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Menopause

By

JoAnn V. Pinkerton

, MD, University of Virginia Health System

Last full review/revision Dec 2019| Content last modified Dec 2019
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Menopause is the permanent end of menstrual periods and thus of fertility.

  • For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular, and symptoms (such as hot flashes) may occur.

  • After menopause, bone density decreases.

  • Menopause is diagnosed when a woman has not had a period for 1 year, but blood tests may be done to confirm it.

  • Certain measures, including hormone therapy and other drugs, can lessen symptoms.

During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the ovary (ovulation) about 2 weeks after the first day of a period. For this cycle to occur regularly, the ovaries must produce enough of the hormones estrogen and progesterone.

Menopause occurs because as women age, the ovaries stop producing estrogen and progesterone. During the years before menopause, production of estrogen and progesterone begins to fluctuate, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and ovulation end permanently, and pregnancy can no longer occur naturally. A woman’s last period can be identified only later, after she has had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed since their last menstrual period.)

Perimenopause refers to the several years before and the 1 year after the last menstrual period. How many years of perimenopause precede the last menstrual period varies greatly. During perimenopause, estrogen and progesterone levels fluctuate widely. These fluctuations are thought to cause the menopausal symptoms experienced by many women in their 40s.

The menopausal transition is the part of perimenopause that leads up to the last menstrual period. It is characterized by changes in the pattern of menstrual periods. The menopausal transition lasts from 4 to 8 years. It lasts longer in women who smoke and in women who were younger when it began.

Postmenopause refers to the time after the last menstrual period.

In the United States, the average age for menopause is about 52. However, menopause may occur normally in women aged 45 (or even 40) to age 55 or older. Menopause may start at a younger age in women who

  • Smoke

  • Live at a high altitude

  • Are malnourished

Menopause is considered premature when it occurs before age 40. Premature menopause is also called premature ovarian failure or primary ovarian insufficiency.

Did You Know...

  • Symptoms of menopause can start years before menstrual periods end.

  • The average age for menopause is about 52, but anywhere between age 40 to 55 or older is considered normal.

Symptoms

Perimenopause symptoms

During perimenopause, symptoms may be nonexistent, mild, moderate, or severe. Symptoms may last from 6 months to about 10 years, sometimes longer.

Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often, but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become regular again. In some women, periods occur regularly until menopause.

Hot flashes affect 75 to 85% of women. They usually begin before periods stop. They last for an average of almost 7 1/2 years but can last more than 10 years. Usually, hot flashes become milder and occur less frequently as time passes.

What causes hot flashes is unknown. But it may involve a resetting of the brain's thermostat (the hypothalamus), which controls body temperature. As a result, very small increases in temperature can make women feel hot. Hot flashes may be related to fluctuations in hormone levels. There is no convincing evidence that alcoholic beverages trigger hot flashes.

During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing the skin, especially on the head and neck, to become red and warm (flushed). Women feel warm or hot, and perspiration may be profuse. Hot flashes are sometimes called hot flushes because the face can become red.

A hot flash lasts from 30 seconds to 5 minutes and may be followed by chills. Night sweats are hot flashes that occur at night.

Other symptoms may occur around the time of menopause. The changes in hormone levels that occur at this time may contribute to the following:

  • Breast tenderness

  • Moodiness

  • Worsening of migraines that occur just before, during, or just after menstrual periods (menstrual migraines)

Depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue may also occur. Many women experience these symptoms during perimenopause and assume that menopause is the cause. However, evidence supporting a connection between menopause and these symptoms is mixed. These symptoms are not directly related to the decreases in estrogen levels that occur with menopause. And many other factors (such as aging itself or a disorder) could explain the symptoms.

Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship between fatigue, irritability, loss of concentration, and mood changes seems less clear.

