Menopause

The term “menopause” is derived from the Greek words “mens” (month) and “pausis” (cessation). For people AFAB, it’s the stage in their lives when their ovaries stop ovulating (releasing eggs) and when menstrual periods stop completely.

This usually marks the end of the childbearing years for most people AFAB, although it’s possible to get pregnant after menopause. Pregnancy may be achieved during this time with the help of fertility treatments such as hormone therapy and a process known as in vitro fertilization, in which egg cells are fertilized by sperm outside of the womb.

When does menopause happen?

The average age of menopause in the U.S. is around 52 years old, although it may occur somewhat earlier or later in life. The average age worldwide is between 45 and 55 years, according to the World Health Organization (WHO).

How long does menopause last?

Perimenopause (the time frame leading up to your last menstrual period) lasts around two to eight years, with an average of four years. Once you haven’t had a period or spotted for 12 consecutive months, you’ve reached menopause. This life stage will continue for the rest of your life.

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Menopause is a gradual process that unfolds in three stages according to the Stages of the Reproductive Aging Workshop (STRAW)+10 staging system. This is the gold standard for describing the stages of menopause:

Reproductive stage

A person’s menstrual cycle proceeds as usual during the reproductive stage of life, although slight changes to menstrual flow may occur, such as lighter or heavier and shorter or longer periods. Lab work that may be done late in this stage may show variable levels of follicle-stimulating hormone (FSH) between the second and fifth day of the menstrual cycle. (FSH is a hormone made in the brain that stimulates the body’s reproductive organs, particularly the ovaries.)

If you’re trying to conceive later in the reproductive stage, your HCP may recommend getting an FSH test to check the health of your ovaries or fertility levels. It may also be ordered if your menstrual cycle has become irregular during this stage.

Perimenopause (menopausal transition) stage

Perimenopause describes the hormonal transition your body goes through before menopause. These hormonal changes can cause perimenopause symptoms, which include hot flashes and sleep issues such as insomnia.

The menopausal transition is part of perimenopause. It describes changes in the pattern of your menstrual cycle. The length of time between each period may be shorter or longer, or you may experience spotting between periods or skip them altogether.

You may also notice your menstrual flow becoming heavier or lighter. For some, menstrual period symptoms may feel more severe.

Some people might not have a menstrual period for 60 or more days as this stage progresses. Early in the perimenopause stage, FSH levels may vary.

For many people AFAB, perimenopause starts in their 40s, although some start to experience it in their 30s. Perimenopause lasts around two to eight years, with an average duration of about four years. This time frame may be longer in people who smoke or are younger when they start perimenopause.

Postmenopause stage

Perimenopause gives way to menopause once you haven’t had a period for one full year. This includes no menstrual bleeding or spotting for 12 months in a row. Postmenopause is the period of time after you’ve reached menopause.

During early postmenopause, lab work might show an elevated FSH level above 40 IU/L. As the stage progresses, these levels tend to stabilize.

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Menopause symptoms can range from mild to severe. Some may not experience any symptoms while others experience a spectrum of symptoms.

Perimenopause and/or menopause symptoms may include:

• Breast tenderness
• Dry eyes
• Dry mouth
• Dry skin
• Emotional and psychological shifts such as being more short-tempered, irritable, or moody along with feeling more anxious or depressed
• Hot flashes and night sweats (see more below)
• Lower self-esteem and confidence
• Insomnia
• Irregular menstrual periods or menstrual flow that’s heavier or lighter than usual
• Urinary urgency (frequent and pressing need to urinate)
• Vaginal dryness that can cause dyspareunia (painful sex), itching, and discomfort
• Worsening of premenstrual syndrome (PMS), a group of symptoms (including food cravings, mood swings, fatigue, menstrual cramps, and bloating) that arise within a week or two before menstruation

For some people, menopause may also lead to:

• Hair loss or thinning
• More intense or frequent migraines, as well as cluster or tension headaches
• Muscle aches and joint pain
• Sexual dysfunction such as low libido (sex drive)
• Trouble concentrating or short-term memory lapses
• Weight gain along with less muscle and more belly fat

What are hot flashes?

Hot flashes are the most common menopause symptom, affecting as many as 60 to 80 percent of people AFAB. They’re what’re known as vasomotor symptoms, which refer to the narrowing or widening of blood vessels.

Blood vessels close to the skin’s surface widen (or dilate) during a hot flash, causing blood flow to increase and a sudden rush of heat that often produces sweating.

Hot flashes usually start in your face, neck, and upper chest and then spread to other areas of your body. They’re also called hot flushes because more blood flow to the area can cause the skin to look flushed or turn a blush or reddish color.

