Introduction

In the years leading up to menopause (perimenopause), the balance of hormones in a woman’s body changes. These hormonal changes can lead to symptoms like hot flashes (also called hot flushes), sleep problems and mood swings. Various things provide relief. Different women may experience this phase of their life very differently. Only few have severe menopause-related problems over a long period of time.

Around their mid-forties, women’s bodies gradually start making less of the female sex hormone estrogen. Their monthly periods become less regular and eventually stop completely. A woman has reached menopause when she has had her last period. The word “menopause” might be misleading because it is not a “pause,” but an ending. Women can no longer get pregnant after menopause.

The average age of menopause is 51, although some women might go through it much earlier, or later. Many women are happy that the hassle of contraception and periods are now a thing of the past. But the idea of no longer being “fertile” can also feel like closing a chapter in your life. And menopause is often accompanied by other significant life changes – many people mainly associate it with getting older.

At a glance

• In the years leading up to menopause (perimenopause), the level of estrogen in a woman's body decreases.
• Most women have hot flashes for a while as a result.
• Many cope well without treatment.
• If the symptoms are severe, short-term hormone therapy can help.
• On average, women have their last menstrual period at the age of 51.

Symptoms

Whether and how often women have menopause-related problems, and how severe they are, varies greatly. The main typical ones include:

• Hot flashes and sweats: This is the most common problem in the menopause transition. It can disrupt your sleep. Some women have phases where they break out in a sweat so often that it limits what they can do in everyday life. Hot flashes generally go away on their own after about 4 to 5 years.
• Changes in the membranes lining the vagina: After menopause, these membranes usually become thinner and drier.

The hormonal changes can also lead to trouble falling asleep and staying asleep, mood swings or a low mood. Some women become less interested in sex. Many gain weight in this phase of their life.

Causes

Between a woman's first and last menstrual period, her ovaries produce the female sex hormones estrogen and progesterone. Both of these hormones prepare the body for a possible pregnancy. But they also affect things like the skin and mucous membranes in the body.

During perimenopause (the time of changes leading up to the menopause), the ovaries gradually produce less and less hormones, and fewer eggs are released. Menopause is reached when the last egg is released. After that, the woman stops having periods.

It is not clear why hot flashes are so common during perimenopause. The sinking estrogen levels are thought to upset the regulation of body temperature.

Women might go through menopause at a younger age as a side effect of a treatment, such as the removal or radiation of both ovaries in the treatment of cancer. This is known as induced or artificial menopause. The symptoms of induced menopause are usually similar to those of natural menopause.

Outlook

The start of the menopause transition can be so subtle that some women don't notice any changes at all. But others have very noticeable symptoms. Their periods might sometimes be lighter or heavier, or the gaps between periods might become irregular.

Women can still get pregnant before they reach menopause. You can only really know that it was your last period in hindsight. As a rule of thumb, if you haven't had a period for twelve months in a row, you very likely reached menopause when you had your last period. Menopause before the age of 40 is called premature menopause.

The one or two years leading up to a woman’s last menstrual period is called perimenopause or pre-menopause, and the time afterwards is referred to as post-menopause. Her body gets used to the new balance of hormones during this time. The transition takes a few years.

The age of menopause is probably genetically determined. This means that mothers and daughters experience menopause at about the same age. There is also some evidence to suggest that women reach menopause earlier if they have a lot of children or smoke a lot. Being underweight or overweight and the length of a woman’s menstrual cycle can also influence when her menopause starts.

Effects

The hormonal changes mean that women can no longer get pregnant after menopause. But estrogen and progesterone also affect the metabolism in the bones, skin and mucous membranes.

As estrogen levels fall, the risk of osteoporosis increases, because this female sex hormone helps to protect bone tissue. But bone strength depends on more than just hormone levels.

