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Women face many changes in their body as they age, particularly hormonal. Every woman will go through menopause at some point in their life and every woman will have a different experience. Learn more about menopause, what to expect throughout the transition, and what you can do to manage any symptoms.

What is menopause?

Menopause is defined as the cessation of menstrual periods for 12 months without any other obvious physiologic or pathologic cause. Women typically undergo menopause around age 51, but the following factors may impact this timing:

  • Genetics - Menopause onset is likely to occur within a few years of when your mother started.
  • Ethnicity - Menopause may occur earlier in Latina women and later in Japanese American women compared to Caucasian women.
  • Smoking - Women who smoke typically enter menopause two years earlier than non-smokers.
  • Hysterectomy with ovarian conservation - Menopause may occur up to three to four years earlier in these women.


Perimenopause is a menopausal transition that usually occurs around age 47 after the reproductive years, but prior to menopause. Women may experience irregular menstrual cycles and hormonal changes at this time.

Menopause Symptoms

Hot Flashes

The most common menopausal symptom are hot flashes, a sudden sensation of heat in the upper chest and face that rapidly expands. They typically last two to three minutes, sometimes associated with profuse perspiration and sometimes palpitations. Chills, shivering, and anxiety can occur afterwards. They may happen once or twice a day, or once every hour. Eighty percent of women experience hot flashes, and only 20 to 30 percent will seek medical attention. If left untreated, hot flashes typically cease in four to five years.

Risk factors for hot flashes include:

  • Obesity
  • Smoking
  • Reduced physical activity
  • Ethnicity - African American women are at higher risk of hot flashes, Asian women are less at risk.

Sleep Disturbance, Anxiety and Depression

Approximately 30 to 40 percent of women will experience sleep disturbances in the early menopausal transition, and 38 to 46 percent of women will experience them in the late menopausal transition. Most women who do not experience night sweats will still experience changes in sleep patterns.

Sleep issues may also be related to anxiety and depression. Women are 2.5 times more likely to be diagnosed with depression during menopause. This risk decreases post-menopause.

To ease menopausal symptoms, the following behavioral changes are recommended:

  • Lower room temperature
  • Dress in layers
  • Avoid triggers (spicy food, stress, hot drinks, alcohol, and caffeine)
  • Exercise regularly
  • Do not smoke
  • Layer bedding and keep a cold pack under your pillow
  • Practice paced respiration (slow, deep abdominal breathing)

Atrophic Vaginitis

The vagina is very dependent on estrogen, therefore lower estrogen levels lead to atrophic vaginitis. Atrophic vaginitis is very common and experienced by 47% of postmenopausal women.

The following symptoms of atrophic vaginitis are progressive and worsen over time:

  • Vagina appears pale with lack of rugae (folds)
  • Decreased pubic hair
  • Decreased elasticity of vulvar skin
  • Narrowing of the vaginal opening
  • Fusion of the labia minora to labia majora
  • Decreased blood flow to the vagina and vulva

Early in the menopausal transition, there is typically decreased lubrication with arousal. Later, vaginal dryness can occur in daily activities and pain can occur with or without intercourse.

Cognitive Function

There is substantial biological basis for the role of estrogen in cognitive function. Although there is limited data to support that estrogen helps preserve cognitive function in perimenopausal or post-menopausal women, the decrease of estrogen causes many women to notice changes in memory and learning capacity.

Long-term consequences of estrogen deficiency include:

  • Bone loss/osteoporosis
  • Cardiovascular disease
  • Osteoarthritis
  • Body composition changes (losing lean mass and gaining fat)
  • Skin changes
  • Decrease in balance

Hormone Replacement Treatments

Most women who are within 10 years of menopause or younger than 60 years old are candidates for hormone replacement treatment (HRT), which treats menopausal symptoms such as hot flashes and vaginal atrophy.

Types of estrogen:

  • Oral
    • Less expensive
    • Prior studies
    • Increase sex hormone-binding globulin (SHBG) which can decrease testosterone
  • Transdermal (patch)
    • Lower risk of blood clots and stroke
    • Better if elevated triglyceride levels or at risk of blood clots
  • Topical skin creams, gels, and sprays
  • Vaginal
    • Ring with the same estrogen levels as a pill or patch
    • Ring, cream, and pill with local estrogen exposure

Bioidenticals are hormones with the same molecular structure that our bodies produce and are made in a laboratory. Biodentical hormones are not the same as compounded hormones. Compounded hormones are hormones that are given and dosed based on serial hormone monitoring with blood or saliva tests. Compounded hormones are not regulated and studies show these prescriptions have anywhere from 67.5 to 268% of the dosage on the label and are therefore not recommended.

Bioidentical hormones include:

  • 17 beta-estradiols (estrogen patch)
  • Progesterone - needed in women with a uterus to prevent endometrial hyperplasia and cancer. Types of progesterone include oral and IUD. Side effects of progesterone include mood changes, bloating, withdrawal bleeding (cyclical), and break through bleeding.

Non-Hormonal Treatment

  • Antidepressants
  • Antiepileptic drugs - Especially good for women with mostly night sweats
  • Cognitive Behavioral Therapy (CBT) - Beneficial if having sleep issues
  • Hypnosis - May help with hot flashes

Menopause can be a difficult time for some women. Fortunately there are ways to manage possible discomfort or symptoms you may experience. It can help to educate yourself on what to expect in advance and talk with your health care provider about any questions you have along the way. For more information on menopause, visit The North American Menopause Society.

August 20, 2018 | by Holly Sato MD, FACOG