Hot flashes, mood swings, the need to pee All. The. Time.: Menopause isn't always the most delightful experience. But there are now lots of ways to get relief so you can feel like yourself again, body and mind.
Menopause symptoms getting in the way of living? There used to be only two treatment options: hormone therapy, or Just Deal With It (official Rx name, obviously). That’s far from the case now. Read on to find the right menopause solutions tailored specifically for you. And if you don’t want to treat menopause, you don’t have to. It's a normal phase of life, and the remedies are here for you only if you want 'em.
We went to some of the nation's top menopause experts to bring you the most up-to-date information possible.
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
First, What Exactly Happens During Menopause?
Menopause affects everyone uniquely. It’s possible you could be in the menopause minority and experience a gradual spacing out and then stop of your periods, wonder what all the fuss is about, and feel positively liberated that you no longer have to shell out for tampons.
Or you may be one of the women who has hot flashes and night sweats. You could experience vaginal pain and urinary symptoms. Or you might be surprised at just how much your moods seem to shift along with your body. All of these menopause experiences are completely normal, and all are related to the drop in (or erratic behavior of) the reproductive hormones estrogen and progesterone.
Once you begin experiencing menopausal symptoms, it helps to find a clinician who has been trained specifically in menopause, whether it’s your gynecologist, PCP, or even another specialist you see who has received the training, such as an oncologist or reproductive endocrinologist. You’re looking for a pro who has certification from The North American Menopause Society (NAMS). The group has a function on its website where you can type in your zip code to search for a NAMS certified medical practitioner (NCMP) in your area.
People tend to have strong preconceptions about hormone therapy, or HT (previously called hormone replacement therapy, or HRT). But a lot of them are based on an outdated study from the Women’s Health Initiative conducted in 2002, which implied that women who were put on HT had higher rates of heart attack, stroke, and breast cancer.
Turns out, the average age of the women enrolled in that study when they started HT was 64, while the average age most women have menopause symptoms and seek treatment is in their early fifties.
In the 17 years since the WHI hubbub, numerous new studies and reviews have shown that the safety of HT depends on how old you are when you start the hormones, your personal family history and other medical conditions, and the strength of the dosage.
The best time to begin (any type of) HT? The first time your symptoms start bugging you. The current recommendation for women without contraindications—such as a history of breast or uterine cancer (estrogen can help some breast cancer cells grow)—is to start as early as possible on the lowest effective dose, and stay on it for the shortest time necessary.
The sooner you start taking hormones, the less potential risks they carry; these vary depending on your medical history but can include an increased risk of certain cancers, blood clots, and heart disease. Start right as menopausal symptoms become bothersome, and those risks significantly drop for most women.
It also helps when the hormones are administered transdermally, in lower doses, such as through a patch or gel or vaginally. As opposed to oral hormones, this method of delivery keeps the effects localized and therefore less likely to substantially affect other parts and systems of the body.
This is particularly the case for women in their 60s or ten years post menopause: For them, docs typically recommend lower-dose or more localized HT (such as vaginal-specific options) or nonhormonal medications (scroll down to read about SERMs and SSRIs).
Are There Different Types of Hormone Therapy?
Your NAMS-certified physician will discuss your particular symptoms and risks before prescribing any medication.
She may come to the conclusion that HT is not right for you, if you have a family history of breast, uterine, or ovarian cancer or heart attacks or blood clots—or if you are already over the age of 59, when risks of certain cancers, blood clots, and heart disease increase.
If you’re low-risk, there are a variety of HT options available, but don’t try any (or any meno treatment, for that matter) without first discussing with your doctor what other meds you’re on.
For Vaginal Symptoms
Forty percent of women have vaginal issues during menopause. Prepare for such delightful things as dryness, irritation, pain during sex or exercise, and having to pee frequently and often.
