Medically reviewed by C.H. Weaver, M.D. 4/2021

Approximately 1.3 million women become menopausal in the U.S. each year, entering into a period that for many will ultimately occupy one-third of their lifespan.1 And yet, a survey of U.S. obstetrics and gynecology residents found that fewer than one in five receives formal training in menopause medicine, and this lack of training extends across family medicine and internal medicine residents.2,3 The result is a gap in education and awareness around menopause for many women, which can lead to insufficient treatment for potentially debilitating symptoms.

“There's no question that there is a lack of education around menopause,” says Stephanie Faubion, MD, MBA, Medical Director, The North American Menopause Society, and Penny and Bill George Director, Center for Women's Health, at Mayo Clinic, “among women themselves and among the providers who are caring for them. It’s a major gap.”

That gap, Dr. Faubion says, is a result of multiple factors, many of which are related to the wide-ranging experiences of menopausal women and the care they receive—spanning everything from disparate cultural conversations about the topic to the wide age range at symptom onset to variable training among healthcare providers.

At the most basic level, Dr. Faubion says, conversations around menopause are not normalized in the same way that discussions about menstruation and childbirth are, creating a significant barrier to care for many women. “Many young women get ‘the talk’ before they start their period—around age 11 or 12—but even though the hormonal symptoms of menopause can be every bit as intense at the end of the reproductive lifespan as they are at the beginning, we’re just not talking about it in the same way.”

Add to that hush on the topic among women themselves the lack of formal training among providers, and it’s easy to see why women are often left in the dark to manage the symptoms of menopause. The good news: education around symptoms, treatment, and getting good care during menopause can bring in the light and help women navigate this period of change.

What is Menopause?

Menopause is a normal change in a woman’s life. It occurs when she has her last period and is confirmed when 12 months have passed without menstrual bleeding. Menopause, however, doesn’t simply happen when menstruation ends—symptoms may begin years before and continue for months or years after.

“The normal age range for onset of menopause spans at least a decade,” Dr. Faubion says. Women enter into perimenopause, or the period of menopausal transition marked by physical changes that are the result of lower levels of estrogen and progesterone (female hormones produced by the ovaries), in their forties (or, in some cases, late thirties), and the average age when a woman has her last period is 51.

Perimenopause continues for a year after a woman’s last period. Once you haven’t had a period for one year, the next phase is called postmenopause, which lasts for the rest of your life.

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Causes

Menopause and its symptoms are the natural result of changing levels of estrogen and progesterone. There are, however, a variety of factors that determine the age of onset of menopause.4 Smoking, for instance, can lead to an early menopause, as can surgeries to remove the uterus (hysterectomy) and/or ovaries (oophorectomy). A hysterectomy will end menstruation, but it won’t cause immediate symptoms of menopause; this is because the ovaries (which produce estrogen and progesterone) are not removed. Women who undergo a hysterectomy alone will typically go through menopause four-to-five years earlier than women who do have a uterus, Dr. Faubion notes, likely related to disruption of the blood flow to the ovaries. If the ovaries are removed, which often coincides with removal of the uterus, symptoms of menopause will also occur as menstruation ends.

Symptoms

Your body may go through many changes at midlife, and it’s not always clear which are caused by menopause and which are part of the aging process. Also, because estrogen is used by many parts of your body—not just your reproductive system—lower levels of estrogen can affect your health in several ways.

Dr. Faubion notes that women experience a wide range of symptoms to varying degrees. “Some women have absolutely no symptoms and some women are in their seventies and still experiencing symptoms, which—in addition to widely anticipated hot flashes—might include everything from joint pain to sleep disturbance to bone loss to weight gain.”

Among the most common changes in women’s bodies occurring at midlife that may be related to menopause:

Changes in your period. Normal changes in your menstrual cycle, including less-regular periods, shorter or longer periods, and more or less bleeding than usual are common during menopause. There are also a few changes that could indicate a medical problem and should be addressed with your medical provider; these include periods that come very close together, heavy bleeding, spotting, and periods lasting more than a week.

