What Is Menopause and the Menopausal Transition? Symptoms, Causes, Diagnosis, and Treatment

Menopause occurs when a woman stops menstruating, usually between ages 45 and 55. The diagnosis is made when a woman hasn’t had her period for 12 months in a row. The transition from being premenopausal to post-menopausal typically lasts about seven years but can take as long as 14 years, notes the National Institute on Aging. The lead-up to the change is called perimenopause; the time after it is post-menopause. During those years, the levels of the hormones estrogen, progesterone, and testosterone drop off. Menopause can be induced artificially by the removal of the ovaries or through chemotherapy.

Every woman’s experience with menopause is unique; she may have all of the following symptoms or just a few of them. The intensity of symptoms may be relatively mild or severe enough to affect a woman's quality of life.

Hot Flashes and Night Sweats

The main menopause symptoms are hot flashes and night sweats. These are a sudden feeling of heat coming from inside, causing a red face and upper torso, a rapid heartbeat, and copious sweating. When experiencing this at night, a woman may become so drenched in sweat that she has to change bedclothes. Afterward, she may feel chilled. Researchers hypothesize that hot flashes are caused by changes in the hypothalamus, the part of the brain that regulates temperature.

However, research presented at the 2022 Annual meeting of the North American Menopause Society showed that night sweats and hot flashes are not the same thing: Night sweats cause a higher level of stress, last longer, are more intense, and produce much more sweating than hot flashes. Also, women who have more hot flashes at night rather than during the day have a higher risk of depression.

Other Symptoms of Menopause

The depletion and fluctuation of hormone levels also can cause the following:

Weight gain and slower metabolism are possible.
Mood swings, including symptoms of depression and anxiety, can also be caused by this stage of life.
Sleep problems.
Hair loss, brittle nails, dry eyes and mouth, and skin issues may occur.
Genitourinary syndrome of menopause, which includes genital dryness, irritation, sexual dysfunction, and urinary issues, according to an overview in Cureus. The hormonal changes can trigger sexual problems including a drop in libido, vaginal dryness, and pain upon penetration.
Memory and cognitive issues, notes research; blame the hormones but also the sleep disruptions, mood changes, and hot flashes.

When the onset of menopause occurs before age 40, it’s considered premature; early onset is before age 45, notes the Cleveland Clinic. The following factors can influence when menopause happens.

Women who have given birth and women who spent months doing breastfeeding exclusively may be less likely to experience early onset menopause, according to research.
Removal of the ovaries (surgical menopause), ovarian failure due to chemotherapy, and genetic or endocrine issues will bring on menopause.
Women who smoke or have certain medical conditions, such as autoimmune diseases, thyroid disease, or Crohn’s disease, have a higher risk of early menopause, per the Cleveland Clinic.
Menstrual cycle length. Women with menstrual cycles less than 25 days are likely to reach menopause earlier.
Experience of trauma or your child’s experience of trauma may have an impact.
Race, ethnicity, and family history may be other factors.
Education. Women who have achieved higher levels of education have been shown to enter menopause later.
Weight extremes. Obesity or being underweight can have an impact, too.

Perimenopause vs. Menopause: What’s the Difference?

Perimenopause occurs before the full onset of menopause, usually when a woman is in her forties, and for many women the transition lasts from about 4 to 8 years, according to the Cleveland Clinic. Erratic periods are common in perimenopause. Spotting between cycles, shorter cycles, lighter or heavier cycles, and even missed cycles can be a part of perimenopause. Conceiving a child while in perimenopause is possible but not probable.

Menopause diagnosis is done in hindsight — women are able to confirm that they’ve reached this milestone after they have passed it. That means that you are classified as having reached menopause or being post-menopausal after you go for more than a year (12 consecutive months) without menstruating. While most women do not need any kind of test or diagnosis if they are entering this phase naturally at midlife, PicoAMH Elisa, a diagnostic tool that can reveal menopause status, is helpful for women who are concerned about fertility or are at risk of early ovarian failure.