Symptoms after menopause

Many of the symptoms that occur during perimenopause, although disturbing, become less frequent and less intense after menopause. However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, increasing the risk of osteoporosis). These changes may worsen, unless measures to prevent them are taken. The following may be affected:

  • Reproductive tract: The lining of the vagina becomes thinner, drier, and less elastic (a condition called vaginal atrophy or sometimes inappropriately called atrophic vaginitis). These changes may make sexual intercourse painful. Other sex organs—the labia minora, clitoris, uterus, and ovaries—decrease in size. Sex drive (libido) commonly decreases with age. Most women can still have an orgasm, but some require more time to reach orgasm.

  • Urinary tract: The lining of the urethra becomes thinner, and the urethra becomes shorter. Because of these changes, microorganisms can enter the body more easily, and some women develop urinary tract infections more easily. A woman with a urinary tract infection may feel a burning sensation when she urinates. After menopause, the need to urinate may suddenly become compelling (called urinary urgency), sometimes resulting in urinary incontinence—the unintended passage of urine. Urinary incontinence becomes more common and severe with age. However, how much menopause contributes to incontinence is unclear. Many other factors, such as the effects of childbirth, obesity, and the use of hormone therapy, contribute to incontinence.

  • Skin: The decrease in estrogen, as well as aging itself, causes a decrease in the amount of collagen (a protein that makes skin strong) and elastin (a protein that makes skin elastic). Thus, the skin may become thinner, drier, less elastic, and more vulnerable to injury.

  • Bone: The decrease in estrogen often leads to a decrease in bone density and sometimes to osteoporosis because estrogen helps maintain bone. Bone becomes less dense and weaker, making fractures more likely. During the first 5 years after menopause, bone density decreases rapidly. After that, it decreases at about the same rate as it does in men (by about 1 to 3% each year).

  • Fat (lipid) levels: After menopause, levels of low-density lipoprotein (LDL—the bad) cholesterol, increase in women. Levels of high-density lipoprotein (HDL—the good) cholesterol remain about the same as before menopause. The change in LDL levels may partly explain why atherosclerosis and thus coronary artery disease become more common among women after menopause. However, whether these changes result from aging or from the decrease in estrogen levels after menopause is unclear. Until menopause, the high estrogen levels may protect against coronary artery disease.

Genitourinary syndrome of menopause is a new, more accurate term used to refer to symptoms that affect the vagina and urinary tract and that are caused by menopause. These symptoms include vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections.

Did You Know...

  • Genitourinary syndrome of menopause is a new term used to refer to symptoms that affect the vagina and urinary tract and that are caused by menopause, such as vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections.

Diagnosis

  • A doctor's evaluation

  • Rarely blood tests to measure hormone levels

In about three fourths of women, menopause is obvious. Thus, laboratory tests are usually not needed.

If menopause begins several years before age 50 or if symptoms are not clear-cut, tests may be done to check for disorders that can disrupt menstrual periods. Rarely, if menopause or perimenopause needs to be confirmed, blood tests are done to measure levels of follicle-stimulating hormone (which stimulates the ovaries to produce estrogen and progesterone).

Before any treatment is started, doctors do the following:

  • Ask women about their medical and family history

  • Do a physical examination, including breast and pelvic examinations and measurement of blood pressure

During the pelvic examination, doctors check for typical changes in the vagina, which support the diagnosis of menopause. Doctors also check for abnormalities in the reproductive organs.

A woman's medical history and family history help doctors determine her risk of developing certain disorders after menopause.

Mammography, if it has not been done recently, is done as part of routine care. Blood tests may be done.

Bone density is measured in the following women:

Treatment

  • General measures

  • Certain drugs

  • Complementary and alternative medicine

  • Hormone therapy

Understanding what happens during perimenopause can help women cope with the symptoms. Talking with other women who have gone through menopause or with their doctor may also help.

Treatment of menopause focuses on relieving symptoms such as hot flashes and vaginal dryness. General measures may help, but when other treatment is needed, the most effective is

Progestogen refers to both synthetic and naturally occurring forms of progesterone (a female hormone). Another term, progestin, refers only to synthetic forms.