The change in hormone levels causes the membranes lining the vagina to become thinner and drier over time. Some women become more prone to vaginal infections as a result. If the vagina isn't lubricated well enough through arousal, sex can be uncomfortable or even painful. But sexual changes around this time of life aren't always caused by the menopause transition alone. The situation in your relationship plays a big role too.

The hormonal changes can also lead to more bladder infections (cystitis).

Many of the physical and emotional changes around the time of menopause aren't only related to changes in hormone levels. For instance, there's no scientific proof to support the belief that menopause could increase women's risk of cardiovascular disease (heart and blood vessel problems). Many women have a higher risk of cardiovascular disease than they did before menopause, but that’s more likely to be because they are getting older.

Menopause can also have positive effects, although they often go unmentioned: It makes contraception and menstrual problems a thing of the past. If a woman used to have heavy, painful periods or endometriosis, her quality of life might actually improve a lot. Migraines sometimes go away after menopause too.

Diagnosis

If a woman would like to be more sure about whether she has entered the menopause, her gynecologist can take a blood sample and measure her sex hormone levels. But checking hormone levels has little practical value: The results can't be used to tell whether a woman can still get pregnant and how long she has to keep using contraception for – or whether she should have treatment if she has menopause-related problems.

Treatment

Menopause is not an illness. It is normal for hormone levels to fall in middle age.

Menopause symptoms can be relieved in various ways. In most women, though, things like hot flashes, sweats and mood swings go away again over time without any treatment.

• The most effective treatment for menopause-related problems is hormone therapy with a combination of estrogen and progestin (synthetic progesterone), or with estrogen alone (for women who have had a hysterectomy). But hormone therapy is associated with certain risks so it should only be used for a limited amount of time. It is a good idea to talk to your doctor and carefully weigh the pros and cons of this treatment before making a decision.
• Problems affecting the lining of the vagina can be treated locally instead, using creams, vaginal suppositories or rings that have hormones in them. Hormone-free alternatives include plant oils, lubricants and creams to relieve vaginal dryness.

Hormones that affect the whole body are available in the form of tablets, patches, nasal sprays and injections. In the first few months of hormone therapy, women might have spotting (bleeding between periods), breast tenderness and/or nausea. Having hormone therapy over several years can also increase the risk of various serious diseases such as cardiovascular disease and breast cancer. The menopause symptoms often return when you stop taking hormones.

Box

Hormones that are used to relieve menopause symptoms don't prevent women from getting pregnant.

A lot of herbal products are also available, often in the form of dietary supplements. It is not clear whether the following products really help to relieve menopause problems:

• Products with plant-based estrogens (phytoestrogens) in them. These include soy-based products.
• Products containing red clover and black cohosh (Cimicifuga racemosa).
• Certain foods.

Various antidepressants and the hormones testosterone and DHEA are sometimes used to relieve menopause symptoms too. They have not been proven to help here in studies. But they can have considerable side effects. Most of them have not been approved for the treatment of menopause symptoms in Germany.

Everyday life

Menopause is often accompanied by other significant life changes: Children are becoming more independent or have already moved out, and some couples have to re-connect with each other. Some women make major career changes, and others may take a step back because their parents need their support. It becomes more apparent that your own body is gradually aging. So the hormonal transition isn't the only reason why menopause is a time of physical and emotional change.

Many women try out things like relaxation techniques, breathing exercises, meditation or yoga to help them get through this sometimes difficult phase of life. Although these activities will probably not relieve symptoms such as hot flashes, they might improve women’s overall wellbeing and help them sleep better. The same is true for sports and exercise: Physical activity has a positive effect on your cardiovascular system and bones, as well as improving your overall fitness, muscle strength and mobility. Exercise can also help you keep a healthy body weight, or lose weight if you're overweight.

Even though the often negative perception is gradually changing, menopause is still mainly associated with growing older and the related problems. But many women see menopause as the start of a new phase of life. Not all women have menopause symptoms or other related problems. Some discover a new sense of freedom and new opportunities during this phase of their lives.

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