Perimenopause is divided into two stages: Early-stage perimenopause is when your menstrual cycle starts to become unpredictable. Over the span of a few months, you get your period a week or more later than during your usual cycle. Late-stage perimenopause occurs when you start having two months between cycles. This whole process can start 8 to 10 years before menopause, according to the Cleveland Clinic. Once you enter post-menopause, you remain in that stage for the rest of your life. You may still feel lingering symptoms, though they’re typically less intense, notes the Cleveland Clinic.

Many menopause symptoms are treatable or at least manageable, either through medications, complementary and alternative medicine, or lifestyle changes. Your doctor can tailor treatments specifically for you. Also, if you plan to try any supplements or vitamins, please check with your physician, because some may interfere with your current medications.

Medication Options

Antidepressants
Clonidine (Catapres)
Dehydroepiandrosterone
Gamma aminobutyric acid (Gabapentin)
Hormone therapy, including bioidentical hormones and low-dose estradiol vaginal inserts
Ospemifene (Osphena)

Complementary and Integrative Health Therapies

Acupuncture
Hypnotherapy
Yoga
Mindful meditation
Lifestyle changes, such as layering clothing, using vaginal moisturizers and lubricants, quitting smoking, exercising more intensely and regularly, eating a bone-health promoting diet of foods with calcium and vitamin C

Risk of Mood Issues Increases Around Midlife

Depression during perimenopause has not gotten a lot of attention until recent years. (Mood disorders happen more often during perimenopause than after menopause.) But data from the Study of Women’s Health Across the Nation, published in Psychological Medicine, noted that for perimenopausal and menopausal women, the risk of depression in those who have never experienced depression before is about 28 percent, and it’s 59 percent for those who have had depression before. In 2018, the North American Menopause Society and the Women and Mood Disorders Task Force of the National Network of Depression Centers published the first-ever guidelines for evaluation and treatment of this disorder. The International Menopause Society has also endorsed these guidelines.

RELATED: Midlife Mood Risks

The Controversy Around the Use of Hormone Therapy to Treat Menopausal Symptoms

There has been a complicated relationship between hormone treatments, known as menopausal hormone therapy and breast cancer. Early results from the Women’s Health Initiative’s Hormone Therapy Trials suggested that women who took estrogen plus progestin had a slightly higher risk of developing breast cancer. But women who did not have a uterus had a slightly lower risk. More than 10 years and many more comprehensive studies later, the nuances are better understood. For most women, hormone therapy is okay to use to help control moderate to severe symptoms such as hot flashes, as long as treatment is started within 10 years of menopause or before age 60, says the North American Menopause Society (NAMS).

The general advice about hormone therapy from NAMS: Use the lowest dose for the shortest amount of time for menopause symptoms. The U.S Preventive Services Task Force recommends against using menopausal hormone therapy, to help prevent chronic diseases like heart disease and cancer.

Everyone’s risk profile is unique; discuss with your healthcare practitioner what would be best for you.

Exercise and the Menopausal Transition: Fitness Recommendations Change at Midlife

Along with so much else, your fitness routine needs to change with age. Your workout may have to be adjusted at this time of your life so that you strengthen and stretch your muscles and generally move your body more. Check out our cheat sheet on age-related exercise recommendations for perimenopause and menopause.