You may also feel anxious during a hot flash. Chills and shivering may briefly follow once the hot flash subsides.

Hot flashes can last from 30 seconds to 5 minutes. How often they occur can vary. Some experience them a few times a day. For others, it’s a round-the-clock menopause symptom that occurs once or more per hour or every few hours.

Like other menopause symptoms, hot flashes can persist for an average of four years or longer. They may start, feel more intense, and occur more often during perimenopause, although some people don’t start having hot flashes until they’re in menopause. Over time, hot flashes tend to occur less often and feel milder.

What causes hot flashes isn’t fully understood, although they may be associated with hormone fluctuations. The hypothalamus, sometimes referred to as the brain’s thermostat because it’s the part of the brain that regulates body temperature, may also play a role. When the hypothalamus resets, it may result in spikes in body temperature.

What are night sweats?

Night sweats are hot flashes that occur at night or while sleeping. For some, these may occur more often than hot flashes that happen while awake.

You may wake up once or more per night feeling uncomfortably hot or cold, sometimes drenched in sweat. This can cause sleep deprivation and insomnia symptoms such as trouble staying asleep.

The cumulative effect of night sweats can lead to disturbances during waking hours such as excessive daytime sleepiness and trouble thinking clearly or staying focused. They may also add to and exacerbate menopause symptoms you may already experience, such as fatigue and mood swings.

Other vasomotor menopause symptoms

Other vasomotor symptoms might include heart palpitations and migraine headaches. These menopause symptoms may be worsened by drinking alcohol, eating certain foods (such as spicy ones), emotional stress, and exertion.

Migraines with aura raise the risk of stroke, especially if people AFAB smoke or use oral contraceptives. Other types of headaches, such as cluster and tension headaches, may also increase with a change in hormone levels.

What symptoms occur after menopause?

Although some symptoms that start during perimenopause can occur less often and become less intense once you reach menopause, dips in estrogen levels can continue to impact health. Without proper treatment, the following may occur or worsen after menopause:

Genitourinary syndrome of menopause

Once referred to as vaginal (or vulvovaginal) atrophy, genitourinary syndrome of menopause (GSM) is the term used to describe a group of chronic, progressive menopause symptoms that lead to physical changes affecting the lower urinary tract, as well as the vagina and vulva (the outer part of the female genitals). Specifically, GSM can affect the:

Reproductive tract: When vaginal atrophy occurs, the tissues lining the inside of the vagina  become dry, thin, and inflamed. This can cause symptoms such as vaginal infections, itching, burning, and discomfort.

The decrease in vaginal lubrication can also cause pain during sex. Bleeding may also result from sexual activity.

Small cuts, tears, or abrasions (sometimes called microabrasions or microcuts) during sex may increase the risk for sexually transmitted infections (STIs). Although most STIs occur in younger people assigned female at birth (AFAB), those in perimenopause and postmenopause remain susceptible to them.

The clitoris, labia minora (inner skin folds of the vagina), ovaries, and uterus also decrease in size. Libido may go down and it may be harder to feel sexually aroused or reach orgasm.

Urinary tract: The urethra (tube that empties urine from your bladder) shortens, and the tissue that lines the urethra becomes thinner. These changes can lead to GSM symptoms such as:

• Dysuria (pain with urination)
• Recurrent urinary tract infections (UTIs)
• Urethral caruncle (red, fleshy, noncancerous outgrowth that protrudes from the urethral meatus, the opening at the end of the urethral tube where urine comes out of the body)
• Urinary incontinence (loss of bladder control, which causes urine to leak out of the urethral meatus)
• Urinary urgency (abrupt and compelling need to urinate)

Other symptoms that occur after menopause

Physical changes that occur after menopause might also include those related to:

Bones: Low estrogen levels can decrease bone mineral density (BMD), also called bone density or bone mass. Bones that are less dense and more porous tend to be weaker because of the loss of bone minerals such as calcium and phosphorus, raising the risk of fractures and bone diseases such as osteoporosis.

Lipids: These include fatty, oily, waxlike compounds in the body such as cholesterol and triglycerides. Levels of low-density lipoprotein (LDL) (also known as “bad” cholesterol) tend to increase after menopause. High levels of LDL raise the risk of conditions such as heart attack and stroke, as well as non-alcoholic fatty liver disease.

Skin: The amount of collagen and elastin decreases with age and as estrogen levels go down. Collagen is a fibrous protein that contributes to the structure and function of skin, blood vessels, bone, cartilage, and other connective tissue. Elastin is the main component of elastic fibers, which allow your skin to stretch and bounce back.