Hot flashes. Sixty to 80 percent of women experience vasomotor symptoms (hot flashes, or flushes, and night sweats) during the menopausal transition.5These sudden feelings of heat affect your upper body, causing your face and neck to become flushed. You may also see red blotches on your chest, arms, and back. Hot flashes can be followed by heavy sweating and cold shivering. When they occur at night, hot flashes are called night sweats and can interfere with sleep, and they can impact memory and mood, as well.6

Dr. Faubion notes that while many women may anticipate hot flashes as a symptom of menopause, it’s important to note the potential severity and long-term impact of this symptom. “We're discovering more and more that hot flashes are neither short in duration nor necessarily benign,” she says. “For some women, certain patterns of hot flashes may be a marker for higher risk of heart disease. And, while we know that the mean duration is seven to nine years, about a third of women will experience moderate to severe hot flashes for a decade or longer.”

Problems affecting your vagina or bladder. As your estrogen levels change, your genital area may become drier or thinner. Referred to as genitourinary syndrome of menopause (GSM), this symptom affects nearly 50 percent of women during menopause.7 Related problems include pain with intercourse, more vaginal and urinary infections, and trouble with bladder control. Bladder control problems include trouble holding urine long enough to reach the bathroom and urine leaking during exercise, sneezing, coughing, or laughing.

Sleep. In addition to the potential interruption of sleep by night sweats, some women find it harder in general to get a good night’s sleep at midlife. Issues may include trouble falling asleep, waking during the night, and waking too early.

Sex. Some women become less interested in sex around the time of menopause, while others feel freer to enjoy it. Practicing safe sex remains important following menopause—though you can’t become pregnant after one full year without a period, you may still be at risk for sexually transmitted diseases, particularly if you have more than one partner or if your partner is having sex with other people. If so, you should always use condoms.

Changes in mood. For reasons that are not entirely understood, some women become more moody or irritable around the time of menopause. As well as biological changes, stress, feeling tired, a history of depression, or changes within the family (like growing children and aging parents) may contribute to mood changes.

“Mood symptoms can be incredibly bothersome and are often associated with perimenopause and early post-menopause timeframe,” Dr. Faubion notes. “Many women are unaware of the connection between these symptoms and changes in estrogen levels that occur during the menopause transition.”

Weight gain or loss. Midlife can be associated with losing muscle and gaining fat, as well as having a wider waistline. In rare cases, women become thinner during this time. These changes are generally thought to be due to the general aging process rather than to menopause, specifically.

Changes to your memory. Many women describe changes to memory and cognition during menopause.8,9 While memory and cognition challenges are common as we age and are often short-term and relatively minor (like not being able to immediately recall a familiar word or occasionally misplacing the car keys), more significant signs of memory loss (like forgetting the way home or how to drive a car) should be addressed with your healthcare provider.

Joint Pain. Dr. Faubion says that many women experience joint aches during the menopause transition. Joint pain may also relate to osteoarthritis, which increases in women after menopause and may be influenced by hormonal changes.10 While there has not been a clear link established between menopause and osteoarthritis, joint aches are a less well-known symptom of menopause and can be bothersome for women.

Related Health Concerns

Though they’re not symptoms of menopause, there are certain health concerns that can accompany the change as estrogen levels decrease and other changes related to aging occur. Two common concerns for women at midlife include osteoporosis and heart disease.

Osteoporosis. At the time of menopause, women may be at risk of osteoporosis, a condition where bones become weak and break easily. The body continually breaks down old bone and replaces it with new, healthy bone. Because estrogen helps control bone loss, when you lose estrogen during menopause, your body isn’t able to replace as much bone as it loses. Your medical provider can test your bone density to determine your risk for osteoporosis as well as discuss ways to prevent or treat it.

Factors that increase risk for osteoporosis include: A family history of osteoporosis; a broken bone while an adult; surgery to remove both ovaries before menopause; early menopause; insufficient calcium throughout life; extended bed rest; smoking; long-term heavy drinking; use of certain medications for long periods (glucocorticoids and some anticonvulsants, for example)

Heart disease. More than one in three adult women has some form of heart disease, and a woman’s risk of heart disease increases after menopause.11This is likely the result of changing estrogen levels and the aging process. Factors associated with increasing age—like weight-gain and high blood pressure—can raise your risk of heart disease. See your medical provider regularly to have your blood pressure and cholesterol levels checked and to discuss ways to keep your heart healthy.

Diagnosis and Symptom Management

There isn’t one clear method to determine when you’re in the menopausal transition or to predict when you may experience the change. You and your medical provider may consider menopausal symptoms, a physical examination, medical history, and certain blood tests for clues about your status. Remember, however, that these are only clues—there’s no definitive test for menopause. Blood tests, for example, are unreliable because the hormones that your medical provider may measure—such as estrogen and follicle-stimulating hormone—may fluctuate significantly during the menopause transition.

