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What Are Menopause and Perimenopause?

Causes, symptoms, treatments, and support

With Stephanie Faubion MD, Monica Christmas MD, and Samar R. El Khoudary MD

It happens to every human with ovaries—an unavoidable life stage for half the population—yet menopause and perimenopause remain perplexingly shrouded in mystery. We’re here to empower you with clear answers to all your pressing Qs.

Definition Causes | Symptoms | Treatments | Sleep | Hot Flashes  | Hormone Therapy |  Bioidentical Hormones | Complications | Support Fast Facts | Timeline

What is menopause?

Technically, menopause lasts only a day, and marks the point at which you have gone 12 consecutive months without a period. The phase leading up to this is called perimenopause, and it typically lasts 3 to 4 years, though it can take up to 10. After menopause, you are technically postmenopause, but the word menopause is often still used to describe that stage of life as well.

In a perfect world, we’d experience a smooth, steady reduction of estrogen. In reality, most of us go on a wild ride of hormonal fluctuation. Think of a plane landing during extreme turbulence, falling and then rising erratically before finally reaching the ground. This hormonal tempestuousness is what’s behind many of the discomforts and challenges of perimenopause and beyond.

What causes perimenopause and menopause?

Perimenopause refers to the time period leading up to menopause (premenopause) and the time following it (postmenopause). During the years preceding menopause, hormone levels fluctuate and average estrogen levels may even be higher. After menopause, hormone levels gradually decline.

You can still become pregnant during premenopause, even with erratic periods, making contraception important for women who don’t wish to become pregnant.

There is no diagnostic test for perimenopause. What we rely on instead is a set of conditions. They are often referred to as menopause symptoms, but keep in mind that perimenopause and menopause are natural phases of life and not a disease.

We hope this shift in perspective helps you manage the discomforts—which can be intense, alarming, and even debilitating for some people—with greater self-compassion and hope. The list of possible signs of perimenopause is long, and many of these conditions may signal a different health concern on their own, so don’t hesitate to make an appointment with a North American Menopause Society (NAMS) certified medical practitioner (NCMP) if you are experiencing any of these changes.

Perimenopause fast facts

All that being said, perimenopause and menopause symptoms may include:

  • Heavier, longer periods. For some women, one of the earliest signs that you’re entering perimenopause is the last thing you’d expect: heavy bleeding with longer and/or more frequent periods. This could also be a sign of fibroids and other health conditions, so it’s wise to check in with your NCMP about it, especially if you are under 40.
  • Irregular periods. If you’re not using hormone-based birth control, this is one of the clearest signs. Your periods may be farther apart, lighter, or you may skip a month or more. Bear in mind, a missed period could also indicate that you’re pregnant, as you can still get pregnant when you’re in perimenopause and until you have gone a full year without a period. Many other health conditions and medications can also cause missed and irregular periods.
  • Hot flashes and night sweats. These are the most famous hallmarks of the phase. Doctors call them vasomotor symptoms, vaso referring to blood vessels, and motor meaning movement, pointing to the way blood vessels can change size as your hypothalamus tries to regulate your body temperature. During perimenopause, your hypothalamus may start functioning differently, resulting in random moments when your body temperature shoots up suddenly, and you may even go into a full-body sweat. Night sweats are basically the same thing, only they wake you in the middle of the night, often leaving you so irritated, roused, sweaty, and chilled that it becomes difficult to fall back asleep.
  • Sleep disruption. Even if night sweats aren’t a problem, during perimenopause and beyond, you may find it harder to fall asleep. More commonly, people find themselves waking in the night (or too early in the morning) and having a difficult time falling back asleep.
  • Fatigue. This can be a result of your disrupted sleep. However, even people who sleep well at night may find they have less energy throughout the day, or that they need more rest than usual.
  • Irritability, mood swings, and bouts of rage. All three may also be a direct result of disrupted sleep, though a decline in estrogen can cause greater sensitivity to stress. Without the soft cushioning of estrogen, known as the “tend and befriend” hormone, your tolerance for life’s daily onslaughts may wear thin. If that motivates you to set stronger boundaries and/or make some lifestyle changes, that’s not necessarily a bad thing.
  • Depression and other mental health issues. A more serious problem, studies suggest women are at increased risk for depression and anxiety during perimenopause and beyond. Just because this is common doesn’t mean that it’s a part of perimenopause or menopause that you have to just endure. Take any signs of depression or other ways you are not feeling or behaving as you normally would seriously and seek help.
  • Vaginal dryness. This becomes more common the closer you get to menopause, and especially postmenopause. As a result of lower estrogen levels, your body slows down the production of natural lubricants in and around your vagina.
  • Painful sex. Along with the dryness, lower estrogen causes tissues throughout your body to become less pliant. The same goes for your vagina, which typically begins to decrease in size as well. The medical community has unhelpfully termed the combined effects of drying, decreased pliability, and size reduction as vaginal atrophy—just in case you happen to hear that term and feel your heart sink. Your vagina is not dying nor becoming obsolete, and this is another thing you don’t have to live with if you’re not feeling like yourself.
  • Loss of libido. Given all that, is it any wonder that some women’s sexual desire begins to wane? But remember that libido is complex—stress, irritability, increased medications, other health conditions, and issues with your partner can all diminish your lust. It’s a good idea to see a NAMS-certified medical practitioner (NCMP) if you would like help getting your groove back, as the most effective strategy is often a combination of interventions such as lifestyle changes, hormone therapy, other medications, or even couples therapy, as recent research continues to confirm the old idea that it really does take two to tango.