Your doctor can help you find the right low-dose hormone therapy, localized around the vagina, if you only have vaginal and urinary symptoms. These include:
Vaginal estrogen ring. This slow-release estrogen ring stays in the vagina for 90 days at a time and provides steady relief. Sold under the brand name Estring, this looks and feels similar to the NuvaRing contraceptive ring, but it releases estrogen. It lasts three months at a time, so if you’d rather not worry about taking meds every day, you might like this.
Vaginal estrogen gel or creams. These vaginal dryness treatments can be applied daily to soothe irritated tissues from sex or exercise that hurts. As vaginal tissue becomes thinner and tighter, you may even feel friction just walking around, cooking, you know, living life—such a moisturizer will also protect against this, too.
Vaginal estrogen tablets or suppositories. If you want to try vaginal HT but gels and creams seem messy, consider these options, which are inserted into the vagina.
For Multiple Symptoms
If you’re really super-duper lucky, you’ll get symptoms that are vaginal and beyond! Oh yay!
This could mean hot flashes, sleep issues, mood swings, or bone loss. If this is you, you’ll likely want hormone therapy that isn’t localized to the vagina.
As with contraceptive hormones, choosing the right hormone delivery method for menopause often comes down to personal preference. Some women like a patch they don’t have to reapply as often, while others can't stand something stuck to them and go instead with gels or pills. The goal is finding something that feels natural for you.
Transdermal estradiol estrogen patch. Stick this on your lower belly or upper butt and get on with your life. Sold by the brands Estraderm and Vivelle.
Transdermal estrogen gel. Rub this gel, sold under the brand name Divigel, into the skin of your thigh each day and ahhhh, relief. It comes in varying strengths so you can experiment with your doctor to find the lowest effective dose. (For both estrogen patches and gels, your M.D. may also add a progestin to your regimen to help lower the risk of uterine cancer. It's always about finding the right hormone balance for you.)
Steroidal vaginal inserts. This is not technically estrogen, but steroids that stimulate the nerves in vaginal tissue to help with sexual arousal. Steroids are hormones that affect, signal to, and act as catalysts for other hormones—in this case, for estrogen.
Look for the brand Intrarosa (prasterone, also known as dehydroepiandrosterone, or DHEA). It may help with depression and bone loss prevention as well. Because prasterone is converted into estrogen, this product may not be recommended for women who cannot take that hormone, such as breast cancer survivors or women with a family history of breast cancer. And it can have adverse interactions with most psychiatric medications, including SSRIs (Selective Serotonin Reuptake Inhibitors), antipsychotics, sedatives, anticonvulsants, and sedatives, as well as other hormones such as estrogen and testosterone. Be sure your doc has your whole medical history before deciding.
Oral estrogen and progesterone. For some women who are experiencing a barrage of systemic symptoms, a combination of oral estrogen and progesterone can be #treatmentgoals. The progesterone balances out the higher estrogen dose, helping to counteract the estrogen-related risks mentioned above.
These oral hormones do carry a larger risk for women with contraindications (such as a family history of breast, uterine, or ovarian cancer) than transdermal and vaginal hormones, because they tend to be prescribed at a higher dosage—but it is still considered low for most women who do not have contraindications and begin HT early. Specifically, women who start and undergo these treatments between the ages of 50-59 have a low risk compared to those who take them later. If you continue using them after 59, you should come in for more checkups to be monitored by your doctor.
Systemic hormone therapy can also cause spotting after menopause. Still, if you’re on it and notice vaginal bleeding, talk to your doctor to make sure there isn’t another cause.
What About Bioidentical Hormones? Safe? Effective?
Bioidentical hormones are hormones that are chemically similar in structure to hormones that naturally exist within the body. FDA-approved hormones for HT are, for practical reasons, “bioidentical”—otherwise, they would not be effective, because they would not work in the body.
