Let's Talk About the Signs and Symptoms of Menopause
Have you entered the big M yet? Or feel like you’re heading down that hormonal highway? Read on to find out exactly how to spot the symptoms of perimenopause and menopause.by Sara Faye Green Health Writer
Menopause affects a full half of the population…but the word has been so vilified, it can strike fear in the hearts of all who have a period. True, it marks a big moment for women—the end of fertility—and, due to the hormonal shifts, can affect many aspects of your physical, mental, and sexual health. But menopause is a Normal. Biological. Evolution! (In other words: Why are we whispering about it?) Plus, the symptoms can be treated. The first step to feeling better is identifying and understanding what exactly is happening in your body. We’re here to answer your questions—honestly and openly.
Our Pro Panel
We went to some of the nation’s top menopause experts to bring you the most up-to-date information possible. Look who's got your back:
Diana Bitner, M.D.
OB/GYN and author of "I Want to Age Like That! Healthy Aging Through Midlife and Menopause"
Monica Christmas, M.D.
Assistant Professor of Obstetrics and Gynecology and Director of the Menopause Program
Juliana Kling, M.D.
Associate Professor of Medicine and Associate Chair of Research in the Division of Women’s Health
About two-thirds of women going through perimenopause and menopause have a harder time remembering things and focusing (the definition of brain fog).
The female hormones estrogen and progesterone contribute to hair growth and keep the hair follicles on your head from falling out, which is why women tend to have less dramatic hair loss than men and more subtle thinning over time. But as these hormones decline in perimenopause and menopause, androgens—typically male hormones—swoop in, leading to fewer hairs on your head but more pesky sprigs on your chin and upper lip.
Doctors can run tests to check hormone levels to confirm perimenopause (for women concerned about how it may be affecting fertility or what course of fertility treatment they choose) or menopause, but these tests are not specifically for this purpose or considered an official "menopause test." A doctor would be more likely to run tests for other health conditions or diseases that could be causing period cessation or irregular bleeding, because that could require urgent treatment. For example, a test of thyroid hormone levels would rule that out as a reason for periods stopping, while ovarian cancer can cause bleeding after menopause.
On average, women experience menopausal symptoms for a total of four to eight years, including a few years in perimenopause and a few years after menopause. (If this sounds terrifying, stay calm: For many years these symptoms can be subtle.) However, the length of time women have signs and symptoms varies greatly, and can last up to ten years, beginning with premenopause symptoms, which can overlap with menopause symptoms, and continuing after. Remember, perimenopausal and menopausal symptoms are just as likely to be mild as severe, and 4-8 years of typical symptoms can often mean that subtle versions of these symptoms are dispersed and popping up sporadically to remind you that your body is slowly transitioning over that long period of time, not necessarily plaguing you daily or even requiring any medical treatment at all.
Let's Recap First: What Is Menopause Exactly?
The actual definition of menopause is when your periods stop completely for a full 12 months—which means no spotting or bleeding in between. The average age for menopause is between 51 and 52 years old. More specifically, most women have their last period at 51, and officially enter menopause at 52.
Do I Have the Early Signs of Menopause?
It's all about your flow. Period changes—whether they are further apart or closer together; longer or shorter, heavier or lighter—are the first indicator that you have entered perimenopause (or pre-menopause), the time frame of hormonal changes a woman goes through leading up to actually completing her period (this can last up to ten years). If you begin having perimenopausal period changes in, say, your late thirties or early forties, it’s no reason to panic, because menopause itself can still be a decade away.
To clarify: Perimenopause is actually the first part of menopause but has only recently been separated from "menopause" in terms of how people talk about them (the two used to be grouped together as—eyeroll with us now—"the menopause transition"). So, it follows that the hormonal fluctuations that eventually lead to menopause begin in perimenopause. Perhaps nix this last sentence?
Speaking of those wacky hormones… Shifts in the female hormones estrogen and progesterone may cause a wide array of symptoms, ranging from physical to psychological, that can sometimes take women by surprise: Initially, you may think that symptoms such as trouble sleeping, mood swings, weight gain, or a lack of interest in sex are a reaction to stress or living a busy life, as opposed to the natural result of menopause’s age-related hormonal shifts.
How to know what's going on with you? When these symptoms are on their own, they may have other causes, but if they are regularly occurring along with period changes that don't have any other explanation, you are likely in perimenopause.
Oh! You should also know this: You can still get pregnant until your periods have fully stopped for an entire year. If you do not want to become pregnant during perimenopause this time, you should continue using contraception.
What Are Other Common Menopause Symptoms?
The list below may look daunting, but relief is available! There are more safe and effective treatment options for menopause symptoms than ever before, so make an appointment with your internist or gynecologist to develop a treatment plan catered to your specific experience. And take heart: Symptoms are usually most pronounced in the first two years (the year when your period stops and the year after). Post menopause, symptoms tend to subside when hormone levels stabilize after a few years.
Of note: While perimenopause conversations tend to focus on period changes because they usually appear first, perimenopause doesn't have its own group of symptoms; other than your period stopping in menopause, the symptoms of the two overlap.