How do I choose the best menopause treatments for my symptoms?

Dealing with sleep issues during menopause

Broadly speaking, there are two different kinds of sleep disturbances, says Dr. Monica Christmas, Assistant Professor of Obstetrics and Gynecology at the University of Chicago Medical School. One is caused by night sweats, in which case, “managing the night sweats will take care of the sleep quality.”

This can be addressed with hormone therapy, as well as some SSRIs (selective serotonin reuptake inhibitors) and other psych meds that have recently been found to reduce vasomotor symptoms such as hot flashes and night sweats, though there are other less medical approaches you can try to make yourself more comfortable as well.

If night sweats are not the only thing causing the changes in your sleep quality, Dr. Christmas highly recommends cognitive behavioral therapy (CBT). “CBT techniques have been shown to be helpful,” she says, noting that even if you don’t have access to a sleep therapist, there are apps and other resources that teach you tricks for better sleep. Mindfulness can be extremely helpful, and that doesn’t have to mean actual meditation, it’s more about learning how to calm and self soothe yourself through a sleepless night.

Tips for getting a better night’s sleep during menopause

  • Banish anything electric that stimulates your brain.
  • Don’t use your phone as an alarm clock or look at it right before bed.
  • Keep your room cool and dark.
  • If you do wake, get up and read a book. “That actually tends to fatigue us again,” Dr. Christmas says.
  • Watch your food and drink triggers before bed. Try reducing how often and how much alcohol you drink at night, in addition to any caffeinated beverages.
  • Do some regular exercise earlier in the day, especially weight-bearing exercise or yoga. We start losing muscle mass and bone mass at this time, and weight-bearing exercises (including walking) have been shown to counteract both as well as reduce vaginal symptoms, as they engage your core and pelvic floor.
  • Proactively manage any anxiety and depression, and seek mental health help if you are not feeling like yourself emotionally.
  • If you are experiencing any other symptoms as well, this kind of sleep disturbance might still be helped with hormone therapy, especially as progesterone aids in sleep.

How to handle hot flashes during menopause

Hormone therapy is the most effective tool. If you can’t take hormone therapy, don’t despair. There are more treatments for vasomotor symptoms than ever before, including the many SSRIs and anti-anxiety meds that have been found to have the welcome bonus of reducing hot flashes, making them a good option if you are having emotional and mental health symptoms along with your physical ones.