Because menopause is a natural change in life, treatment is not about “curing” anything but is instead focused on managing the symptoms of menopause and related health concerns. That said, symptoms of menopause can have a significant impact on quality of life, so making sure that you are making lifestyle changes that can reduce the severity of symptoms and seeking medical care when necessary is important.

“The majority of women who report menopausal symptoms go untreated,” Dr. Faubion says. It’s not uncommon for women to see a number of medical providers about symptoms without anyone noting the connection to menopause. “I have seen several women at the Mayo Clinic who were seeking a diagnosis of an unknown condition, when that ‘condition’ was really menopause,” she says. “Women may have heart palpitations, experience anxiety, gain weight, and lose hair—all of which together sounds and feels ominous—but when we look at the symptoms together, it comes down to menopause.”

Unfortunately, Dr. Faubion says, the lack of widespread comprehensive training in menopause among providers and a general lack of conversation among women themselves on the topic means that women are often left to navigate the changes in their health without clear information and guidance. “If a woman has to travel across the country to our hospital to be given that diagnosis, we’re not doing a good job with menopause education in his country, and we need to do better.”

While there are efforts to improve providers’ training around menopause, Dr. Faubion notes that women can proactively educate themselves through a variety of sources. “In addition to really ramping up lifestyle modification like stress management, exercise, eating, right, sleeping enough hours, not drinking too much, not smoking, et cetera, arming yourself with education is probably the best thing a woman can do.”

There are a variety of excellent sources of current information on menopause available online, including: North American Menopause Society: Menopause and Me and The National Institute on Aging: What is Menopause?.

For many women, managing symptoms of menopause can begin with lifestyle changes designed to improve and maintain your general health; these include:

Don’t smoke or use any tobacco products. Avoid second-hand smoke. If you do smoke, you can benefit from quitting at any age.

Eat a healthy diet. Recommended food selections are low in fat, high in fiber, and include plenty of fruits and vegetables as well as whole-grain foods. You may need to cut back on calories as you age to control weight-gain, but be sure to eat plenty of nutrient-dense foods (foods loaded with protein and vitamins that are low in calories). Make sure you’re getting adequate amounts of vitamins and minerals from food sources or supplements. Calcium and vitamin D, for example, are important for bone health.

Maintain a healthy weight. Your doctor can help you determine a healthy weight, and a balanced diet and regular exercise can help you maintain it.

Stay active, including weight-bearing exercise. Protect your bone health with activities like walking, jogging, dancing, and lifting weights at least three days per week. Other types of physical activity (such as swimming, bicycling, and gardening) are also important, as they support overall health and help you maintain a healthy weight.

You can also directly address some of the symptoms of menopause and related health concerns by doing the following:

  • If your medical provider has prescribed medications, make sure you take them as prescribed. Health problems around the time of menopause that can be treated with medication include high blood pressure, high cholesterol, and osteoporosis.
  • You can manage vaginal discomfort and dryness with a water- or silicon-based lubricant for sexual activity. To help maintain moisture, a moisturizer used every one-to-three days or low-dose vaginal hormonal therapy containing estrogen (cream, vaginal tablet, insert, or ring) or /DHEA (insert) can be helpful. Avoid petroleum jelly.
  • See your healthcare provider for regular breast and pelvic exams and Pap tests and mammograms. Report immediately to your healthcare provider any changes to your body or health status, like a lump in your breast.
  • Get screened for colon and rectal cancer and skin cancer.
  • Keep track of your blood cholesterol levels, blood pressure, and blood sugar. Maintaining normal levels of all three can help protect your cardiovascular health.

Discuss urinary problems (such as infections and leakage) with your provider. There may be ways to control these problems. Urinary incontinence is also treatable—bladder control training, medicines, implants, or surgery may help.

There are a variety of things you can do to manage hot flashes. Consider the following:

  • Determine what might be triggering hot flashes. Keep track of when hot flashes occur and in what circumstances. When possible, avoid situations that seem to trigger them.
  • Try to go to a cool place when a hot flash starts.
  • To manage night sweats, keep your bedroom cool. A fan may help.
  • Dress in layers. This way, you can remove clothing when you get too warm.
  • Use sheets and clothing made of fabrics that allow your skin to breath.
  • Drink something cold—like water or juice—when a hot flash is starting.