The loss of these body proteins can make your skin drier, thinner, less elastic, and more fragile. As such, your skin may look and feel less plump and be more prone to injury and damage.

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Menopause results from the loss of ovarian follicular function. That is, the ovaries produce far less of the hormones estrogen and progesterone and no longer release eggs for fertilization. As people AFAB approach menopause, the number of follicles quickly dwindle. (Follicles are small, fluid-filled sacs in the ovaries that hold immature egg cells called oocytes.)

Because ovarian follicles produce estrogen and progesterone, the levels of these hormones also drop off as the follicles reduce in number. As a result, the brain makes more follicle-stimulating hormone (FSH) to stimulate the remaining follicles. But FSH remains largely unused since there aren’t enough follicles to take advantage of it, causing FSH levels in the bloodstream to rise.

Waning estrogen and progesterone levels affect the reproductive process by causing menstrual periods and ovulation to occur less often. Eventually, these cease altogether.

After menopause, the ovaries continue to produce small amounts of the androgen (“male” hormone) testosterone while the adrenal glands continue making an androgen called androstenedione, which is converted into testosterone. This is then converted into small amounts of estrogen.

What is follicle-stimulating hormone (FSH)?

FSH is a gonadotropin, a hormone made by the brain’s pineal gland that stimulates and supports the function of the gonads (reproductive organs). It helps the ovaries make estrogen and the testes produce testosterone. Ovaries need FSH to produce and grow eggs and testes need it to make sperm.

Although the hormone supports the function of both male and female gonads, FSH is so named because of its effects on ovarian follicles, which decrease in number with age.

FSH levels stay somewhat constant for people assigned male at birth (AMAB), unlike people AFAB, whose levels change throughout the menstrual cycle, with peak levels occurring right before ovulation. The amount of the FSH hormone present in the bloodstream is measured in milli-international units per milliliter (mIU/mL) or international units per liter (IU/L).

In general, typical FSH ranges for people AFAB are as follows:

• Before puberty: 0 to 4 IU/L
• During puberty: 0.3 to 10.0 IU/L
• While still menstruating regularly: 4.7 to 21.5 IU/L
• After menopause: 25.8 to 134.8 IU/L

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Menopause that occurs before age 40 is referred to as premature menopause. When it occurs  before age 45, it’s called early menopause. These can occur for many reasons, including:

• Autoimmune diseases like rheumatoid arthritis, thyroid disorders such as Graves’ disease, and a type of inflammatory bowel disease called Crohn’s disease
• Early menarche (also known as a person’s first menstrual period), usually before age 11
• Chromosome abnormalities such as Fragile X or Turner’s syndrome
• Chronic fatigue syndrome (also called myalgic encephalomyelitis/chronic fatigue syndrome)
• History of early or premature menopause among closely related biological relatives (such as a parent or sibling)
• Smoking tobacco
• Viral infections such as mumps or HIV

Medical and surgical treatments may induce menopause

Certain medical or surgical treatments may also result in premature or early menopause. These include treatments such as:

Bilateral oophorectomy (surgery to remove both ovaries): Often performed at the same time as a hysterectomy (surgery to remove the uterus), surgical removal of both ovaries ends menstrual periods and induces early or premature menopause. The procedure may be performed to treat diseases such as ovarian cancer, endometriosis, or to help prevent breast and ovarian cancer if you have a breast cancer (BRCA) gene mutation.

Cancer treatments: Some types of chemotherapy (chemo) and radiation therapy used to treat various cancers can damage the ovaries and cause early or premature menopause. In some cases, the ovaries may recover and function properly again, depending on the type of chemo and the amount of chemo or radiation received.

The larger the treatment doses received, the greater the likelihood that menopause will be permanent. Menopause is more likely to be temporary in younger people or those who aren’t close to the age when natural menopause tends to occur.

Hormone therapy: A side effect of hormone therapy for breast and uterine cancers may be early or premature menopause. This may also be temporary or permanent.

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To help determine if you’re in menopause and which stage you’re likely in, your healthcare provider (HCP) will consider factors such as your age and symptoms. They’ll also talk with you about your personal and family medical history to help identify any health conditions you might be at risk for after menopause or whether you have a greater chance of early or premature menopause.

They’ll then likely perform a physical exam, which includes measuring your height, weight, and blood pressure and performing a breast and pelvic exam. During the pelvic exam, they’ll examine the vagina, cervix, uterus, and ovaries to look for physical changes that support a menopause diagnosis.