But it’s not a medical phrase; "bioidentical hormones” is mostly a marketing term for unregulated hormone products without a prescription. For example: companies selling unregulated yam creams and pharmacists whipping up their own (a big no!) compounded hormones (see “Any non-prescription menopause treatments I can try?” for more deets).
It’s being used in the same way wellness, food, and beauty companies have co-opted the term “all natural”: Both sound good but are essentially meaningless labels with no real scientific definition or basis.
In the case of hormones, choosing something because it says “bioidentical” can be quite risky. The dosage is unregulated, so you simply don’t know what you’re getting. In fact, the term irks many doctors, as patients come to them after trying “bioidentical” hormones from an unreputable place and experiencing negative results.
The takeaway: If hormones are not FDA-approved, they are dangerous, whether they are “bioidentical” or not. There is no situation in which you should get hormones without a prescription. Ask your doctor for the FDA-approved hormones that are right for you.
So What Are My Non-estrogen Treatment Options?
As we’ve mentioned, there are various reasons people aren’t able to use estrogen, including certain preexisting health conditions or a genetic predisposition to breast cancer. Here are the most common no-estrogen options.
Selective Estrogen Receptor Modulator (SERM)
A SERM acts like and redirects estrogen to parts of the body that need it (see: bones, uterus) but not to the breasts. It can be a boon for women concerned about osteoporosis, because SERMs can also redirect existing estrogen to the bones, where it can help to prevent bone loss.
Some SERMs—such as Nolvadex, Soltamox, Tamoxen, Tamofen, Emblon, and Tamosin (all tamoxifen), and Evista (raloxifene)—are even prescribed for the prevention and treatment of breast cancer. So, in all, SERMS can be a good option for breast cancer survivors, those with a family history of BC, or if you’re at a high risk for bone loss or osteoporosis.
SSRIs (Selective Serotonin Reuptake Inhibitors, Colloquially Known as Antidepressants)
These increase the amount of serotonin in the brain by blocking its reabsorption. Though the exact relationship between estrogen, serotonin, and hot flashes is still being investigated, we do know that estrogen boosts serotonin production. When serotonin drops in menopause as a result of decreased estrogen, SSRIs have been found to reduce hot flashes and night sweats that can accompany the estrogen/serotonin deficit. These can be good options for women without psychological concerns who don’t want to go on HT.
But! If you are experiencing emotional as well as physical symptoms (thanks, Lady M!), the beauty of an SSRI is it can knock out both. Estrogen increases production of the feel-good neurotransmitter serotonin; as it drops, you can have a steep decline in feelings of well-being and contentment. Not to mention crappier sleep. There can also be emotional stress as related to issues with sex and self-image. Enter: an antidepressant.
Do know that many psychiatric medications get served with a steaming side of sexual issues (such as lack of libido), so many women combine one with a low-dose vaginal product (as opposed to just higher-dose systemic HT). It’s a balancing act that your doctor can help guide you through. The goal: the fewest symptoms, the lowest risk of side effects, and the best quality of life overall.
Brisdelle (paroxetine). Brisdelle is the only version of the SSRI paroxetine that has been specifically created for treating hot flashes and night sweats alone, minus other mental health symptoms. (Other SSRIs can decrease hot flashes without psychological symptoms too, they just aren’t marketed that way.)
Paxil and Pexeva (paroxetine). If you are experiencing hot flashes, night sweats, and mental health symptoms at the same time, your doctor can help you arrive at the right dosage and type of paroxetine to treat the combination. In these cases, it can be prescribed in a lower dose than would be used for people who also have depression, anxiety, or OCD.
Lexapro (escitalopram). According to a new study, this SSRI can reduce the frequency and severity of hot flashes while helping with other mood-related symptoms. As with taking SSRIs for other reasons, such as depression, it may take a while to see which one from this group works best for you.
SSNRI (Selective Serotonin and Norepinephrine Reuptake Inhibitor)
Another class of antidepressants used to treat anxiety, SSNRIs increase not just serotonin in the brain but also norepinephrine. This latter neurotransmitter is linked to learning, attentiveness, emotions, and sleep.
