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Demystifying Menopause: A Guide to the Basics and Beyond


Befuddled by unexplained crying or anger, breast growth, and a sudden onset of acne, I sometimes tell my patients, “It’s like puberty in reverse.” As many of these women are parents to teenagers, this idea helps put it all together.

Menopause is a transitional time in a woman’s life, just like puberty signals the start of the menses, menopause defines the cessation. Menopause is officially counted as 12 months after the final menstrual period. The average age of menopause is 51, but can occur anywhere from 41-61. It sometimes does happen sooner than that but that is a medical condition called primary ovarian insufficiency, and would signal the need for medical care.



“Perimenopause” begins with the start of the menopausal transition and ends one year after the final menstrual period. This can be further divided into the early menopausal transition and the late menopausal transition. The early transition period can last a varied amount of time, and hormone testing is unreliable as it too is variable from cycle to cycle. During this time, the length of the menstrual cycle (that is, the length of time between the first days of 2 periods) begins to change. For example, someone who always got their periods every 28 days, now may occasionally get one after 21 days, or 34 days, etc. Sometimes there can even be two periods within a cycle - basically 2 ovulations within a month. This can show itself as having a period every two weeks! If this is happening, however, it is important to go see your doctor as it can also signal other health problems and require a workup.

The changes in bleeding accompany changes in hormones from cycle to cycle. The hormonal fluctuations (mostly estrogen and progesterone) can lead to a number of variable changes in the body. Acne, mood changes (swings, anxiety, depression), breast changes (tenderness, growth), hot flashes and night sweats (often during particular times in the cycle), libido changes (some women report transient increases! But also decrease), and many others are possible during this time. The hormone levels and patterns can be different from cycle to cycle, which is why I often do not test levels as they are not all that helpful!



As we progress into the late menopause transition, the cycles become more irregular and start to skip cycles altogether. But beware! Just because you skipped a few months doesn't mean you are done! Most women will continue to get periods every few months and it can be quite an unpredictable time. Also important to know that you can still ovulate during this time and therefore can still get pregnant so contraception is key. We don’t often hear about children naturally born to 50-year-olds - as unfortunately most of these pregnancies would end in miscarriage due to genetic abnormalities in the eggs, but pregnancy can happen and if that’s not an ideal situation for you then I strongly suggest contraception of some kind. And the “rhythm method” doesn’t work so well during this time since there is no predictable cycle. When the periods do come, they might be different than what you are used to. They can be anything from just spotting to extremely heavy. If you are having bleeding that is extremely heavy, please see your doctor to make sure nothing else may be going on (for example fibroids, polyps, anemia, a thyroid problem or even cancer).

Also during this late menopause transition, symptoms of estrogen loss start to show up. This can include hot flashes and night sweats, sleep disturbances, brain fog/poor concentration, low mood, anxiety, joint pains, dry/itchy skin, heart palpitations, vaginal dryness/painful intercourse, and others. Another important symptom to note: is feeling fine! Not everyone has bothersome symptoms of menopause! Some women feel great during these times :)



Postmenopause is everything after 12 months since the final menstrual period. So how long will symptoms last? Well, it depends on the symptoms. Vasomotor symptoms such as hot flashes and night sweats were studied in a large meta-analysis of 10 studies and a total of ~35,000 women. They found that 50% of women still had vasomotor symptoms 4 years after the final menstrual period, and about 10% still had symptoms 12 years after the final period!



In late postmenopause, (approximately 6 years after the final period and everything after) hormone levels have reached stability. That means that for most, vasomotor symptoms have settled down as well as mood changes and many of the other symptoms. However, some symptoms do not go away, and chronic lack of estrogen can have cumulative effects on some tissues in the body. Most notably, the vulva and vagina. Estrogen helps with cell turnover, moisture, and elasticity in the vagina and vulva. Lack of estrogen can cause dryness and stiffness in the tissues which can make sex and vaginal exams uncomfortable or painful for some. Topical treatments such as lube, moisturizers, and vaginal estrogen can be helpful to alleviate these discomforts. There is, of course, more to it than that, so talk to your [menopause and/or sexual health-trained] doctor for help in this area!


It may sound scary, but it probably also sounded scary when you first learned that you would bleed from your vagina every month! It’s important to know it's not all gloom and doom. Some women coast through the transitions without any trouble at all. For the rest of us though, there is help and support out there. There are safe and effective treatments for bothersome symptoms and many ways to prevent some of the symptoms and health concerns that come along with aging and menopause. I am dedicated to helping patients navigate this transition and live their best life through the transition and beyond!


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