Menopause 101
What is Menopause?
Menopause is a natural biological process marking the end of a woman's reproductive years, typically occurring between the ages of 45 and 55. It is defined as the cessation of menstrual periods for 12 consecutive months and signifies the end of ovarian function, which leads to a decline in the production of hormones such as estrogen and progesterone. This transition can bring a variety of symptoms and an increased risk of certain health conditions. While menopause is a normal part of aging, its symptoms and the age at which it occurs can vary widely among women.
Early menopause, occurring before the age of 40, can be caused by factors such as genetics, autoimmune diseases, or medical treatments like chemotherapy, leading to premature ovarian failure and a higher risk of long-term health issues.
What are the stages of menopause?
Menopause occurs in two main stages: menopause transition or “perimenopause”, and “post-menopause”. Each of these phases is further split into two stages each (see images below). Some individuals may experience menopause earlier than expected, known as early or premature menopause.
Perimenopause
This transition commonly lasts two to eight years and usually begins in a persons 40s, although for some women signs and symptoms can present much earlier. There are two stages of perimenopause: the early transition and the late transition. The early transition is characterized by menstrual cycles with few irregularities or interruptions, and the late transition involves periods of 60 days or more when there’s an absence of menstruation. In this stage, the body begins producing less estrogen and progesterone.
Menopause
Menopause officially occurs after 12 consecutive months of having no menstrual period, at which time the person stops having periods permanently. In this stage, hormones decline to their lowest levels. In the United States, the average age at which people experience menopause is 52, but the transition commonly occurs between the ages of 45 to 58 years old.
Post-menopause
Post-menopause, which refers to the period after menopause, is characterized by the absence of menstruation and the inability to become pregnant. Although the body no longer menstruates during this time, menopausal symptoms such as hot flashes, trouble sleeping, and vaginal dryness may persist. Low estrogen and progesterone levels may also be associated with certain health risks during this time, such as osteoporosis, stroke, and heart disease.
If you experience vaginal bleeding post-menopause, speak with your healthcare provider right away. This could be a sign of a serious health problem and is not typical during this stage.
Early or Premature Menopause
For some, menopause occurs earlier than average. If menopause occurs before the age of 40, it’s considered premature menopause, and if it occurs between the ages of 40 to 45, it’s considered early menopause. Those who were never pregnant may experience menopause earlier than people who were pregnant more than once. Early or premature menopause can occur also occur as a result of certain surgeries, health conditions, or medications. The following reasons may contribute to early or premature menopause:
Certain cancer treatments (e.g., chemotherapy or pelvic radiation)
Certain health conditions (e.g., thyroid disease, rheumatoid arthritis, HIV and AIDS, chronic fatigue syndrome)
Family history of early or premature menopause
Missing chromosomes (e.g., Turner’s syndrome)
Surgery to remove the ovaries
Surgery to remove the uterus
Those with premature or early menopause usually experience the same symptoms as those who go through menopause. However, because they will be in the post-menopause stage for longer, they may have a higher risk of certain health conditions associated with post-menopause such as heart disease or osteoporosis. They may also experience more intense menopausal symptoms in general, such as feelings of depression related to the early and abrupt onset of these bodily changes.
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Perimenopause: Early Transition
— Persistent difference of 7 days or more in the length of consecutive cycles
— Levels of FSH are variable and may still reflect premenopausal levels
— Mild hormone fluctuations
— variable length of years
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Perimenopause: Late Transition
— 45+ years old with one episode of 60+ days of amenorrhea (no period)
— 40-44 yrs old with at least two episodes of 60+ days of amenorrhea in 1 year
— inreased variability in cycle length
— extreme fluctuations in hormone levels due to inconsistent and less frequent ovulation
— FSH still variable; a random level >25 IU/L would be indicative
— can last 1-3 yrs
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Post-Menopause: Early Stage
— No period for at least 12 months
— Hot flashes often peak within the first 2 yrs of this stage
— High FSH and low estrogen levels stabilize around years 3-6 after last menstrual cycle
— higest rate of bone loss
— consists of the 8 years following the last menstrual cycle
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Post Menopause: Late Stage
— Remaining lifespan
— Estradiol remains low
— FSH consistently over 20 IU/L
— Marked increase in genitourinary symptoms
Signs and Symptoms of Menopause
It's important to note that the intensity and duration of these symptoms can differ significantly from one woman to another. These symptoms can range from mild to severe and may last for several years, affecting daily life and overall well-being. A number of factors may influence the type and severity of symptoms experienced, including:
Activity Level
Body mass index (BMI)
Ethnicity
Geographic location
History of anxiety and depression
Medications
Medical history
Smoking status
Vasomotor (temperature dysfunction aka hot flashes), urogenital (affecting the urinary and genital tracts), and mental health-related symptoms are the most common types of symptoms that individuals experience during menopause. Signs and symptoms of menopause may include:
• Changes in menstrual periods
• Changes in arousal, decreased interest in sex (libido), and/or difficulty achieving orgasms
• Difficulty maintaining bladder control
• Headaches or migraines
• Hot flashes
• Insomnia and sleep disturbances
• Irregular heart beat
• Joint pain
• Mood changes
• Night sweats
• Pain during sex
• Skin flushing
• Vaginal dryness
• Weight gain
Did you know?