Effexor XR (venlafaxine). It's been shown to ease hot flashes as well as reduce menopause-induced depression and anxiety. If you’re experiencing either and hot flashing, it might be your pick.
These are non-SSRIs that are also commonly prescribed for women during menopause.
Neurontin (gabapentin). An anticonvulsant that calms nerves in the brain, thus helping decrease hot flashes, stabilize mood, regulate pain, and improve sleep. Some opt for this because it often doesn’t come with sexual side effects the way SSRIs can.
Gabapres (clonidine). Originally a blood pressure medication, it can decrease hot flashes and works as a mild sedative, hushing hormone-induced anger or feelings of rage. It’s a good option for women who have high blood pressure and are seeking hot flash relief, as women with high blood pressure have contraindications for HT (that said, you don’t have to have high blood pressure to take this med for menopause symptoms).
What About Premenopause Treatments for Period and PMS Symptoms?
If you are in the perimenopause part of menopause—a years-long phase before you hit full meno in which your periods start getting wonky—consider the hormonal options below if you are experiencing:
frequent periods that are getting in the way of your life, or
exacerbated PMS symptoms (mood swings, cramping, irritability and sleep disturbances) that are getting worse with age.
Both options we’re going to tell you about tap into the hormone progesterone, which can lighten heavy bleeding, lessen the length of time your period lasts (if it’s become prolonged), and even out your hormone levels. That latter part? Stabilized hormones = less extreme mood swings and sleep disruption.
Why choose one over the other? It’s just personal preference.
Low-dose progesterone IUD. A levonorgestrel intrauterine device (made by Mirena, Kyleena, Skyla, and Liletta) is a type of birth control that is inserted into your uterus and prevents your uterine lining from thickening up enough to allow pregnancy. That is also why it lightens periods, which are the monthly shedding of that lining. With an IUD, some women end up with no periods at all. This is a solid option if heavy bleeding is one of your main issues.
Low-dose oral birth control. There are many FDA-approved options with just progesterone, so your menopause physician can go over the pros and cons of each to find the type that best suits your symptoms.
Can I Still Enjoy Sex After Menopause?
Chant it with us (and Obama): Yes, we can!
The best treatment for menopausal dryness, irritation, and pain is an FDA-approved, low-dose vaginal estrogen (ring, gel, cream, or tablet). See deets on this above, in the section hormone therapy for vaginal symptoms.
If your vagina feels irritated even when you’re not having sex and you’d rather not go on HT, or you want more soothing, there’s such a thing as a vaginal moisturizer. Yep, it’s like a daily, over-the-counter moisturizer you put on your face when your skin is dry, only it’s specifically formulated for your vagina and vulva.
You can go with an over-the-counter vaginal moisturizer or a lubricant. It’s fine to use lube as moisturizer, if you find one you like. For both, here’s how to pick a good one:
Avoid fragrance and alcohol—or make sure both are low on the ingredients panel on the label. They can further irritate already inflamed vaginal tissue.
Look on the label for an osmolality—the concentration of substances immersed in a solution— around 380, with 1200 as the tippy-top, according to the World Health Organization (WHO). This is close to the natural osmolality of vaginal secretions, so it should feel liquidy, slippery, and not too dense.
You want a pH as close as possible to natural vaginal moisture; a range of 3-5 is ideal and should be listed on the label.
The brands Ah! Yes and Good Clean Love make a variety of moisturizers and lubes in this sweet spot of osmolality and pH.
Also remember: Sex is not just intercourse. Give other stuff a try!
Use menopause as an opportunity to explore other types of intimacy and pleasure. Outercourse—any foreplay and sexual activities not dependent on penetration as the main event—can be revelatory for women at any age.
Any Natural Remedies for Menopause Symptoms?