That said, many lifestyle interventions will also help, especially in combination, including:

  • Cognitive behavioral therapy (CBT)
  • As with sleep, yoga has been found to relieve hot flashes.
  • Exercise
  • If you are a smoker, one of the most important things you can do for your health is to stop smoking. It’s linked with earlier perimenopause. But, once you’re in perimenopause, stopping can also help minimize the severity of hot flashes during menopause and beyond.
  • You may also want to start limiting alcohol. We all become more sensitive to its effects as we grow older, and the associated health risks rise. Research seems to show that once you’re postmenopause, drinking can trigger hot flashes. Read more about the effects of alcohol during menopause here.

What to do about vaginal symptoms during menopause

For vaginal dryness during sex or that’s bothering you any other time, there are a wide array of lubes and vaginal moisturizers to choose from. Products such as Revaree, Good Clean Love , and Ah Yes! are made without fragrance and tend to be closer to the consistency of natural vaginal secretions – think slippery and liquid as opposed to sticky and viscous.

You can use a vaginal moisturizer the same way you would any other type of moisturizer, daily or as needed, and women tend to have personal preferences toward which one they like the same way they do for facial moisturizer.

If you feel like OTC products just aren’t cutting it, there are also plenty of estrogen creams, gels, suppositories, and even a vaginal ring that slowly releases a low dose of estrogen to choose from. If your menopausal symptoms are mostly around your vagina, localized estrogen, no matter what method you prefer, is one way to take a lower dose of hormone therapy that is only targeting that specific area as opposed to affecting your whole body.

As with birth control and contraceptive hormones, different women tend to have different hormone therapy delivery methods they prefer during menopause, and it may take you some trial and error with the help of your NCMP (NAMS-certified menopause practitioner) to arrive at the method and dose of hormone therapy that feels best for you. Or you may not want to try HT at all, and that’s perfectly fine too.

For over-active bladder (OAB), try giving your pelvic floor some attention

This is a group of muscles supporting your core and abdominal organs. Over time it can become weak or stressed, particularly after childbirth, leading to issues like incontinence that can progress with age. Doing Kegel exercises can help. Now is a good time to see a pelvic floor specialist who can evaluate you and teach you how to do those Kegels effectively. In popular culture, Kegels tend to be discussed as a simple clenching and unclenching, but when done correctly, they are more like slowly pulling an imaginary ball up a long hallway and then slowly releasing it back down. Pilates is also a form of exercise that specifically targets your pelvic floor, so it’s worth giving it a try as you enter perimenopause if you feel like your pelvic floor could use a little TLC.

What is hormone therapy?

Can you take more estrogen and progesterone to return yourself back to “normal?”  Not exactly, but you can get hormone therapy (HT) to help make yourself more comfortable if you have been feeling uncomfortable or irritable and to help lower your risk for diseases like osteoporosis which are linked to less estrogen.

It used to be called hormone replacement therapy, but the name has changed because the goal isn’t to “replace” the estrogen to premenopausal levels, but to provide the minimal amount needed to relieve hot flashes and other menopausal conditions if and when they’re bothering you. Let’s take a look at some of the hormone therapies available today.

Estrogen-progestogen therapy

Most menopausal women who do hormone therapy use a combination of estrogen and progestogen. This is because when taken alone, estrogen can increase your risk for certain types of cancer, which progesterone can help to mitigate.

Estrogen therapy comes in two main types. “Systemic” delivers estrogen throughout your body and can come as a patch you place directly on your skin or as a tablet. “Local” delivers a low dose of estrogen directly to your vagina to address vaginal symptoms and can come as a cream, gel, or an inserted ring.

Progestogen therapy can come in the form of natural progesterone or synthetic progestin, as well as an IUD.

With long term use (more than 5 years), there is an increased risk of breast cancer, blood clots, and stroke. Because of the breast cancer risk, many doctors do not recommend estrogen-progestogen therapy for women with a family history of breast cancer (they occasionally prescribe progestogen-only, which can provide some relief for hot flashes and sleep issues). This is also why the menopause mantra for HT that you will hear repeatedly is to take the lowest dose for the shortest time that is effective to treat your symptoms.

If you are not eligible for hormone therapy, don’t despair. There are more non-hormonal menopause treatments than ever before, including SSRIs, anti-anxiety meds, steroids, and other medications that have recently been found to also relieve menopausal symptoms, so make sure to check with your NCMP to find the solution that’s best for you, no matter what your reasons are for being unable to try hormone therapy.