Effective measures that do not involve hormones include

  • Hypnosis by a qualified health care practitioner to help relieve hot flashes

  • Cognitive-behavioral therapy

  • Other drugs such as two types of antidepressants (selective serotonin reuptake inhibitors or serotonin- norepinephrine reuptake inhibitors) or the antiseizure drug gabapentin

Cognitive-behavioral therapy has been adapted to be used during the menopause transition and postmenopause. It can help women manage hot flashes and night sweats.

General measures

The following may help relieve hot flashes:

  • Wearing layers of clothing, which can be taken off when a woman feels hot and which can be put on when she feels cold, can help her cope with hot flashes.

  • Wearing clothing that breathes (such as cotton underwear and sleepwear) or that can wick away moisture (such as certain kinds of underwear and exercise clothes) may enhance comfort.

  • Avoiding things that trigger symptoms (such as hot environments, spicy foods, and bright lights) may also help.

  • Using fans or lowering the thermostat may help.

  • Exercising regularly and losing weight may help control hot flashes and have other health benefits.

Although mindfulness (the practice of being aware of the present moment), relaxation techniques, and/or yoga may be of general benefit to women, it is not clear whether they relieve hot flashes.

To manage sleep disturbances, women can follow a routine to calm themselves before they go to bed and when night sweats wake them up. Developing good sleep habits and exercise can also help improve sleep.

Bladder control may be improved by Kegel exercises. For these exercises, a woman tightens the pelvic muscles as if stopping urine flow. Women may be taught how to use biofeedback to help them learn to control their pelvic muscles. Biofeedback is a method of bringing unconscious biologic processes under conscious control. It involves using electronic devices to measure information about these processes and to report it back to the conscious mind.

If vaginal dryness makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. For some women, applying a vaginal moisturizer every 1 to 3 days helps. Staying sexually active or masturbating also helps by stimulating blood flow to the vagina and the surrounding tissues and by keeping tissues flexible.

Drugs

Several types of drugs can help relieve some of the symptoms associated with menopause.

Paroxetine (an antidepressant) can help relieve hot flashes. Gabapentin, an antiseizure drug, and other antidepressants (such as desvenlafaxine, fluoxetine, sertraline, or venlafaxine) are somewhat effective at relieving hot flashes. Antidepressants may also help relieve depression, anxiety, and irritability. However, none of these drugs are as effective at relieving symptoms of menopause as hormone therapy.

A sleep aid is sometimes recommended to relieve insomnia.

Table
icon

Some Drugs Used to Treat Symptoms and Effects of Menopause

Drug

Advantages

Disadvantages

Female hormones

*Estrogen therapy, with or without a progestogen

Relieves hot flashes, night sweats, vaginal dryness, and pain during intercourse

Helps prevent osteoporosis and reduce the risk of bone fractures

Combination therapy (estrogen plus a progestogen):

*Estrogen alone:

  • Increases the risk of blood clots in the legs and lungs, stroke, gallbladder disorders, and urinary incontinence

  • Increases the risk of endometrial cancer (cancer of the lining of the uterus)

  • May slightly increase the risk of breast cancer but probably not for many years

A progestogen, such as medroxyprogesterone acetate or micronized progesterone (a natural rather than synthetic progesterone)

Reduces the risk of endometrial cancer, which is associated with taking estrogen alone

Is not as effective as estrogen for relieving hot flashes

Does not relieve vaginal dryness

May cause abdominal bloating, breast tenderness, increased breast density, mood disturbances, and/or headache

Increases LDL (the bad) cholesterol levels

May increase the risk of blood clots in the legs and lungs

Has less clear effects on the risk of other disorders

Micronized progesterone: May have a less negative effect on mood and LDL cholesterol than synthetic progestins

May cause drowsiness (and so is usually taken at night)

Appears to have fewer side effects than other progestogens

Selective estrogen receptor modulators (SERMs)

Ospemifene

Relieves pain during intercourse

May worsen hot flashes temporarily

Conjugated estrogen plus bazedoxifene

Conjugated estrogen plus bazedoxifene (a SERM)

Relieves hot flushes, improves sleep, prevents bone loss, and lessens vaginal atrophy (thinning and drying of the vagina with loss of elasticity)

