Menopause unveiled. Navigating change with confidence

The term “menopause” is used to mark the end of a woman’s reproductive years, and the primary signs are the cessation of menstruation (amenorrhea). Menopause isn’t a disease or disorder but the outcome of natural biological processes accompanying aging. Typically, menopause can occur anywhere between the ages of 45 and 55, but it can vary, and the process itself can be different for each woman.

What are the main stages of menopause?

Menopause isn’t an overnight change but rather is a gradual process that includes several stages:

• Perimenopause is the transition phase leading up to menopause, often beginning several years before the last menstrual period. During this stage, the ovaries gradually produce less estrogen. 
• Menopause can be diagnosed after 12 consecutive months without a menstrual period, known as amenorrhea. At this stage, it is almost certain that the ovaries have stopped releasing eggs, and the production of the main hormones, estrogen and progesterone, will have sharply tapered off. 
• Postmenopause is the years after menopause, which can be free of any obvious signs of the change, but due to the lower levels of estrogen, it can carry the risk of a variety of health problems.

How do you know that menopause is starting?

Although it is a highly individual experience, and the signs and symptoms vary, the most common signs include significant changes, both physically and emotionally. All of what is felt and seen as menopause sets in is the result of hormonal changes that are taking place deep inside the body, as production of the main hormones produced in the monthly cycle of fertility starts to fall off. Perimenopause, often referred to as the transitional phase, is the period leading up to menopause in which many women first begin to experience the signs and symptoms of that hormonal change. Estrogen and progesterone levels decrease sharply, leading to the observable symptoms. Understanding these hormonal changes is key to recognizing the transition into menopause.

What are the hormonal differences between fertility and menopause?

The typical menstrual cycle in a healthy and fertile woman is a complex interplay of hormones that prepare the body for potential pregnancy. This cycle, typically around 28 days, includes several phases:

• The menstrual phase (typically days 1-5) starts with the shedding of the uterine lining, marking the beginning of the menstrual cycle.
• The follicular phase (days 1-13) progresses parallel with the menstrual phase, as the pituitary gland in the brain releases follicle-stimulating hormone (FSH), which stimulates the ovaries to produce egg-containing follicles. Alongside rising FSH, estrogen levels rise, preparing the uterine lining to receive a fertilized egg.
• Around mid-period, the pituitary gland responds to the high estrogen levels. It releases a surge of luteinizing hormone (LH), triggering the release of an egg from the ovary. This is ovulation.
• Finally, in the luteal phase, the ruptured follicle transforms into the corpus luteum after ovulation, releasing progesterone and some estrogen. These hormones thicken the uterine lining, preparing it for implantation. If fertilization does not occur, these hormone levels drop, and the cycle restarts with menstruation.

  With the onset of perimenopause, the main differences that come with menopause begin. As a woman approaches menopause, typically in her 40s, the regularity and predictability of these hormonal cycles begin to change: In early perimenopause, the changes are subtle. Estrogen and progesterone levels fluctuate more widely than previously, leading to changes in menstrual cycle length and flow. In mid to late perimenopause, the fluctuations become more pronounced. Ovulation may become irregular or cease altogether, leading to more significant variations in hormone levels and more noticeable symptoms like hot flashes, night sweats, and mood swings. As estrogen levels decrease, the body attempts to stimulate the ovaries by increasing FSH production. High follicle-stimulating hormone levels are often a marker of approaching menopause. Ultimately, the ovaries cannot continue releasing eggs (or the supply of eggs has run out), and menstrual periods stop. A woman is considered to have reached menopause after twelve consecutive months without a menstrual period (amenorrhea). This final transition to menopause will be triggered by a steep decline in estrogen and progesterone production as the ovaries gradually reduce their production. Along with the decrease in estrogen levels, symptoms such as hot flashes, night sweats, mood changes, vaginal dryness, and bone density loss can occur. Some women may experience these symptoms more acutely during perimenopause than in the subsequent menopausal stage.

Is there a diagnosis of the start of menopause?

