Menopause and perimenopause

Menopause marks the end of your menstrual cycles. If you have gone 12 full months without having a period, you have officially begun menopause, which is a biological process that comes with aging. Perimenopause is the period of time when your body is gradually transitioning to menopause that typically starts in your 40s and lasts anywhere from two to eight years.

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Perimenopause and menopause symptoms

Perimenopause is sometimes called the menopause transition. During this time, your estrogen levels go up and down and then decrease. As a result, you may notice some of these symptoms:

  • Increased premenstrual syndrome (PMS) symptoms.
  • Menstrual periods that come more or less often than normal.
  • Menstrual periods that are lighter or heavier than normal.
  • Chills.
  • Headaches or migraines.
  • Hot flashes.
  • Mood swings.
  • Night sweats.
  • Trouble going to sleep or staying asleep (insomnia).
  • Decreased sexual drive and function.
  • Vaginal dryness with possible pain during sex.
  • Hair loss or thinning.
  • Urinary symptoms such as frequent urination, a sudden need to urinate, or loss of urine when coughing or sneezing.

These symptoms can linger into menopause and postmenopause. They can vary widely from person to person, some people have minimal symptoms, while others experience severe symptoms that need to be managed.

What causes perimenopause and menopause?

A natural part of aging

Perimenopause is a natural process caused when the ovaries gradually stop working. As you age and your ovaries stop producing as much of the hormones estrogen and progesterone, your menstrual cycle lengthens and flow may become irregular. Eventually, as estrogen levels continue to fall, your flow will stop altogether.

Perimenopause is officially over after 12 consecutive months without a menstrual period. At this stage, your body has officially begun menopause.

Other perimenopause symptoms are also caused by these hormonal changes. When estrogen is higher, you may have symptoms similar to PMS. When estrogen is low, you may have hot flashes (vasomotor symptoms) or night sweats.

Other causes of menopause

Sometimes menopause happens for other reasons. These include:

Chemotherapy and radiation therapy. If you have chemo or radiation therapy as part of ovarian or pelvic cancer treatment, you may begin early menopause. These therapies can halt your periods and disrupt the production of estrogen and progesterone, which can cause hot flashes and other symptoms. However, depending on the treatment, this may be temporary. You should talk to your doctor about birth control methods and fertility treatments if you are receiving these therapies.

Primary ovarian insufficiency (premature ovarian failure). Primary ovarian insufficiency occurs when your ovaries stop functioning normally before age 40. It may be the result of a genetic or autoimmune condition. You may have irregular periods and fertility problems. If primary ovarian insufficiency leads to a sustained decrease in hormone production, you may experience premature menopause.

Surgical menopause. If you have surgery to remove your ovaries (oophorectomy), then you will immediately start menopause. This is because your ovaries are responsible for producing estrogen and progesterone. If your ovaries are gone, then so too are the hormones. Symptoms may be severe since the change is abrupt as opposed to gradual.

Note that surgery to remove your uterus (a hysterectomy) does not cause menopause. You will no longer have periods, but your ovaries will still produce estrogen and progesterone, meaning you will go through the gradual process of perimenopause and then begin menopause.

Managing menopause symptoms

Talk to your doctor or gynecologist to find management solutions that work best for you.

Medications

  • Hormone therapy Estrogen therapy through a pill, patch, gel, or cream provides the most effective relief for both premenopausal and menopausal symptoms. If you still have your uterus, progestin may also be included in this hormone therapy. When delivered through a pill or patch, the hormones can travel throughout your body. This is referred to as systemic estrogen therapy. Systemic estrogen therapy can help relieve hot flashes and night sweats, as well as prevent bone loss and osteoporosis.
  • Vaginal estrogen The body does not absorb vaginal estrogen well, though it is appropriate in some cases. If you are not a good candidate to take body-wide hormone therapy, locally applied vaginal estrogen might be right for you. Your healthcare provider is able to advise you about which option is best.
  • Antidepressants. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) can reduce menopausal symptoms of depression and anxiety. This is especially useful for people who are unable to have estrogen replacement therapy for any health reasons such as recent treatment for breast cancer, or who simply need them to treat a mood disorder.
  • Gabapentin (also known as Neurontin). This anti-seizure medication is also shown to reduce hot flashes and migraines. It is especially useful for those who cannot take hormone replacement therapy.

Lifestyle changes and home remedies

Sometimes, lifestyle changes can help manage menopause symptoms. These include:

  • Eating a healthy diet. A healthy diet is imperative to help prevent heart disease and osteoporosis that may arise from menopause. Adopt a low-fat, high-fiber diet full of fruits, vegetables, and whole grains. Limiting alcohol and caffeine can also help lessen the effects of hot flashes.
  • Keep it cool. Use fans to keep yourself cool whenever you feel a hot flash. Keep your room cool at night and avoid heavy or synthetic blankets to avoid night sweats. Try to wear cotton and linen clothes, since these fabrics are breathable.
  • Maintaining good sleep habits. Keeping a consistent sleep schedule, sleeping in a cold environment, and avoiding caffeine and alcohol will help ensure your sleep is not interrupted.
  • Practice stress reduction techniques. Paired with good sleep habits, stress reduction techniques can help ease anxiety and depressive symptoms of perimenopause and menopause. Paired with regular exercise, stress reduction techniques such as yoga and meditation can help keep a mental and physical balance and prevent weight gain.
  • Strengthen your pelvic floor. Exercises like Kegels can help you maintain the muscle tone of your pelvic floor, and can help with discomfort during sex and urinary incontinence.
  • Using lubricants. Over-the-counter water-based lubricants can help ease sexual discomfort and vaginal dryness. Lubricants paired with continued sexual intercourse may stimulate blood flow to the vagina, which may ease vaginal symptoms.
  • Taking Vitamin D. Taking Vitamin D supplements can help the body absorb calcium and promote bone growth.