These are the most common, yet least understood, menopausal symptoms and affect 75 to 85 percent of all women. They often begin in your face, with a feeling of heat and sweating, before spreading to the rest of your torso. Hot flashes vary in frequency, intensity, length, and location on the body, and can be accompanied by blushing, a racing heart, sweating, and chills (read all about that two paragraphs down!). They can happen multiple times per day or only occasionally and can come on at any time.
On average, women experience hot flashes for six months to two years, though it is not uncommon to have reoccurrences much later in menopause, such as in your seventies or even later.
The exact cause of hot flashes is still unknown, but many theorize that lower reproductive hormones lead the hypothalamus—a region of the brain often referred to as the body’s thermostat—to become more sensitive to slight changes in temperature; because of this, the hypothesis goes, the hypothalamus overcompensates by turning the heat all the way up. Your body then reacts to this rise in body temp by putting its cooling systems into overdrive: blood vessels dilate, sending fresh blood to the area of the flash in an attempt to regulate the excessive production of internal heat by releasing and dispersing it on the surface of your skin—causing a flushed, sweaty feeling and appearance. This cooling response is so swift that many women often end their hot flashes with chills and in cold sweats.
Hot flashes that, yep, happen at night. You may wake up with your hair wet, your pajamas damp or stuck to you, or, again, shivering from a chill in a pool of your own sweat.
Night sweats can keep you wide-eyed in the dark. In fact, according to the National Sleep Foundation, 61 percent of menopausal women report insomnia symptoms. Because of the drop in the hormone progesterone—which aids in sleep—you'll also have an increased sensitivity to caffeine and more difficulty dosing off.
Sleep jokes abound—and we've all made jokey comments about how little or how much we get—but insomnia can snowball into other physical and mental health symptoms, so don't ignore it. Seek treatment from your PCP, who can recommend a sleep specialist if it regularly takes you more than 30 minutes to fall asleep or you get fewer than six hours of shuteye more than three nights a week.
Vaginal Dryness and Painful Sex
Low estrogen can make your vulvar and vaginal tissue feel dry and irritated, resulting in pain during sex. Your body will produce less natural lube, which, because of the friction, can cause microabrasions and an increased likelihood of vaginal infections, such as yeast infections, urinary tract infections, and bacterial vaginosis.
At least half of menopausal women experience vaginal dryness, irritation, and pain during intercourse—a combination of symptoms medically known as genitourinary syndrome—but as many as 90 percent of them don’t receive treatment. Two reasons for this: Either they 1) are afraid or embarrassed to talk about it, or 2) assume that this blend of symptoms is just a part of aging they have to put up with.
Please! There is no need to suffer, with so many good treatments available to assist with both menopause and climaxing. You shouldn’t—and don’t—have to sacrifice great sex as you age. A North American Menopause Society (NAMS) certified practitioner (NCMP) can help you determine which fix is best for you. Settings are weird on this doc but added link in markdown format for Jenna.
Urinary Frequency or Urgency
To sum it up: less estrogen, more peeing. Additionally, a drop in the hormone can make it more difficult to hold it when you feel the urge. At night, this need to go can make sleep issues worse.
Many of the same localized treatments for vaginal dryness, irritation, and pain can ease this other part of genitourinary syndrome—yet another reason to discuss these very common symptoms with your doctor to find the right remedy.
Loss of Libido
How many times can we say "drop in hormones" in 1,000 words? That drop in hormones combined with the resulting dryness and irritation of vulvar and vaginal tissue can make some women feel less interested in sex altogether.
New studies increasingly show how complex decreased desire is, and menopausal women experience this change in desire differently. There tends to be two camps: Women who seek treatment to correct their loss of libido ASAP because they truly crave sex. And those who are liberated by the change (how freeing to not have to think about pregnancy, child-rearing, and autopilot sex 2.1 times a week!). This latter group considers it a kind of renaissance era with more mental space and energy for their own hobbies and interests.
Not feeling liberated minus a libido? As we said above, your sex life isn't over: If you are part of the 12 percent of women experiencing a menopausal loss of desire—and one of the third of that group who is troubled by it—many of the same hormone therapies (previously known as hormone replacement therapies) that treat genitourinary syndrome have also been shown to help increase sexual arousal and pleasure.
Plus, there are so many other ways to alleviate sex-related menopausal symptoms, from different prescription medications, to over-the-counter lubricants and moisturizers, to focusing on outercourse (which includes any and all sexual activity that is not penetrative) and other types of intimacy.
If a libido dip is also connected to shifts in a long-term relationship or your partner’s health and aging, your doctor can connect you to a sex therapist who can help with those dynamics and get you back in the groove again.
Estrogen and progesterone can be mood-enhancing—so when they slump, so can your disposition. Especially when combined with insomnia, lower hormone levels can lead to a lot more irritability and anger.
Think back to the days of PMS: If you experienced crying jags or were quicker to anger than usual, you're more likely to have those same hormone-induced symptoms during menopause (though they can also affect women with no prior history).