Like most OTC supplements and tinctures that claim to help with medical issues, those for menopause are running around like it’s the Wild West! Here are a few things to know:
Remember: The FDA does not regulate supplements that sell without a prescription. The North American Menopause Society (NAMS) recently did a full review of unregulated supplements currently being marketed specifically for menopause, with the conclusion that they all did more harm than good. Black cohosh (the root of an herb), for example, was found to be no more effective than a placebo, and in some cases even caused liver damage.
Any hormone-product that you can buy without a prescription is dangerous and unregulated, even if it is a “natural” cream, gel, spray, or pill.
There are also compounded hormones—combinations of various estrogens and sometimes other hormones, which are often DIY recipes—mixed by pharmacists, doctors, or other people trying to profit on menopause.
They’re not a good idea: They aren’t mixed in labs, aren’t regulated by the FDA, and some have been found to contain hugely varied estrogen amounts, many at dangerously high levels that could cause blood clot. Others have so little estrogen, they’re a waste of money.
There are some standard vitamins not specifically marketed as menopause supps but that can be beneficial during this time.
For example, magnesium has been shown to aid sleep, and calcium can protect against bone loss. Getting enough calcium as you age can help prevent osteopororis; this is because estrogen is an instigator of osteoblasts, the cells that build bone.
These dried, powdered mushrooms and other plants may help with focus, alertness, memory, and mood. They have not been shown to have any ill effects and even help some people cut down on caffeine (which can contribute to insomnia in menopause).
MUDWTR is a tea that is a mix of chai herbs and spices as well as adaptogenic mushrooms and plants including lionsmane, cordyceps, reishi, chaga, turmeric, and cacao.
With zero sugar and less caffeine than coffee, it is a safe—and tasty!—morning substitute that (because of the adaptogens) may also help with some menopausal symptoms, such as mood swings and brain fog, according to recent studies.
Ye olde weed may be a political lightning rod, but products containing its compounds are relatively safe sleep and sex abettors. The two main compounds in marijuana are:
CBD: This relaxes people but won’t get you high. It’s also found in hemp.
THC: Tetrahydrocannabinol is the psychotropic cannabinoid part of marijuana, still illegal in some states. Where it is legal, you want products with low amounts.
Some people like cannabis for menopause because it has fewer dangerous side effects and contraindications and a lower risk of being addictive than many prescription drugs for sleep or sex problems.
The product options for both CBD and THC include:
Vaginal lubes and moisturizers
Edibles, such as gummy candy, lozenges, mints, and chocolates
Tinctures (drops you put under your tongue)
If you’re trying an edible or tincture for the first time, start with a small dose and see how you feel, whether it is THC, CBD, or a combination of the two. A vaginal lube or moisturizer with THC is unlikely to give you the giggles and the munchies; instead, it’ll feel slightly numbing, warm, or tingling, effects some women find help with arousal.
In states where marijuana is legal, you can find products with THC from companies such as Foria which will direct you to dispensaries and other suppliers in your state for purchase. For online CBD products, we like Lord Jones. Its CBD goodies are shippable to states even where marijuana is illegal.
What Can I Do for Hot Flashes?
If you don’t need HT or other meds and are looking for help for mild or occasional flashes, your best bet is to chill out! Like, litrally (said with British accent). Get cool with the basics (drink ice water, sleeping with the windows open) or these six tricks, no Rx necessary.
Many menopausal women enjoy swimming or water fitness classes for exercise, partly for the comfort of spending as much time as possible in the pool.
Try facial beauty tools, such as jade rollers or other cosmetic devices like Allegra Magic Globes, that can be kept in the freezer; roll them over your face and neck, where hot flashes often start, to comfort and quell a minor flash. Added bonus: less facial puffiness!
Look for other cooling beauty items, such as gel freezer masks, facial mists, sheet masks, or cooling moisturizers that contain aloe, cucumber, blue tansy, milk thistle, chamomile, or green tea.