There is no single test that can definitively produce a confirmation of whether or not a woman has transitioned into menopause. One of the hallmark signs of perimenopause is a change in the menstrual cycle, in which periods may become longer or shorter, lighter or heavier, or more or less frequent. This irregularity can be due to the fluctuating estrogen levels that happen during perimenopause but can also be the result of other external factors. So, while the symptoms of perimenopause are often indicative of the transition to menopause, specific medical tests may be needed to clarify and confirm. These are mainly blood tests of the relevant hormone levels:

• As the ovaries produce less estrogen, follicle-stimulating hormone (FSH) levels increase. An elevated FSH level, especially when combined with the typical symptoms of perimenopause, can indicate that a woman is nearing menopause.
• Lower levels of estrogen can also signify the approach of menopause. However, since hormone levels fluctuate significantly during perimenopause, a single test may not provide a definitive answer.

These tests are more indicative if performed when a woman has experienced several months of amenorrhea (absence of menstruation). The tests are not always conclusive because individual factors such as recent hormonal contraception use can influence the results. Therefore, they are usually considered with a full clinical investigation of the symptoms. The most relevant signs are:

• Irregular periods, which are often the first sign. Periods may become less frequent or unpredictable in flow.
• Hot flashes (or flushes) and night sweats causing sudden feelings of heat, usually in the upper part of the body, are common.
• Vaginal dryness, discomfort, and sometimes pain during intercourse.
• Mood swings, irritability, or increased levels of depression.
• Thinning hair and dry skin.
• Weight gain.

How important are health screenings to detect the onset of menopause?

Postmenopausal women have an increased risk of health problems such as osteoporosis, cardiovascular disease, and breast cancer. Regular health screenings are crucial, including mammograms, bone density tests, and cholesterol checks. Since there are no ways of stopping the transition into menopause, it is necessary to treat the symptoms rather than look for a cure. The main option is hormone replacement therapy (HRT), in which the body’s levels of estrogen are boosted. It can relieve hot flashes and night sweats (vasomotor symptoms), help sleep better, and maintain bone density. The most popular drugs for this are Premarin tablets, which supply conjugated estrogens available in three strengths (0.3mg, 0.625mg, and 1.25mg), and Estrace (estradiol), which supply natural estrogen. For women suffering vaginal dryness and itching, the same compounds come in external creams and gels such as Estrogel Topical Gel and Premarin Vaginal Cream. Another hormone that is affected by menopause is testosterone. Although thought of as the “male hormone”, in fact testosterone is an essential substance that plays a significant part in regulating a woman’s wellbeing. It works to maintain energy levels, a healthy sexual libido, and bone health. The lower testosterone levels that come with the start of menopause can cause:

• Decreased libido or a loss of sexual desire
• Diminished sense of well-being
• Unexplained fatigue
• Reduced motivation
• Depression
• Body shape changes
• Mood changes

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Questions we are asked

How do you know that menopause is starting?

Several signs indicate the start of menopause, including irregular periods, hot flashes, night sweats, mood swings, vaginal dryness, decreased sex drive, and difficulty sleeping. Some women may also experience weight gain or thinning hair. Suppose you are experiencing any of these symptoms. In that case, it is best to consult your doctor to confirm whether or not you are entering menopause.

How long does menopause last?

Menopause itself is a point in time when a woman has gone through 12 consecutive months without a menstrual period. However, the entire process leading up to menopause, which includes perimenopause and postmenopause, can take several years. On average, perimenopause can last anywhere from a few months to several years, while postmenopause can last for the rest of a woman’s life. The duration of menopause can be different for each woman, and it can be influenced by various factors such as genetics, lifestyle, and overall health.

Can menopause occur before the age of 45?

Yes, menopause can occur before the age of 45. This is known as premature menopause or premature ovarian insufficiency. It can happen naturally or due to specific medical treatments or conditions. Women who are experiencing symptoms of menopause before the age of 45 should talk to their healthcare provider to determine the cause and discuss potential treatment options.

Can menopause affect a woman’s sex life?

Menopause can affect a woman’s sex life. The hormonal changes that occur during menopause can cause vaginal dryness, which can make sexual intercourse uncomfortable or painful. Menopause can also decrease libido, making women less interested in sex. However, it’s important to note that not all women experience these symptoms, and there are treatment options available to alleviate them.