Menopausal Hormonal Therapy. There has been much debate surrounding the use of menopausal hormonal therapy to relieve some of the symptoms of menopause and to prevent bone loss around the time of menopause.

Though some women find that taking estrogen (and progesterone, among those who still have a uterus) does provide relief of symptoms like hot flashes, night sweats, and vaginal dryness, there are also risks associated with MHT. Studies have suggested that major health concerns associated with long-term use of MHT include an increased risk of breast cancer.12

Research is ongoing into the impact of MHT on cardiovascular health. Current guidance from the American College of Obstetricians on Gynecologists states that “recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiovascular outcomes and should be considered candidates for the use of estrogen therapy or conjugated equine estrogen plus progestin for relief of menopausal symptoms.”13 And, Dr. Faubion notes that while cardiovascular risk can be increased among older women using MHT, this risk may actually be reduced in women who start MHT in their fifties for management of menopause symptoms.14

Risks related to MHT vary by type of MHT used (estrogen-plus-progestin versus estrogen alone). Talk with your provider to determine whether and what type of MHT might be right for you and about its risks and benefits. Dr. Faubion says that, to minimize these risks, each woman should work with her healthcare provider to plan a course of treatment that reflects “the right dose for the amount of time needed to meet her unique treatment goals.” Know that your symptoms may return when you stop taking the hormones.

It’s important to note that, in addition to the potential risk factors outlined here, some women experience additional side effects from MHT. These include breast tenderness, spotting, cramping, and bloating. These side effects will sometimes go away on their own or may be alleviated by changing the dose or timing of MHT. Today, Dr. Faubion says, the position of the North American Menopause Society (NAMS) is that “for most symptomatic women under the age of 60 and within 10 years of the last menstrual period, the benefits outweigh risks of MHT.”

Birth Control Pills. Healthcare providers sometimes recommend birth control pills during perimenopause. Birth control pills can help manage heavy, frequent, or unpredictable periods and can prevent pregnancy. As well, they may help relieve symptoms like hot flashes.

Non-hormonal Agents. While hormonal therapy is the first-line option, some women find that non-hormonal therapies, including some antidepressants, can help control hot flashes. Discuss these options with your provider.

Novel Therapies. Given the concern that some women have about using MHT, research related to a new class of nonhormonal drugs to treat some menopausal symptoms is generating excitement. Dr. Faubion says that if approved, neurokinin receptor antagonists (NK3 inhibitors), currently in Phase III trials, could provide women experiencing vasomotor symptoms another option. “This novel therapy has been shown to reduce hot flashes by approximately 70 percent within days, so it can be extremely effective,” she says.15 “We don't know yet if these drugs will do anything for the other symptoms of menopause, but that research is ongoing.”

Alternative Approaches

Phytoestrogens. Some women look to non-medical methods to manage the symptoms of menopause. One approach is to increase dietary intake of phytoestrogens, which might work in the body like a weak form of estrogen. These estrogen-like substances are found in food sources including some cereals, vegetables, legumes (soy, for example), and herbs and can also be taken as an herbal supplement. The ability of phytoestrogens to relieve symptoms of menopause, however, has not been determined, and there may be risks associated with their use. It’s important that your talk to your provider if you’re thinking about using a supplement.

Bioidentical or “natural hormones.” Estrogen and progesterone can be made from plants such as soy or yams; these so-called “natural hormones” are supposed to closely resemble hormones naturally produced by the body. A healthcare provider determines the formula for each patient, and a pharmacist puts it together in a process called compounding. There is little data about the safety or efficacy of compounded bioidentical hormones, as they are not regulated or approved by the FDA.

In 2020, at the request of the FDA, the National Academies of Sciences, Engineering, and Medicine (NASEM), published a report outlining recommendations for the clinical use of bioidentical hormone therapy, which advised against the use of bioidentical hormone therapy due to a lack of evidence proving safety or effectiveness of bioidentical hormone therapy.16

Conclusion

The best course of action to be sure you receive the care you need and manage symptoms effectively during menopause is to maintain habits of a healthy lifestyle and proactively seek information about this time of transition. “Educate yourself about what's coming to set yourself up for good health,” Dr. Faubion says. This approach will help you navigate not only the period of transition but also help you maintain health in postmenopause—a period that, for many women, occupies a third of your lifespan.

Note: This article was updated with insight from Stephanie Faubion, MD, MBA, Medical Director, The North American Menopause Society, and Penny and Bill George Director, Center for Women's Health, at Mayo Clinic, in April 2021.