Lab tests aren’t usually needed to diagnose menopause. Moreover, menopause symptoms may happen before any significant changes in hormone levels can be detected. In addition, test results won’t be accurate if you’re using contraceptives and other medicines that contain hormones such as estrogens and androgens.

But if symptoms don’t clearly point to menopause as the cause, lab tests may be ordered to check for conditions that might disrupt menstruation. In these cases, your HCP might recommend an FSH hormone test since elevated levels may indicate that you’re in menopause, especially if the result indicates an FSH level greater than 40 IU/L.

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Not all people require menopause treatment, especially if symptoms are mild, if they come and go infrequently, or if they last for a short duration before going away completely. In some cases, lifestyle measures (see below) may sufficiently ease menopause symptoms.

For more severe or bothersome symptoms, your primary HCP can help you create an effective menopause treatment plan that may involve both lifestyle measures and medical interventions such as medicines. If you’d prefer, you can also consult with and seek care from a medical doctor known as an obstetrician-gynecologist (OBGYN) or other certified menopause practitioners. The North American Menopause Society (NAMS) website provides a directory of licensed HCPs certified by their organization.

Hormone therapy for menopause symptoms

Menopausal hormone therapy (MHT) helps replenish or replace hormones that have dwindled over time. It’s therefore also referred to as hormone replacement therapy (HRT) or simply hormone therapy (HT).

MHT can help alleviate moderate to severe menopause symptoms, including hot flashes, night sweats, and vaginal atrophy. It doesn’t prevent other symptoms tied to menopause such as thinning hair or weight gain and it’s unclear whether the treatment can help balance mood.

The choice to start this menopause treatment is a decision you must make for yourself with guidance from your HCP. Consider your symptoms, health status, and treatment preferences and discuss the benefits, risks, and side effects of MHT with your HCP before you decide what’s best for you.

For instance, side effects of MHT, especially at high doses, may include:

• Breast tenderness
• Fluid retention
• Headache
• Nausea
• Mood changes

The two main types of MHT include:

Estrogen therapy (ET)  

This MHT involves the use of only estrogen. Common types of ET include estradiol and a mixture of estrogens called conjugated estrogens.

The most potent and preferred form of estrogen used by the human body and in ET is estradiol. It plays a vital role in many types of physiological functions, from reproduction, growth, and food digestion and metabolism to body temperature management, bone development, energy balance, and mood.

Estrogen is the hormone that treats menopause symptoms. It can help prevent, relieve, and reduce the risk of:

• Hot flashes (estrogen is the most effective treatment for this menopause symptom)
• Drying and thinning of vaginal and urinary tract tissues
• Recurring UTIs
• Osteoporosis
• Urinary urgency

Estrogen-progestogen therapy (EPT)

If you still have your uterus (that is, you haven’t had a hysterectomy), your HCP might prescribe EPT, also called combination hormone therapy. Taking estrogen by itself can raise the risk for endometrial cancer. Therefore, another type of hormone called progestogen is combined with estrogen to protect the endometrium (lining of the uterus) and lower the risk for this type of uterine cancer.

Progestogens include naturally occurring forms of progesterone or the synthetic form of this hormone, known as progestin. The injectable progestin contraceptive hormone medroxyprogesterone acetate can control hot flashes about as well as estrogen, but it’s not commonly used due to side effects such as acne, depression, headache, and irregular vaginal bleeding.

Dehydroepiandrosterone (DHEA)

DHEA is a steroid made in the adrenal glands that’s converted into estrogens and androgens. Available as a vaginal suppository, DHEA helps with vaginal dryness, atrophy, and other GSM symptoms.

Risks of hormone therapy

In general, MHT is considered safe for otherwise healthy people AFAB who started menopause fewer than 10 years ago and are having associated symptoms. But your HCP will take necessary precautions when prescribing this treatment.

They’ll likely prescribe the lowest effective dose for the shortest duration possible. That’s because higher ET and EPT doses and longer use of these menopause treatments may raise the risk of several conditions, including:

• Coronary artery disease (CAD)
• Breast cancer
• Endometrial cancer (the most common type of uterine cancer)
• Gall bladder disorders such as gallstones
• Ovarian cancer
• Stroke
• Thromboembolism (blood clot)

For instance, breast cancer risk goes up after taking EPT for three to five years and after taking ET for seven years. MHT isn’t recommended for people older than 60 or who reached menopause more than 10 to 20 years ago. It’s also not recommended for people with a history of or at high risk for:

• Angina (temporary chest pain), heart attack, CAD, or other heart and blood circulation issues
• Breast cancer
• Deep vein thrombosis (blood clot in a vein deep in the body, most often the legs)
• Endometrial cancer
• Liver disease
• Pulmonary embolism (blood clot that travels through a vein and blocks blood flow to a lung)
• Stroke
• Unexplained vaginal bleeding

