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Menopause is a single point in time: the day you reach 12 consecutive months without a period. Everything leading up to it is perimenopause, and that is the phase that causes the trouble. It commonly lasts four to eight years, and it can start in your late thirties.

The average age of menopause in the United States is 51. Before 45 it is called early menopause; before 40 it is primary ovarian insufficiency and it needs a different, more urgent approach.

Menopause is not an illness. It also does not need to be endured in silence. Most of what makes it difficult is treatable.

What we treat

Hot flashes and night sweats, the symptoms with the best treatment options and the biggest impact on sleep
Sleep disruption, whether or not it is caused by night sweats
Vaginal dryness, burning, and pain with sex — the genitourinary syndrome of menopause, which unlike hot flashes does not improve on its own and progresses without treatment
Recurrent urinary tract infections and urinary urgency related to the same tissue changes
Mood change, irritability and anxiety, which peak in the transition rather than after it
Brain fog and concentration problems
Joint aches, which are common and rarely connected to menopause by the people experiencing them
Irregular and heavy bleeding during perimenopause
Bone loss, which accelerates sharply in the years around the final period

Diagnosis: what you do and do not need

If you are over 45 with irregular periods and typical symptoms, no blood test is required to diagnose perimenopause. Hormone levels swing wildly from week to week in the transition, so a single FSH or estradiol level tells you little and a normal one does not rule anything out. Testing is useful when the picture is atypical, when you are under 45, when your periods have stopped early, or to exclude thyroid disease and other causes.

Salivary hormone testing is not a valid basis for dosing. Any clinic that builds a treatment plan around it is selling something the evidence does not support.

What does matter is a proper history, blood pressure, a review of your cardiovascular and breast cancer risk, and up-to-date screening — see routine check-ups.

Treatment options

Hormone therapy. The most effective treatment for hot flashes and night sweats, and it also protects bone. For most healthy women under 60, or within 10 years of their final period, benefits outweigh risks. Estrogen alone if you have had a hysterectomy; estrogen plus a progestogen if you still have a uterus, to protect the uterine lining. Read hormone replacement therapy: a practical guide, signs you may be a candidate and our hormone therapy service.

Vaginal estrogen. A separate decision from systemic hormone therapy. Low-dose vaginal estrogen treats dryness, painful sex and recurrent UTIs with minimal absorption into the bloodstream, and it is appropriate for many women who cannot or do not want to take systemic hormones.

Non-hormonal prescription options. Certain antidepressants at low dose, gabapentin, oxybutynin, and a newer class of non-hormonal drugs developed specifically for hot flashes. These are real options for women with a history of breast cancer, clotting disorders, or a preference to avoid hormones.

Non-drug measures. Layered clothing, a cool bedroom, limiting alcohol and caffeine, cognitive behavioural therapy for hot flashes and insomnia, and regular exercise. Modest effects individually, worth combining.

Bone and heart protection. Weight-bearing exercise, adequate calcium and vitamin D, bone density testing at 65 or earlier with risk factors, and attention to blood pressure, cholesterol and glucose. Cardiovascular risk rises after menopause and this is the decade to act on it.

What menopause does not explain

Some symptoms get attributed to menopause and should not be.

Any bleeding after 12 months without a period requires evaluation. Not monitoring, not waiting. See abnormal uterine bleeding.
Very heavy or prolonged bleeding in perimenopause needs a cause identified, not just tolerating.
Fatigue, weight change and low mood are also thyroid disease, anemia, sleep apnoea and depression. All are checked before everything is filed under menopause.
New pelvic pain, bloating that persists, or early fullness when eating need evaluation — see gynecologic cancers.

Talk to us

Medical disclaimer

This page is general health information, not medical advice for any individual. Whether hormone therapy is appropriate for you depends on your age, time since menopause, medical history and personal risk, and must be decided with a physician. Any vaginal bleeding after menopause needs prompt medical evaluation.