How do you decide if hormone therapy is right for you?

It depends on what your goals are. Here are a few questions to consider.

What are you trying to treat? If you want to relieve hot flashes, night sweats and related sleep disturbances, manage mood swings, reduce urinary incontinence; and prevent bone loss, HT can help.

How intense are those symptoms? How much do they disrupt your life?

Are there any contraindications? For example, do you have undiagnosed vaginal bleeding, breast or uterine cancer, a history of blood clots, heart attack, or stroke risk?

What is your age and how far past menopause (if at all) are you? The risks and outcomes look better for people who start HT under the age of 60 and as soon as possible in relation to when they first enter menopause. (Beyond that, the risk for heart disease, stroke, and dementia rise.) This is why the recommendation is to start HT at the first signs of bothersome menopause symptoms at the lowest dose for the shortest possible time.

Hormone therapy delivers major relief for a lot of people, and for many, it is by far the most effective menopause treatment. But its intended purpose isn’t to turn back time and return you back to “normal,” whatever that means.

The menopause train has left the station and you are on this ride no matter what. HT is not going to make everything all better either. For best results with HT, getting your lifestyle on the right track (nutrition, movement, sleep habits, mental health) will drastically help improve its efficacy.

How safe is hormone therapy?

Women enjoyed the benefits of HT from the 1970s until 2002, when the bottom fell out. That’s the year the Women’s Health Initiative (WHI) trial released its findings. The study focused on 16,600 American women aged 50-79. Half of those women were randomly selected to take oral estrogen combined with progesterone HT for 5 years and the other half took a placebo.

The trial found that the women on HT were at increased risk for breast cancer, heart disease, stroke, blood clots, and urinary incontinence. Alarmed by media reports, doctors stopped prescribing HT and women stopped asking for it. As a result, the prevalence of use dropped from 19% in 2000 to 4.9% by 2009.

However, further analysis of the study later found nuances that had been lost in the initial report. Namely, HT was actually health-protective for women under 60 (a third of the women in the study), while it was the women who started HT after 70 who faced greater health risks than benefits.

Also, the study looked at one combined dose only, a dose considered appropriate for women over 60 but too high for women in their 70s, and higher than the dose most women use today. We know now that if you start at the lowest dose earlier instead of a high dose later, risks decrease, and health-protective effects increase.

What are bioidentical and compounded hormones?

Partly in response to the WHI report, women turned to “bioidentical” hormones. These are hormones that are often touted as chemically identical to the ones the human body produces. Surprise! The hormones typically used in most traditional, FDA-approved HT are not.

However, there are no peer-reviewed studies that show that bioidentical and compounded hormones are any safer or more effective than HT. In fact, studies have shown that the amounts of hormones in them can be wildly unreliable, unlike FDA-approved hormones, which are regulated. When hormones doses are too high, they can cause health issues like blood clots and increased risk. When they are too low, they are a waste of money. More reasons to only use FDA-approved HT under the care of you doctor:

The FDA does not recognize the term “bioidentical” as a real thing. It is more of a marketing term to sell products than anything else.

The FDA has approved some products that happen to be chemically identical to human-made hormones, so if that is important to you, you can still find that type of hormones with the help of your NAMS-certified medical practitioner (NCMP). Keep in mind that these products will not be labeled as “bioidentical,” because the scientific and medical community does not recognize it as a valid word or medical term.

Bioidenticals are often sold as compounded hormones (cBHT). They are marketed as customized according to your unique hormonal profile. This entails taking a hormonal diagnostic test from which your compound is formulated. You can see the appeal. Who wouldn’t want a hormone treatment tailored just for you? As a result:

  • An estimated 2.5 million US women use cBHT
  • Of the 9% of American women taking HT, a third of them are using cBHT
  • Among women ages 40-44, cBHT use is equal to FDA-approved HT

As ideal as this kind of bioidentical hormone replacement therapy sounds, there are even more reasons to avoid it. One is with the related diagnostic tests: they are not standardized, and they lack independent quality control measures. We also don’t have data showing the ideal hormone levels that would effectively relieve hot flashes or vaginal dryness.