Wear breathable fabrics such as cotton and linen, which allow air to circulate. And be sure to layer so you can easily slip into something less toasty.
To decrease night sweats, stash an ice pack under your pillow.
Keep your bra in the fridge! Weird but works.
No matter which menopause symptoms you experience, know that relief is available. That said, your body is experiencing a natural—we repeat, natural—change. We hope this guide helps you assess talking points when discussing treatment options with your doctor. And if you decide you want to embrace your symptoms sans-treatment, we salute you.
Frequently Asked QuestionsMenopause Treatment
Is an ob/gyn the only kind of doctor to see for menopause care?
Menopause care is different than other types of women’s health care, because it is less important that the doctor is an ob/gyn and more important that she has NAMS (North American Menopause Society) certification. (This doc could also be your primary care physician, fertility specialist, reproductive endocrinologist, or even your cancer specialist, for example.) Generally, doctors, including gynecologists, receive little to no menopause training in medical school. NAMS offers its own training and certification specifically for menopause; you can do a search on their site by zip code to find all of the NAMS certified physicians in your area.
I keep hearing about “compounded hormones.” What does that mean?
It means hormones mixed together without any medical or regulatory supervision; even if done by a pharmacist or an entrepreneurial doctor, these are not FDA-regulated or -approved. Creams, gels, supplements, or any other product containing compounded hormones have been found to contain wildly varying amounts of estrogen, which is dangerous. Too much can cause blood clots and other avoidable health issues, and too little means they’re ineffective and a waste of moolah. FDA-approved prescription hormones are both safer and more affordable: Your doc will make sure the dosage is kept as low as possible, while your insurance will likely cover the cost.
Are there vitamins specifically for menopause?
The best way to get vitamins during menopause is through a balanced diet. However, if you are concerned that you may be lacking, have your doctor check your blood work to determine if there is something specific you need. Just feeling a little run down and want to make sure your bases are covered? The Smarty Pants brand of multivitamin gummies has a Masters variety for women over 50, whch contains an arsenal of energizing vitamins such as B and D that menopausal women sometimes lack, and which are often not found in basic multis. They also boast DHA, omega-3, and CoQ10 for heart health, vitamin K for bones, lutein for eyes, as well as your daily RDA of everything else you’d expect in a good women’s multi.
My doc says pot might help me feel less inhibited during sex in menopause, but I don’t want to smoke or vape it. Thoughts?
There are many cannabis solutions for sexual dysfunction, so you definitely don’t have to start inhaling to get your groove back. First, let’s clarify: THC is the psychotropic compound in marijuana that can make you high and only legal in certain states. CBD is the part of the plant that relaxes you, almost like a mild sedative, to help you get in a chill mood without the high. In states where marijuana is legal, you can find lube, vaginal moisturizers, and low-dose edibles with THC from the brand Foria. (A topical vaginal product with THC isn’t likely to get you high; it should feel slightly numbing, warming, or tingling, which some women find helpful for arousal.) In states where marijuana is still illegal, you can find the same wide array of products with CBD only; check out the brand Lord Jones.
What the Women’s Health Initiative has taught us about hormone therapy:Clinical Cardiology. (2018). "What the Women's Health Initiative has taught us about menopausal hormone therapy." ncbi.nlm.nih.gov/pmc/articles/PMC6490107/
Vaginal lubricants and moisturizers for menopause:Climacteric. (2016). "Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?" ncbi.nlm.nih.gov/pmc/articles/PMC4819835/
Magnesium and sleep:Journal of Research in Medical Science. (2012). "The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial." ncbi.nlm.nih.gov/pubmed/23853635
Adaptogens:Pharmaceuticals. (2010). "Effects of Adaptogens on the Central Nervous System and the Molecular Mechanisms Associated with Their Stress—Protective Activity." ncbi.nlm.nih.gov/pmc/articles/PMC3991026/
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