Stay Up-to-Date with Updates Related to Menopause and Other Women's Health Topics with the AWomansHealth Newsletter. Subscribe here.

Sources

North American Menopause Society: Menopause and Me
https://www.menopause.org/for-women. Accessed March 24, 2021.

Women’s Reproductive Health: Menopause. Centers for Disease Control and Prevention Website. https://medlineplus.gov/menopause.html. Accessed March 24, 2021.

National Institute on Aging: What is Menopause?
https://www.nia.nih.gov/health/what-menopause#:~:text=It%20is%20not%20a%20disease,any%20trouble%20with%20menopausal20symptoms. Accessed March 24, 2021.

References

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2. What Do Ob/Gyns In Training Learn About Menopause? Not Nearly Enough, New Study Suggests. Johns Hopkins Medicine website. Available at: https://www.hopkinsmedicine.org/news/media/releases/what_do_obgyns_in_training_learn_about_menopause_not_nearly_enough_new_study_suggests. Accessed April 9, 2021.

3. Kling JM, MacLaughlin KL, Schnatz PF, et al. Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicie, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey.Mayo Clinic Proceeding. 2019; 94(2): 242-253. doi:https://doi.org/10.1016/j.mayocp.2018.08.033

4. Ceylan B, Özerdoğan N. Factors affecting age of onset of menopause and determination of quality of life in menopause. Turk J Obstet Gynecol. 2015;12(1):43-49. doi:10.4274/tjod.79836

5.Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women's Health across the Nation. Obstet Gynecol Clin North Am. 2011;38(3):489-501. doi:10.1016/j.ogc.2011.05.006

6. Drogos LL, Rubin LH, Geller SE, Banuvar S, Shulman LP, Maki PM. Objective cognitive performance is related to subjective memory complaints in midlife women with moderate to severe vasomotor symptoms. Menopause. 2013;20(12):1236-1242. doi:10.1097/GME.0b013e318291f5a6

7. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey. Menopause. 2013 Oct;20(10):1043-8. doi: 10.1097/GME.0b013e318287342d. PMID: 23571518.

8. Weber M, Mapstone M. Memory complaints and memory performance in the menopausal transition. Menopause. 2009 Jul-Aug;16(4):694-700. doi: 10.1097/gme.0b013e318196a0c9. PMID: 19276998.

9. Weber MT, Mapstone M, Staskiewicz J, Maki PM. Reconciling subjective memory complaints with objective memory performance in the menopausal transition. Menopause. 2012 Jul;19(7):735-41. doi: 10.1097/gme.0b013e318241fd22. PMID: 22415562; PMCID: PMC3773730.

10. Jung JH, Bang CH, Song GG, Kim C, Kim JH, Choi SJ. Knee osteoarthritis and menopausal hormone therapy in postmenopausal women: a nationwide cross-sectional study. Menopause. 2018 Dec 21;26(6):598-602. doi: 10.1097/GME.0000000000001280. PMID: 30586007.

11. https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/menopause-and-heart-disease

12. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017; 24,(7) doi: 10.1097/GME.0000000000000921

13. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/06/hormone-therapy-and-heart-disease#:~:text=Nevertheless%2C%20recent%20evidence%20suggests%20that,for%20relief%20of%20menopausal%20symptoms.

14. Boardman HMP, Hartley L, Eisinga A, Main C, Roqué i Figuls M, Bonfill Cosp X, Gabriel Sanchez R, Knight B. Hormone therapy for preventing cardiovascular disease in post‐menopausal women. Cochrane Database of Systematic Reviews. 2015; 3. Art. No.: CD002229. DOI: 10.1002/14651858.CD002229.pub4. Accessed 29 March 2021.

15. Prague JK, Roberts RE, Comninos AN, et al. Neurokinin 3 receptor antagonism rapidly improves vasomotor symptoms with sustained duration of action. Menopause. 2018;25(8):862-869. doi:10.1097/GME.0000000000001090

16. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on the Clinical Utility of Treating Patients with Compounded Bioidentical Hormone Replacement Therapy. The Clinical Utility of Compounded Bioidentical Hormone Therapy: A Review of Safety, Effectiveness, and Use. Jackson LM, Parker RM, Mattison DR, editors. Washington (DC): National Academies Press (US); 2020 Jul 1. PMID: 33048485.

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