Hormone therapy forms

Various forms of MHT are available, depending on which type of hormone therapy is used. These include:

• Oral: estrogen or progestogen tablets taken by mouth
• Topical: ET gels, lotions, or sprays applied to the skin
• Transdermal: ET or EPT patches placed on the skin
• Vaginal: ET creams, rings (like a dome-shaped contraceptive device called a diaphragm), suppositories, or tablets inserted into the vagina
• Vaginal forms of ET may help relieve symptoms affecting the vagina more effectively than oral forms. These include reducing GSM symptoms such as vaginal atrophy, painful sex, urinary urgency, and UTIs.

Selective estrogen receptor modulators (SERMs)

SERMs are hormone therapies that act and function like estrogen but don’t cause endometrial growth or raise the risk of cancers such as breast and endometrial cancer. For instance, raloxifene acts as an estrogen antagonist on the breast and uterus and estrogen agonist on bones and lipids. (An antagonist blocks the action of a hormone or chemical, while an agonist supports its action.) SERMs therefore can help prevent and treat mild osteoporosis and lower LDL levels in the blood.

When combined with estrogen, bazedoxifene (another SERM), can treat hot flashes without affecting the endometrium. A newer SERM called ospemifene can effectively treat urinary tract symptoms such as vaginal atrophy and dryness. Note that SERMs may initially make hot flashes worse, but they’ll eventually improve this symptom with continued use.

Nonhormonal medicines for menopause

Menopause treatments that don’t involve hormones might also be an option. These include:

Low-dose antidepressant medicines: Commonly used to treat mood disorders such as depression, antidepressants help increase levels of neurotransmitters such as norepinephrine and serotonin. (Neurotransmitters are molecules that transmit messages between nerve cells called neurons throughout the body.) Antidepressants may also help lessen the frequency of vasomotor symptoms (such as hot flashes), improve sleep, and boost mood by acting on the hypothalamus and correcting imbalances in neurotransmitters that contribute to these menopause symptoms.

A selective serotonin reuptake inhibitor (SSRI) antidepressant called paroxetine mesylate is one of two non-hormone medicines approved by the U.S. Food and Drug Administration (FDA) for treating vasomotor symptoms, the other being fezolinetant (see below). Though not FDA-approved for this purpose, other SSRIs such as citalopram and escitalopram can also ease hot flashes.

Another class of antidepressants called serotonin-norepinephrine reuptake inhibitors (SNRIs) may also help ease vasomotor symptoms, although they don’t yet have FDA approval for this use. One such SNRI is venlafaxine. 

Gabapentin: Another alternative or adjunct to MHT is gabapentin. It’s commonly prescribed for treating seizures and nerve pain, but it’s also been shown to reduce hot flashes and support sleep.

Clonidine: This medicine is prescribed for people with hypertension (high blood pressure), but it may also help with mild hot flashes.

Oxybutynin: Although this medicine is a prescription treatment for overactive bladder and urinary incontinence, it’s also been shown to help ease hot flashes.

Neurokinin 3 receptor antagonist for hot flashes (fezolinetant)

In May 2023, fezolinetant became the second nonhormonal drug approved by the FDA to treat moderate to severe vasomotor symptoms such as hot flashes and night sweats. First in a new class of drugs called neurokinin 3 receptor (NK3R) antagonists, the oral medicine works by blocking activity in the part of the hypothalamus that causes the brain’s internal thermostat to malfunction.

Specifically, the NK3R antagonist keeps a brain chemical called neurokinin B from binding to kisspeptin/neurokinin B/dynorphin (KNDy) nerve cells, which helps the brain’s thermoregulatory center function properly. This function is usually performed when the body has sufficient amounts of estrogen.

Stellate ganglion blockade for hot flashes

One promising alternative to MHT is stellate ganglion blockade (SGB). This menopause treatment involves injection of a local anesthetic (numbing medicine) such as lidocaine into nerves in the neck to block sympathetic nervous system activity, potentially affecting blood flow, norepinephrine levels, and the thermoregulatory areas of the brain. (The sympathetic nervous system controls unconscious functions such as heart rate, blood pressure, breathing rate, body temperature, and digestion.)

Data indicates that SGB can reduce the frequency of vasomotor symptoms such as hot flashes and night sweats by 4 to 90 percent, according to a 2022 review of studies published in the Cleveland Clinic Journal of Medicine. The treatment can be considered with caution in people with severe vasomotor symptoms that haven’t improved with more conservative care such as hormone and nonhormone medicines along with lifestyle changes.