Decreases incidence of breast tenderness and bleeding

Does not appear to increase breast density or incidence of breast cancer

Protects the uterus without the need for a progestogen

May increase the risk of blood clots in the legs and lungs

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs), such as desvenlafaxine, fluoxetine, sertraline, paroxetine in low doses (particularly), and sustained-release paroxetine

Serotonin- norepinephrine reuptake inhibitors, such as venlafaxine

Relieve depression, anxiety, irritability, and insomnia

Are somewhat effective for relieving hot flashes

Depending on the drug, can have side effects, such as sexual dysfunction, nausea, diarrhea, weight loss (in the short term), weight gain (in the long term), drowsiness (sedation), dry mouth, confusion, and increased or decreased blood pressure

Antiseizure drug (only one)

Gabapentin

Is somewhat effective for relieving hot flashes and may help relieve night sweats

Can have side effects, such as drowsiness, dizziness, headache, rash, weight gain, and leg swelling

* Determining whether the risk of certain disorders is increased by estrogen alone or by estrogen plus a progestogen (combination therapy) is difficult.

HDL = high-density lipoprotein; LDL = low-density lipoprotein.

Complementary and alternative medicine

Some women take medicinal herbs and other supplements to relieve hot flashes, irritability, mood changes, and memory loss. However, black cohosh, other medicinal herbs (such as dong quai, evening primrose, ginseng, and St. John’s wort), and over-the-counter drugs do not appear to be more effective than placebo, which works about 50% of the time. Also, such remedies are not regulated as drugs are. That is, their manufacturers are not required to show that they are safe or effective, and what their ingredients are and how much of each ingredient a product contains are not standardized (see Overview of Dietary Supplements/Safety and Effectiveness).

Studies of soy protein have had mixed results. One soy product, called S-equol, may help relieve hot flashes in some women.

Some supplements (for example, kava) can be harmful. Furthermore, some supplements can interact with other drugs and can worsen some disorders.

Concerns about using standard hormone therapy have led to an interest in using hormones derived from plants such as yams and soy. These hormones have nearly the same molecular structure as hormones made by the body and thus are called bioidentical hormones. Many of the hormones used in standard hormone therapy are also so-called bioidentical hormones derived from plants. However, the hormones used in standard hormone therapy have been tested and approved, and their use is closely monitored.

Sometimes a pharmacist custom-makes (compounds) bioidentical hormones for a person according to a health care practitioner's prescription. These are called compounded bioidentical hormones. Their production is not well-regulated. Thus, many doses, combinations, and forms are possible, and purity, consistency, and potency of the products varies. Compounded bioidentical hormones are often marketed as substitutes for standard hormone therapy and sometimes as a better, safer treatment than standard hormone therapy. But there is no evidence that compounded products are safer, more effective, or even as effective as standard hormone therapy. Sometimes women are not told that compounded bioidentical hormone products have the same risks as standard hormones.

Women who are considering taking such supplements are advised to discuss them with a doctor.

Hormone Therapy for Menopause

Hormone therapy can relieve moderate to severe symptoms of menopause such as hot flashes, night sweats, and vaginal dryness. However, hormone therapy may increase the risk of developing certain serious disorders.

Hormone therapy improves quality of life for many women by relieving their symptoms, but it does not improve quality of life if women do not have symptoms. Thus, hormone therapy is not routinely given to postmenopausal women. Whether to take hormone therapy is a decision that must be made by a woman and her doctor based on the woman’s individual situation.

For many women, risks outweigh potential benefits, so this therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, potential benefits may outweigh risks.

For example, hormone therapy may be recommended for women who have a high risk of bone loss or fracture plus one of the following:

  • They are under age 60.

  • Menopause was diagnosed fewer than 10 years previously.

  • They cannot take other drugs (such as bisphosphonates) to prevent bone loss and fractures.

Hormone therapy reduces bone loss and risk of fracture in these women.

Usually, doctors do not recommend that women start taking hormone therapy if

  • Women are older than 60.

  • Menopause was diagnosed more than 10 to 20 years previously.