— The age that your biological mother went through menopause may be a clue that you’ll experience it around the same time.
— Hot flashes can be triggered by spicy food, alcohol, caffeine, a hot environment, or stress. Tracking your daily habits and hot flashes can help you figure out what triggers them and help prevent them in the future.
Health Issues Associated with Menopause
Heart Disease
Cardiovascular disease (CVD), also known as heart and blood vessel disease, encompasses different conditions related to the buildup of plaque in artery walls or the formation of a clot, hindering or blocking blood flow in the body. CVD is the leading cause of premature death in women in the United States, and the risk of developing CVD increases after menopause. Although menopause doesn’t cause CVD, studies continue to investigate the relationship between the menopausal transition and the associated increased CVD risk.
Increased Risk: After menopause, women's risk of developing heart disease increases due to the decline in estrogen levels, which had previously offered some cardiovascular protection.
Cholesterol Levels: Menopause can lead to unfavorable changes in cholesterol levels, such as higher LDL (bad) cholesterol and lower HDL (good) cholesterol, contributing to heart disease risk.
Blood Pressure: The loss of estrogen may also contribute to increased blood pressure, a significant risk factor for heart disease.
The following factors may play a role in increasing the risk of CVD:
Menopause age
Compared to women who experience menopause after the age of 45, people who experience menopause before the age of 45 may have an increased risk of developing coronary artery disease (CAD). CAD is a condition in which plaque builds up in the arteries of the heart.Type of menopause
People who have undergone a bilateral oophorectomy (BLO) at an early age (less than 40 to 45 years), a surgery to remove the ovaries, with no accompanying estrogen therapy, may be at higher risk of developing CAD compared to people who experience menopause at an older age or had a BLO at an older age.Menopause stage
Blood pressure and cholesterol levels may rise more significantly during the late perimenopause and postmenopause stages than during premenopause or early perimenopause.Estrogen levels
Estrogen protects against CAD by regulating cholesterol levels and the buildup of plaque in artery walls of the heart. When estrogen levels decrease during the menopausal transition, an increased risk of developing CAD or a stroke from the build-up of plaque in the arteries is possible. This relationship continues to be studied.Hot flashes, sleep, and depression
Vasomotor symptoms (e.g., hot flashes and night sweats), poor sleep quality, and depression, have been linked to a higher risk of CVD.
Osteoporosis
One in two women will develop osteoporosis in their lifetime, and of these, many will fracture. Research is showing that up approximately 20% of those who suffer a hip fracture will die within 1 year. The primary cause of bone loss is menopausal estrogen decline. The most rapid bone loss occurs in the first few years of menopause.
Osteoarthritis/Joint Pain
Osteoarthritis (OA), the most common form of arthritis, causes inflammation and pain as a result of the breakdown of cartilage between joints. OA is more common in females, with incidences of hand and knee OA increasing after menopause. Hormonal changes during menopause may contribute to increased inflammation in the body, exacerbating arthritis symptoms. Conditions like rheumatoid arthritis, an autoimmune disorder, can be influenced by hormonal fluctuations, potentially leading to changes in disease activity during menopause. It is believed that this is due to estrogen’s role in the maintenance of bones and joint tissues.
Urinary Incontinence
A decrease in estrogen levels may weaken the urethra (the tube that allows urine to pass out of the body) and contribute to urinary incontinence. Urinary incontinence is the loss of bladder control, causing urine to involuntarily leak. It is a common issue; about half of postmenopausal people in North America report having trouble holding in their urine.
Vaginal Atrophy
Vaginal atrophy, also known as atrophic vaginitis, is a condition where the vaginal walls thin and become less elastic due to decreased estrogen levels during menopause. Symptoms of vaginal atrophy include dryness, itching, burning, and discomfort in the vaginal area, which can significantly impact quality of life. Vaginal atrophy often leads to dyspareunia, or painful intercourse, as reduced lubrication and elasticity make sexual activity uncomfortable or even painful. The changes in vaginal pH and thinning of the vaginal walls can increase the risk of urinary tract infections (UTIs) and other vaginal infections.
Oral Issues
Changes in hormone levels during and after the menopausal transition may lead to oral issues such as pain and inflammation of the gums (gingivitis), an increased risk of cavities, and a decrease in saliva production which can lead to a dry mouth and cavities. Chronic inflammation from gingivitis has been linked to an increased risk of heart disease. Bacteria from gum infections can enter the bloodstream, potentially contributing to the formation of arterial plaque, leading to atherosclerosis, a major risk factor for heart disease.
Anxiety and Depression
Fluctuating hormone levels, particularly decreases in estrogen, are linked to an increased risk of mood disorders, including depression and anxiety, during perimenopause and menopause. Women with a prior history of depression or anxiety are more likely to experience a recurrence of these conditions during menopause. Up to 60% of menopausal women report sleep problems, which can exacerbate symptoms of depression and anxiety.