Complementary and alternative medicine (CAM) for menopause

Because of the risk of side effects of MHT and other medicines or simply due to personal preference, some people opt to manage their menopause symptoms using a CAM approach. CAM therapies may include:

Herbs and supplements for menopause

A variety of products are marketed as natural remedies for menopause symptoms. It’s important to understand that herbs and supplements aren’t classified by the FDA as medicines used to treat disease. As such, the agency doesn’t regulate or provide oversight for these products.

Therefore, manufacturers aren’t required to show they’re safe and effective before they’re marketed and sold to the public. There’s also no guarantee that the potency, purity, ingredient list, or product claims are accurate.

Herbs such as black cohosh, dong quai, evening primrose, ginseng, and St. John’s wort are marketed as natural remedies for symptoms such as hot flashes, mood swings, and memory loss. In most cases, however, their effectiveness is no better than that of a placebo, which means they are just as likely to work as not work.

Some products, such as kava, come with risks and side effects of their own. Moreover, they can interact with other medicines you take and worsen certain health conditions you might have. It’s always essential to check with an HCP before adding natural remedies to your menopause treatment plan to discuss the risks and benefits.

Phytoestrogens (plant-derived estrogens) for menopause

Phytoestrogens are forms of estrogen derived from plants. They are often touted as natural alternatives for managing menopause symptoms and viewed as having fewer risks and side effects than conventional MHT.

The chemical structure of phytoestrogens is similar to that of estradiol, making them capable of binding to estrogen receptors. This means phytoestrogens may possess weak estrogen or anti-estrogen properties when taken by humans.

The most widely studied and most popular type of phytoestrogen for menopause symptoms are isoflavones, which are mainly found in soy and soy products such as edamame and tofu but can also be found in other foods such as lentils and legumes.

Other examples of phytoestrogen compounds are:

• Coumestans from foods such as alfalfa, clover, mungo beans, pinto beans, kala chana seeds, and split beans
• Lignans such as those found in flaxseeds (also called linseeds)
• Prenyl-flavanones found in hops (a type of flower used in beer)
• Resorcylic acid lactones found mainly in grain products such as whole-grain breakfast cereals and breads 

Phytoestrogen supplements can also be purchased over the counter. These include formulas that use alfalfa, clover, hops, flaxseed, and soy. Like other dietary supplements, these products aren’t regulated by the FDA.

For the most part, results from clinical studies show that phytoestrogens aren’t effective for treatment of hot flashes. They’re generally safe when you consume them in foods. But In supplements, quality and dose consistency can be a concern. Phytoestrogen supplements aren’t recommended for breast cancer survivors.

In general, the effect of phytoestrogens on menopause symptoms remains a topic of debate. This is because their effectiveness varies across people and stages of menopause, and there’s a strong possibility that a placebo effect is in play, according to a 2023 review of studies published in Nutrients. Many studies are based on self-declarations, the authors of the review point out, which means the effect is based on users’ first-person accounts rather than clinically controlled observation.

Bioidentical hormones for menopause

Another alternative to MHT used by some people is bioidentical hormone therapy (BHT), which consists of hormones derived from plants such as soy, cactus, and wild yams.

Bioidenticals are so named because they have just about the same molecular structure as endogenous hormones (those the body makes). Though they’re structurally similar, they have to be commercially processed to become bioidentical. Therefore, they’re not an all-natural alternative.

Bear in mind that many of the hormones used in MHT are also sourced from plants. The hormones used in MHT are tested and closely monitored for purity, potency, consistency, safety, and effectiveness by the FDA, whereas BHT products may not always be subjected to the same level of rigor.

Bioidentical hormones are sometimes compounded (custom-made) in a pharmacy. Pharmacists at some of these compounding pharmacies tailor BHT formulas to individual patients based on hormone levels indicated on saliva test results. But because the hormone levels of people AFAB can fluctuate throughout the day, these saliva tests may not accurately reflect their hormone levels.

Some compounded formulas also use a weaker form of estrogen called estriol, which hasn’t been FDA-approved for use in any medicine. And although BHT products may be less effective than conventional MHT, they carry the same potential risks as MHT. There is, in fact, no evidence to prove they’re actually a safer alternative to MHT.

Mind-body and other approaches to menopause symptom management

Various mind-body interventions have been studied as possible CAM treatments for menopause symptoms, including stress-management and relaxation techniques such as deep breathing and yoga.

While study results haven’t been consistent in proving their effectiveness, these approaches aren’t likely to cause harm and may confer other benefits such as easing anxiety and tension. Some people have found that approaches such as acupuncture and hypnosis ease their menopause symptoms, even if they haven’t been definitively proven to do so.