When hormone therapy is used, doctors prescribe the lowest hormone dose that controls symptoms and for the shortest time needed.

Hormone therapy can include

  • Estrogen

  • A progestogen (such as progesterone or medroxyprogesterone acetate)

  • Both

All hormones used in hormone therapy are made in laboratories. They may or may not be identical to those made in the body, but the way they act in the body is very similar. Progestogens resemble progesterone, a female hormone made by the body.

Estrogen and progestogens come in several forms. Estradiol and conjugated estrogens (a mixture of estrogens) are commonly used forms of estrogen.

Women who have a uterus are usually given estrogen plus a progestogen (combination hormone therapy) because taking estrogen alone increases the risk of cancer of the uterine lining (endometrial cancer). The progestogen helps protect against this cancer. Women who no longer have a uterus may take estrogen alone.

The benefits and risks of hormone therapy depend on whether the hormones are taken alone or together.

Estrogens with or without a progestogen: Potential benefits and risks

Estrogen has several benefits:

  • Hot flashes and other symptoms: Estrogen is the most effective treatment for hot flashes.

  • Drying and thinning of vaginal and urinary tract tissues: Estrogen can prevent these tissues from drying and thinning. Thus, it can reduce pain with sexual intercourse. When the only problem a woman has is drying and thinning of these tissues, doctors may recommend a form of estrogen that is inserted into the vagina. These forms include low-dose estrogen tablets, a low-dose estrogen ring, a low-dose estrogen cream, and suppositories. When a low dose of estrogen is used, women who still have a uterus do not have to take progestogen.

  • An urgent need to urinate and recurring urinary tract infections: Forms of estrogen that are inserted into the vagina (creams, tablets, or rings) help relieve these problems.

  • Osteoporosis: Estrogen, with or without a progestogen, helps prevent or slow the progression of osteoporosis. However, taking hormone therapy for the sole purpose of preventing osteoporosis is usually not recommended. Most women can take a bisphosphonate or another drug to help prevent osteoporosis instead (although these drugs have their own risks). Bisphosphonates increase bone mass by reducing the amount of bone the body breaks down as it re-forms bones. The body continuously breaks bone down and re-forms it to help bones adjust to the changing demands placed on them. As people age, more bone is broken down than is re-formed.

Estrogen taken without a progestogen increases the risk of endometrial cancer in women who have a uterus. The risk increases with higher doses and longer use of estrogen. Taking a progestogen with estrogen almost eliminates the risk of endometrial cancer, reducing the risk below that for women who do not take hormone therapy. Nonetheless, doctors evaluate any vaginal bleeding in women taking hormonal therapy to rule out endometrial cancer.

Estrogen, taken with or without a progestogen, increases the risk of the following:

  • Breast cancer: The risk of breast cancer begins to increase by a very small amount after taking estrogen plus a progestogen for about 3 to 5 years. But if estrogen is taken alone at the beginning of menopause, risk may not begin to increase until after 10 years or even 15 years.

  • Stroke

  • Blood clots in the legs (deep vein thrombosis) and blood clots in the lungs (pulmonary embolism)

  • Gallbladder disorders (such as gallstones)

  • Urinary incontinence: Taking estrogen increases the risk of developing incontinence and worsens preexisting incontinence.

For certain disorders, determining whether the risk is increased by estrogen alone or by estrogen plus a progestogen (combination therapy) is difficult.

Although taking hormone therapy increases the risk of all the above disorders, the risk is still low in healthy women who take hormone therapy for a short time during or shortly after perimenopause. Risk of most of these disorders increases with age, particularly 10 years or more past menopause, whether hormone therapy is taken or not. In older women, taking estrogen plus a progestogen also increases the risk of coronary artery disease.

Risks of hormone therapy are thought to be lower when low doses of estrogen are used. Forms of estrogen that are inserted into the vagina (such as estrogen creams or tablets or rings that contain estrogen) often have lower doses than tablets taken by mouth.

Estrogen given through a patch on the skin (transdermal form) appears to have a lower risk of blood clots, stroke, and gallbladder disorders (such as gallstones) than with forms taken by mouth.