Fighting Menopausal Belly Fat and Midlife Weight Gain

That stubborn spare tire around your middle owes its existence to the drop in hormones, which in turn slows down your metabolism. The scale number creeps up, and the fat migrates from hips and thighs to your belly. Fight the slide with these tips:

Exercise regularly. Focus on aerobics for at least 150 minutes a week, and strength train two or more times a week. Mix moderate and intense activities. If you get in an exercise rut or start feeling bored, try different workouts to target different muscle groups or exercise with friends to keep you on track.
Sit less, stand more. Try a standing desk.
When eating, control your portions and eat three meals a day. Don’t eat late at night, and have healthy snacks around for those late-afternoon hunger attacks.
Choose healthy unsaturated fats. Cut back on restaurant and takeout food, which is loaded with unhealthy fats, salt, and sugar. Especially watch your carb intake; your body converts it into sugar.
Eat according to your circadian rhythm, during an 8 to 12 hour window — such as from 7 a.m. to 7 p.m. only. No late-night fridge raids.
Follow good sleep hygiene to get better z’s at night. (Not enough sleep wakes up your hunger hormones.) Weight gain during menopause has been linked to disrupted sleep cycles.
Reduce stress, which can lead to unhealthy eating.
Talk with your doctor or nutritionist.

The main feature of perimenopause and menopause is the drop in levels of hormones such as estrogen, and with that, a coinciding drop in estrogen’s many protective effects. As your estrogen levels decline, you may experience other complications.

Mood Disorders As mentioned earlier, the risk of depression is higher in menopausal women, even those who have never experienced this mood disorder.
Weight Gain Not only do you tend to put on pounds — fat distribution also changes, with most of it landing around your belly. This can increase your risk of type 2 diabetes, hypertension, heart disease, and some cancers.
Metabolic Syndrome Your chances of developing metabolic syndrome, a combo platter of conditions that includes high blood pressure, belly fat, and high cholesterol and blood sugar, rises as much as 38 percent after menopause.
Sleep Disorders Menopausal women may have problems with falling asleep and not staying asleep once they do. They are also at risk of obstructive sleep apnea, notes Johns Hopkins Medicine.

The average age of menopause in the United States is 51 years old, per the Mayo Clinic.
Many women spend one-third of their lives post-menopausal, notes a study in BMC Women’s Health.
Women often enter menopause around the same age that their mother did, according to an article in Obstetrics and Gynecology Clinics of North America.
Ninety-five percent of women experience their last menstrual period between ages 45 and 55, notes UpToDate.

Every woman’s menopause experience is different. One may breeze through it with minimal discomfort; another may suffer from extreme hot flashes and mood disorders. Research from the Study of Women's Health Across the Nation suggests that race and ethnicity may play a role in the experience of menopause in the United States. Black women, Native American women, and Latinas were found to have higher rates of early menopause and more severe symptoms, notes an analysis published in Menopause. Women of color experience more hot flashes and night sweats than white women, and these symptoms persist for a longer time. Black women tend to have heavier menstrual flow, Central American Latinas experience more intense hot flashes, and Puerto Rican Latinas have the most sleep disturbances. The reasons why are complicated and not fully understood, but the current hypothesis is that chronic stress and lifestyle and socioeconomic status may contribute significantly.

Premature menopause can be triggered by a hysterectomy, with ovarian removal or failure, as well as by smoking and certain other medical issues, according to the Office on Women’s Health. Research suggests that giving birth and breastfeeding exclusively may help prevent early onset.

When you enter the post-menopausal phase, other changes in your body besides the drop in estrogen may increase your risk of other serious issues such as an increase in blood pressure, LDL (“bad”) cholesterol, and the blood fat triglycerides. Those include:

Heart Disease
Osteoporosis To help reduce bone loss, your physician may prescribe osteoporosis medications, calcium, and vitamin D.
Urinary Incontinence New research shows that hormone therapy may help prevent urinary tract infections in older women.
Sexual Function Some post-menopausal women experience vaginal dryness or pain during sexual intercourse.

Age-Related Cancer Risks and Health Concerns You Can Get Ahead Of

While menopause does not necessarily cause cancer, your risk of developing it increases with age. Women who go through menopause later in life (after the age of 55) face a higher risk of developing breast and uterine cancer because of longer lifetime estrogen exposure. Ovarian cancer risk is slightly elevated as well, according to Cancer.net.

RELATED: Menopause and Cancer Risks

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