Herbal remedies and supplements

You may find that lifestyle fixes are not enough for you, but you want to avoid prescription medication. Many menopausal women face this dilemma and turn to herbal remedies or supplements.

Here are some options to consider:

  • Herbal supplements. Many herbal supplements are advertised as being beneficial for the treatment of menopausal symptoms; none of them are FDA approved and none of them have been proven to be safe and effective in randomized, clinical trials. The Menopause Society recommends against these treatments because they are ineffective.
  • Plant estrogens (phytoestrogens). Foods like soy, chickpeas and flaxseeds contain compounds similar to estrogen. While these foods may be part of a healthy diet, there is currently no proof that they are effective for managing menopausal symptoms. Additionally, isoflavone – the plant estrogen compound found in soy – may not be suitable for people who previously had or are at risk for breast cancer. Talk to your doctor about any dietary changes.
  • Bioidentical hormones. These hormones biologically match estradiol and progesterone exactly. They are pharmaceutical grade hormone therapy treatments that are widely available and preferred for most women. Hormones advertised as “bioidentical” are not regulated by the FDA and not required to meet their standards for safety and efficacy. This includes preparations delivered as pellets and most creams that are labelled as containing active hormones. The National Academy of Medicine report in 2020 advises against the use of compounded bioidentical hormones.
  • Fezolinetant (Veozah) is the newest FDA approved non hormonal treatment and is a safe and effective alternative to hormone therapy. It was approved in Spring of 2023, and has been studied in more than one thousand women to date. It demonstrates relief of hot flashes comparable to that achieved with hormone therapy. Fezolinetant taken with certain medications may require additional monitoring for safety. Based on health history and current medications, your health care provider can help you determine whether this medication is appropriate for you.
  • Cognitive behavioral therapy (CBT) and hypnosis may be helpful for women with hot flashes.

Complications of perimenopause and menopause


Hormonal changes can increase risk for developing certain conditions.

The hormonal changes associated with perimenopause and menopause can put you at increased risk for certain conditions or complications. These include:

Osteoporosis. Hormonal changes during menopause can cause women to lose bone mass more rapidly than men do, and increase the risk for fractures. Women who are at risk for osteoporosis should get screened for early signs of the disease, as there are a variety of safe and effective treatments.

Sexual dysfunction. Menopause can change your sex life in many ways. For one, declining estrogen levels can decrease your libido (sex drive). Common symptoms of menopause, like vaginal dryness, can also make sex uncomfortable or painful and may cause bleeding. Many people also experience vaginal atrophy, or a loss of muscle tone in the vagina. This can make sex less pleasurable and sometimes painful. If you experience sexual dysfunction, you should talk to your doctor or gynecologist as well as your partner. They can help you find solutions that work for you and your lifestyle. You may find water-based lubricants or vaginal creams containing estrogen helpful.

Urinary incontinence. With menopause, the tissues around your urethra (the opening where urine comes out) lose some of their muscle tone and elasticity. This can cause more frequent urination and urinary incontinence, or the involuntary loss of urine, especially when laughing or coughing.

Urinary tract infections (UTIs). UTIs may become more common as you go through perimenopause and menopause. This is because of changes in the elasticity of the tissues around your vagina and urethra, which can leave you more prone to infection. As your hormone levels change, so too does the bacterial flora of your vagina, which can also increase your risk of infection.

Weight gain. Weight gain during menopause is common. Your metabolism starts to slow down as your hormones change, meaning you may need to eat less and exercise more during perimenopause and after menopause just to maintain your current weight.

Heart disease and high blood pressure. Cardiometabolic disease can increase in women in their postmenopausal years. Women should be screened regularly for heart disease and diabetes, and to treat conditions such as high blood pressure early to prevent complications.

References

National Institute of Aging (NIA). What Is Menopause? (https://www.nia.nih.gov/health/what-menopause)

MedlinePlus: National Library of Medicine. Menopause (https://medlineplus.gov/menopause.html)

The Office on Women’s Health (OWH). Menopause (https://www.womenshealth.gov/menopause)

National Center for Biotechnology Information (NCBI): National Library of Medicine. Perimenopause: From Research to Practice (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834516/)

The National Academies of Sciences, Engineering, and Medicine:https://www.nationalacademies.org/our-work/clinical-utility-of-treating-patients-with-compounded-bioidentical-hormone-replacement-therapy

NAMS POSITION STATEMENT-The 2022 hormone therapy position statement of The North American Menopause Society:https://www.menopause.org/docs/default-source/professional/nams-2022-hormone-therapy-position-statement.pdf

SWAN-Study of Women’s Health Across the Nation:https://www.swanstudy.org/fact-sheets/