Generally, women who have breast cancer, coronary artery disease, or blood clots in the legs, who have had a stroke, or who have risk factors for these disorders should not take estrogen therapy.

Combination hormone therapy reduces the risk of the following:

  • Osteoporosis

  • Colorectal cancer

Progestogens: Benefits and risks

Progestogens have some benefits:

  • Endometrial cancer: Taking a progestogen with estrogen almost eliminates the risk of endometrial cancer in women who have a uterus.

  • Hot flashes: High-dose progestogens can relieve hot flashes. But they are not as effective as estrogen.

Progestogens may increase the risk of the following:

  • An increase in LDL (the bad) cholesterol levels: Progestogens may have this effect. However, micronized progesterone (a natural rather than synthetic progesterone) appears to have a less negative effect on LDL levels than synthetic progestins.

  • Blood clots in the legs and lungs.

The effect of a progestogen alone on the risk of other disorders is not clear.

Side effects

Side effects of estrogen and progestogens, especially at high doses, may include nausea, breast tenderness, headache, fluid retention, and mood changes.

Forms of hormonal therapy

Estrogen and/or a progestogen can be taken in several ways:

  • Estrogen or a progestogen tablets taken by mouth (oral form)

  • Estrogen creams, tablets, rings, or suppositories inserted into the vagina (vaginal form)

  • Estrogen lotions, sprays, or gels applied externally to the skin (topical form)

  • Estrogen or combination estrogen-progestogen skin patches (transdermal form)

As tablets taken by mouth, estrogen and a progestogen may be taken as two tablets or as a combination tablet. Commonly, estrogen and a progestogen are taken every day. This schedule may result in irregular vaginal bleeding during the first year or more of therapy. (However, if bleeding continues for more than a year, women should see their doctor.) Alternatively, estrogen may be taken daily, with a progestogen taken for 12 to 14 days each month. With this schedule, most women have monthly vaginal bleeding on the days after they take progestogen.

Vaginal forms of estrogen are inserted into the vagina. These forms include

  • A cream that is inserted with a plastic applicator

  • A tablet that is inserted with a plastic applicator

  • A ring that contains estrogen (similar to a diaphragm)

  • A suppository that contains estrogen

There are many different products, which come in different doses and which contain different types of estrogen. Creams and rings may contain a high or low dose of estrogen. If a high dose of estrogen is used in vaginal forms, women are also given a progestogen to reduce the risk of endometrial cancer. Usually, a low dose is sufficient for vaginal symptoms.

Using a vaginal form of estrogen may be more effective than taking estrogen by mouth for symptoms that affect the vagina (such as drying or thinning). Such treatment helps prevent intercourse from being painful, lessens urinary urgency, and reduces the risk of bladder infections.

As a lotion, spray, or gel, estrogen can be applied to the skin.

As a patch, estrogen or estrogen plus a progestogen can also be applied to the skin.

Selective estrogen receptor modulators (SERMs)

SERMs (such as raloxifene and tamoxifen) function like estrogen in some ways but reverse the effects of estrogen in other ways. Raloxifene is used to treat osteoporosis and prevent breast cancer. Tamoxifen is used to treat breast cancer. Ospemifene can be used to relieve vaginal dryness.

When women take a SERM, hot flashes may temporarily worsen.

Bazedoxifene is a SERM that is given with estrogen in a combination tablet. It can relieve hot flashes and symptoms of vaginal atrophy, reduce breast tenderness, improve sleep, and prevent bone loss. Like estrogen, this drug increases the risk of blood clots in the legs and lungs, but it may reduce the risk of endometrial cancer and affect the breast less.

Dehydroepiandrosterone (DHEA)

Dehydroepiandrosterone (DHEA) is a steroid that is produced in the adrenal glands and that is converted into sex hormones ( estrogens and androgens). It is available as a suppository to be placed in the vagina. DHEA appears to relieve vaginal dryness and other symptoms of vaginal atrophy. It is also used to reduce pain during sexual intercourse due to vaginal atrophy.

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