Depression and Anxiety
Similarly, if you had bouts of depression, postpartum depression, anxiety, or other mental health issues before menopause, you’re more prone to see them return. Consider returning to the medications and treatments you previously took to deal with the combination of menopause and anxiety, or menopause and depression.
If you're experiencing psychological symptoms for the first time, take it seriously: Any instance of depression, severe anxiety, or other mental health episode is reason to speak with your doctor. There are so many treatment types—hormonal, psychiatric medications, and therapy—that can provide much relief.
Some women entering perimenopause or menopause can add pounds or have more difficulty dropping them. The typical weight-management advice applies here: Practice healthy habits such as regular exercise, good sleep hygiene, and limiting refined carbohydrates such as sugar and other "white foods," which are more likely to be turned into fat due to increased insulin resistance during menopause.
Do Menopause Symptoms Look Like the Symptoms of Other Health Issues?
Before you rush to your own menopause diagnosis, consider that you could have a case of mistaken identity here. In fact, one reason you will always be asked the date of your last period at any medical appointment is because a change in periods can be an indicator of a great many health conditions—plus, a wide swath of medications may cause period changes and spotting.
Discussing your suspected perimenopausal or menopausal symptoms with an NCMP will help rule out other causes. While not comprehensive, this list contains medical conditions and medications that could be the cause of your recently wonky periods or other seemingly menopausal symptoms:
Thyroid disorders. Low or high thyroid hormones can mimic the symptoms of perimenopause by causing heavier, skipped, or stopped periods. They can also halt ovulation, and symptoms of hyperthyroidism mirror those of perimenopause and menopause, including lack of periods, mood swings, insomnia, and even hot flashes.
Untreated, hyperthyroidism can actually bring about early menopause, which is why middle-aged women should have their thyroid checked regularly at their annual physical so any thyroid problems can be caught early and treated before they cause lasting damage.
Psychiatric medications. Common antidepressants called SSRIs (or selective serotonin reuptake inhibitors)—like Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline)—help make more serotonin, a neutrotransmitter often called "the happiness hormone," available in the brain. Estrogen and serotonin have a complicated relationship that is still not completely understood, which is why many psychiatric meds can affect periods, cause spotting, and even make hormonal birth control less effective.
If you are on any psychiatric medications and experiencing spotting or period changes, make sure to read all the fine print, because some psychiatrists themselves don't even know to warn women about these little-discussed side effects.
Spironolactone. A prescription medication that is often given to women in their thirties who experience hormonal acne, spironolactone is an androgen blocker (meaning it barricades male hormones that can cause breakouts) with progestin, a form of progesterone—which can throw off your hormonal balance and cause breakthrough spotting and irregular periods.
Steroids. Any medication that interacts with hormones can deregulate your own hormones and lead to heavier bleeding or skipped periods. Steroids usually taken for which conditions?
Hormonal birth control. While it seems nonsensical that the very thing you might be taking to regulate your periods could also have the unwelcome side effect of deregulating them, hormones are tricky little things, complex and specific to each person. If you are on hormonal birth control such as TK and experiencing irregular periods or a change in bleeding, make an appointment with your doctor to go over what is happening and to determine if there is another contraceptive that would work better for you.
Anticoagulants. From prescription blood thinners to OTC NSAIDS as basic as aspirin, anything that works by thinning your blood can affect how much and how often you are bleeding.
Polycystic ovary syndrome (PCOS). One of the main symptoms of PCOS is heavy, irregular, or missed periods.
Endometriosis. This health condition, in which menstrual tissue grows outside of the uterus, can cause heavy and irregular periods.
Being very overweight or underweight. Either can affect and throw off periods; eating disorders, such as anorexia, can also have this consequence, even stopping your period for years.
Pregnancy, birth, breast feeding, and having a C-section. These can all change the frequency and heaviness of periods.
All in all, there are tons of things that might cause the symptoms that you are mistaking for menopause—but if you are a woman in her mid-40s, it very well could be menopause. To be sure, talk to your doctor and get a full medical checkup.
How hormones change in menopause: The Cleveland Clinic. (2019). "Menopause, Perimenopause, and Postmenopause." my.clevelandclinic.org/health/diseases/15224-menopause-perimenopause-and-postmenopause
Symptom assessment: The North American Menopause Society (NAMS). (n.d.). "What Are the 34 Symptoms of Menopause?" menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/are-we-there-yet-navigate-now-with-our-guided-menopause-tour
Benefits of hormone replacement therapy (HRT): Menopause. (2017). "The 2017 hormone therapy position statement of The North American Menopause Society." menopause.org/docs/default-source/2017/nams-2017-hormone-therapy-position-statement.pdf
HRT and heart disease risk: Menopause. (2019). "The Kronos Early Estrogen Prevention Study (KEEPS): what have we learned?". journals.lww.com/menopausejournal/fulltext/2019/09000/The_Kronos_Early_Estrogen_Prevention_Study.21.aspx
Solutions for menopause symptoms: Faubion Stépanie S. (2016). The menopause solution. New York, NY: Time Inc. Books.
Updates on HRT: Nature Reviews Endocrinology. (2017). "Hormone-replacement therapy: current thinking." nature.com/articles/nrendo.2016.164