Lifestyle changes to help manage menopause symptoms

Certain lifestyle changes may help ease various menopause symptoms and associated complications (see more below). Approaches that may be worth trying include the following:

Turn down the heat. Try dressing in layers and shedding them as needed. Opt for clothing made with breathable material such as cotton or moisture-wicking material such as polyester and nylon.

Pinpoint your hot flash triggers and try to avoid them. For some, these include spicy foods, hot drinks, alcohol, and warm or hot environments. Eat and drink something cool instead.

Turn on the air conditioner or fan or use a wearable cooling device such as a neck wrap. Place a cool-gel mattress topper over your mattress to pull the heat from your body while sleeping.

Take the pain out of sex. Try using a vaginal lubricant. These include OTC water- or silicone-based lubricants or moisturizers.

Glycerin can cause burning or irritation. Therefore, it’s best to avoid products made with this chemical if you’re sensitive to it. Sexual activity also increases blood flow to the vagina, which might also help ease vaginal discomfort.

Set up your sleep sanctuary. In addition to using a cool-gel mattress topper, try to make your bedroom as cozy as possible. This includes making sure your mattress, bedding, and pillows are comfortable and support your body, neck, and head properly without causing pain.

Keep the lights low, turn down the temperature, and turn on soothing sounds from a white noise machine or listen to relaxing music. These can set you up for restful sleep.

Perform Kegel exercises. These exercises can help strengthen your pelvic floor muscles, which support organs in your pelvis such as your bladder, bowels, and vagina. Practicing these may help with urinary incontinence.

Eat nourishing foods. Although there’s no such thing as a specific menopause diet, following a wholesome eating plan can help you lower the chances of long-term complications of menopause. Focus on whole, nutrient-rich foods such as fruits, vegetables, lean meats, and whole grains.

Limit saturated fats, added sugars, and alcohol. Before adding supplements to your eating plan, ask your HCP if taking supplements such as calcium or vitamin D might help you meet your health goals, as they might not be appropriate for all people.

Stay physically active. Get at least 30 minutes of moderate-to-vigorous exercise most days of the week. Doing so can help you lose weight during menopause and keep it off, which, along with exercise, can help curb hot flashes. Exercise can also lift your mood.

Quit smoking or never start. Along with lowering your risk of heart disease, osteoporosis, cancer, and many other health conditions, kicking the smoking habit may also reduce hot flashes and the chances of early or premature menopause.

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Long-term complications or health risks tied to menopause may occur as a result of the drop in estrogen levels. These include:

Osteoporosis

Osteoporosis involves the weakening and loss of bone tissue, structure, and strength—all of which can raise the risk of fractures. The hip, spine, and wrist bones are most commonly affected.

The condition affects more than 250,000 people AFAB who have reached menopause. After age 40, people AFAB begin to lose bone density at a rate of 0.3 to 0.5 percent each year. This rate climbs to around 3 to 5 percent during the first five to seven years of menopause due to the loss of estrogen, raising the risk of osteoporosis.

Although MHT may benefit some people AFAB at risk for fractures and osteoporosis, it isn’t the first line of treatment if you have osteoporosis but don’t have menopause symptoms. Instead, your HCP might prescribe medicines for osteoporosis such as bisphosphonates and denosumab along with calcium and vitamin D supplements.

Bone-density testing

If you’re at risk for fractures, osteoporosis, or osteopenia (a condition involving weakening of bones that often leads to osteoporosis), your HCP may recommend getting a bone-density test. Also called a bone mineral density test or bone densitometry, the test is conducted using a dual-energy X-ray absorptiometry (DEXA or DXA) scan.

A DEXA scan may be recommended for people AFAB with a high risk for osteoporosis or fractures. These may include people AFAB who:

• Are age 65 and older
• Have had fragility fractures, as indicated by a fracture sustained after a minor accident or low-impact trauma such as a fall from standing height or less
• Have had gastric bypass (weight loss) surgery or an eating disorder
• Have a history of prolonged use of drugs or medicines that weaken bones and cause them to be less dense. These include corticosteroids (also called steroids or glucocorticoids) and medicines that slow or block estrogen production, such as aromatase inhibitors used to lower the risk for or treat breast cancer
• Have lost more than 1.5 inches from their tallest height
• Have low body mass index (BMI) of less than 18.5
• Have malabsorption syndrome, a group of digestive disorders such as Crohn’s and celiac disease, which affect proper nutrient absorption in the small intestine
• Smoke or drink excess amounts of alcohol

The DEXA scan produces a T-score, which compares your bone density with the average bone density of a healthy young adult.

