussions with their healthcare providers to make informed decisions based on their unique health circumstances and preferences.


Dr Sobia Mohyuddin

MCPS, FCPS, MRCOG, Consultant Obstetrics & Gynaecology

Doctor Sobia Mohyuddin is a highly skilled and experienced Obstetrician and Gynecologist, with 25 years of training and experience in renowned, large institutions. She holds the position of Associate Professor and Fellow at the College of Physicians and Surgeons Pakistan. She is also a member of the Royal College of Obstetricians and Gynecologists (UK).