“None of it is based on science,” says Dr. Stephanie Faubion, Medical Director of the North American Menopause Society and Director of the Mayo Clinic Center for Women’s Health. “The idea of customizing hormones for any one woman based on levels is a myth.”

What’s more, the dosing isn’t uniform, the manufacturing standards and oversight are inconsistent, and there’s a potential for contamination and impurities in addition to dangerously varying amounts of hormones. You know that printed material you get with prescriptions outlining all the risks? Even the lowest doses of FDA-approved HT include them, but they’re not included in cBHT products, giving users a false sense of security (the risks are at least the same, if not greater). Surveys show that 10-50% of users assume their cBHT is FDA-approved, and 76% are uncertain, but it is not. Users also assume that these products have lower dosages than prescription HT, while they have been proven time and again to have higher dosages.

Additionally, compounding pharmacies are different from prescription pharmacies. Because the compounds are sold as supplements, not pharmaceuticals, they’re not regulated, and are therefore much riskier. Because every compound is different, there’s no standardization, making users vulnerable to accidental overdose, underdose, and contamination.

In July 2020, a report from the National Academies of Sciences, Engineering, and Medicine recommended that compounded products be restricted to patients who:

  • are allergic to FDA-approved HT products
  • require a dosage level not available in an FDA-approved product.

But that’s a recommendation, not a mandate, so they are still out there.

What happens postmenopause?

Relief is in sight. Once you reach that critical point—12 months without a period—you have reached menopause. There isn’t one specific menopause age, but the average age for reaching menopause is 51.

Everything after that is technically postmenopause (although it is referred to as menopause all the time), and it’s typically a time when your hormone levels stabilize. This is also the point in which women consistently report the greatest life satisfaction, even over their younger years.

Once you’re postmenopause, your hormone composition is similar to what it was before puberty. You have returned to:

  • Low estrogen and progesterone levels, though you are still producing a kind of estrogen called estrone (E1).
  • Testosterone declines gradually with age regardless of gender, but those levels are higher than those for estrogen and progesterone.
  • FSH and LH levels are now significantly higher than testosterone.
  • Your adrenals take over the work your sex hormones used to do, so it’s more important than ever to avoid burnout.
  • While most women report feeling better overall postmenopause, you may continue having hot flashes into your 70s.
  • Vaginal dryness and pain during intercourse becomes more of an issue, but most people have also figured out their preferred treatments and ways to mitigate these symptoms by this time.
  • You should not have any vaginal bleeding at this point if you are no longer on HT (which can cause bleeding in some women). If you do, contact your doctor immediately, as it can be a sign of other medical conditions.

What are the more serious complications of menopause?

Early menopause and premature menopause

Menopause is considered “early” if it happens between 41 and 45, and “premature” if it happens before the age of 40. This can occur for several reasons, including:

  • Premature ovarian failure, which is when your ovaries stop producing eggs before the age of 40. This can be caused by a genetic anomaly, autoimmune diseases like lupus, and other hormonal insufficiencies and medical conditions, such as hyperthyroidism and hypothyroidism.
  • Damage to your ovaries caused by cancer treatments such as chemotherapy or radiation, as well as treatments for other conditions that involve chemotherapy or radiation
  • Hysterectomy and bilateral oophorectomy, when both ovaries are removed, usually because of an issue like cancer or endometriosis
  • Primary ovarian insufficiency, which is when your ovaries don’t produce the normal amount of estrogen or don’t release eggs regularly before age 40. You may still get periods (just infrequently), and you can still get pregnant and receive fertility treatment.
  • Premature ovarian failure is not reversible. However, pregnancy may still be possible through IVF. Unlike premature ovarian failure, primary ovarian insufficiency is treatable with estrogen.

Menopause and increased risk of cardiovascular disease

Once you complete your transition to menopause, a lot of things get easier, but unfortunately you are now at much higher risk for heart disease. To be clear, menopause does not cause cardiovascular disease. However, says Dr. Samar El Khoudary, PhD, MPH, Associate Professor of Epidemiology at the University of Pittsburgh Graduate School of Public Health, women seem to become more vulnerable to cardiovascular disease because of multiple changes that accompany menopause and aging, which are basically the same thing. That’s one reason the verdict is still out on what makes heart disease risk increase as women get older and further into postmenopause, including how much the change is caused by hormonal fluctuations versus old age.