The more negative the T-score, the weaker and less dense your bones are. Scores fall into the following ranges:

• +1 to -1: Normal bone density
• -1.1 to -2.4: Osteopenia
• -2.5 or below: Osteoporosis

Cardiovascular disease (CVD)

Cardiovascular disease is an umbrella term for diseases that affect the heart and blood vessels. Estrogen dips that occur during menopause can increase LDL levels and cause vasoconstriction (narrowing of the blood vessels), which can raise blood pressure. In turn, this can amplify the risk for CVDs such as stroke and coronary artery disease (CAD, also called coronary heart disease), the most common type of heart disease.

In fact, people who’ve reached menopause experience CAD two to three times more often compared to people AFAB of the same age who have yet to reach this life stage. Starting MHT within 10 years of menopause onset (if appropriate), quitting smoking, and keeping LDL levels below 100 milligrams per deciliter (mg/dL) can help lower CVD risk.

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Although menopause is a natural part of life and isn’t a disease or disorder that necessarily requires treatment, you may want to seek help from an HCP if you experience persistent, disruptive, or severe symptoms that affect you physically, mentally, emotionally, or socially.

It’s especially important to consult with an HCP and seek prompt medical care if you’re experiencing symptoms that may point to the presence of a serious health condition such as hypothyroidism (underactive thyroid), heart failure, kidney disease or failure, and undiagnosed or worsening anxiety or depression. The risk of conditions such as these may go up after menopause, with certain symptoms overlapping.

These include symptoms such as:

• Abdominal pain, tenderness, or swelling
• Arrhythmias (irregular heart rhythms); symptoms may include feeling like your heart’s racing, fluttering, or skipping a beat
• Extreme or unrelenting fatigue
• Increased sadness, anxiousness, irritability, and emptiness along with more trouble sleeping, thinking, or concentrating
• Sudden and unexplained weight loss or gain
• Vaginal bleeding or spotting after you’ve reached postmenopause

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This can vary for each person, depending on which symptoms, complications, and other health conditions they may experience. Menopause symptoms often start to manifest and are most intense during perimenopause. They may start to taper off once you’re in postmenopause, although some people continue to experience symptoms for up to a decade or longer after starting the menopausal transition.

Left untreated, some menopause symptoms might get worse. Vasomotor symptoms such as hot flashes and night sweats will eventually ease over time, regardless of whether they’re treated.

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Menopause isn’t a disease, disorder, or illness. Reaching this natural point in your life doesn’t mean you’re somehow less than you were before.

The stigma that surrounds aging in general can contribute to fear, uncertainty, and negative feelings around the concept of menopause. But it doesn’t have to be this way.

This natural part of your life can be a time of great reflection, inspiration, and newfound wisdom and freedom. Instead of being held back by preconceived notions about menopause and aging in general, you can live your life to the fullest during the transition and beyond, as have countless people before you.

Knowing what to expect during this life stage—and addressing any concerns or menopause symptoms with your HCP—can help you feel more confident and hopeful. You’re not alone. Your HCP is there to guide you and your loved ones are there to support you as you embark on this new path.

These tips might also help:

Find social support. Reach out to trustworthy people in your life whenever needed. If you need some extra support to help you find balance amid the ups and downs that come with menopause, consider reaching out to a mental health provider or joining an in-person or online menopause support group.

You can find information on these support groups and additional resources on the North American Menopause Society (NAMS) and Endocrine Society websites.

Laugh more. Laughter can stimulate your immune system, help you connect with people, shift your mindset, improve your learning and memory, and help ease stress, including the mental stress associated with menopause.

Stay present. Instead of dwelling on the past or worrying about the future, be aware and present for each moment of your life now, without judgment or apprehension. Focus on what you see, hear, smell, and even taste. Notice your heartbeat and breathing. This meditative practice can help you tune out negativity while helping ease tension and stress.

Take time for you. Make yourself a priority. Exercise regularly, eat nutritious foods, engage in meaningful hobbies and activities, and find healthy ways to cope with stress in addition to laughing more. If this means taking a physical break from everything, do so whenever you can—even if it’s just for minutes at a time.

Think positively. There’s growing evidence that the absence of positive thoughts can have more of a harmful impact on health and well-being than the presence of negative ones, according to NAMS. Try to have a more positive outlook overall, including how you view menopause. This might help lessen anxiety and the impact menopause symptoms have on your life moving forward.

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• 7 Must-Know Truths About Menopause
• Things No One Tells You About Menopause
• Natural Ways to Ease Menopause Symptoms