Lower levels of estrogen were long believed to be the main reason for this higher risk (among other things, tissues throughout the body become less supple). And so, there was an assumption that hormone therapy could reverse this. “You would think that once you give a woman this magic, it will flip things for her, but that’s never been the case. In fact, hormone therapy in women over 60 may actually increase the risk for cardiovascular disease. The process is quite complex, and it’s really a multifactorial process that we are still unraveling,” says Dr. El Khoudary, who specializes in this area of research.

Factors that make postmenopausal and aging women at higher risk for cardiovascular disease

High LDL cholesterol (the bad kind)

  • Thickness of carotid intima-media (the inner two layers of your carotid artery)
  • Signs of metabolic syndrome (elevated blood pressure and blood sugar, excess abdominal fat, and abnormal cholesterol and triglyceride levels)
  • The volume of fat around your heart, a risk factor newly linked with postmenopause

All of that said, Dr. El Khoudary points out that all the research on how estrogen therapy affects cardiovascular health has focused on postmenopausal women over 60 using one specific higher dose formulation of estrogen. Subsequent studies have shown that different formulations (e.g. oral vs. vaginal) and lower doses may have different effects and pose less risk.

Additionally, researchers are working on the theory that hormone therapy could be heart protective for women under 60 or within 10 years of the menopause transition (which is when we are more likely to use it to manage hot flashes, etc.). So, the timing and dosage of hormone therapy appears to be very important, though we still have much to learn. “We still need to conduct clinical trials on women in their 40s and 50s,” Dr. El Khoudary says.

A few other health issues to keep an eye on in menopause

  • Bone health: Check your vitamin D levels and get a DEXA scan
  • You’re losing muscle mass faster than ever: This is called sarcopenia. It’s never too late to start weight-bearing exercise, and it’s not as hard as it may seem. For example, walking regularly and getting your steps in is a weight-bearing exercise.
  • Cognitive health: your risk for Alzheimer's and dementia increases postmenopause and with age, so be aware of the early signs.

Where can I find support during perimenopause and menopause?

Join or form a community. Isolation can make menopause feel worse. 60 million people in the United States are currently in menopause, so you are definitely not alone, even though it may feel like it. If you don’t already have a network of friends going through it, find a community online (there are so many different Facebook groups to choose from!), or start one of your own.

Build a support team. How much does your GP or gynecologist know about all these aspects of menopause? Do you have a therapist who gets it? Make sure you are getting your needs met, even if it’s from a nurse practitioner who is NAMS-certified.

Perimenopause timeline

Timeline: Menopause Moments

  • 1800 Humans begin living past the age of menopause
  • 1821 Dr. Charles Negrier, a French physician, creates the term “la ménépausie
  • 1938 Synthetic estrogen is created
  • 1970s Doctors begin prescribing hormone therapy
  • 1994 The first transdermal estrogen patch is launched, enabling women to take a lower dose of the hormone than for oral medication
  • 2001 Dr. Christiane Northrop publishes The Wisdom of Menopause, the first major handbook on the topic for women
  • 2002 Women’s Health Initiative trial raises alarms over hormone therapy
  • 2014 Sandra Tsing Loh publishes her menopause memoir Madwoman in the Volvo: My Year of Raging Hormones
  • 2016 Genneve, a femtech startup, launches and eventually becomes the first company offering telehealth services specifically for menopause
  • 2017 North American Menopause Society releases a statement on the safety of HT, so long as it begins under the age of 60 and within 10 years of menopause
  • 2019 The FX series Better Things features a main character going through perimenopause
  • 2019 Darcey Steinke publishes Flash Count Diary: Menopause and the Vindication of Natural Life

Menopause Fast Facts

  • 60 million women in the US are in menopause
  • There is no diagnostic test for perimenopause
  • Most medical schools spend zero hours on menopause
  • You can get pregnant until you’ve gone a full year without a period
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