Understanding the Stages of Menopause: A Comprehensive Guide

Menopause is a natural process that marks the end of a woman’s reproductive years. Also called the “change of life,” it is diagnosed when a woman has gone 12 consecutive months without having menstrual periods. 

While menopause can occur in your 40s or 50s, the average age at which menopause occurs is 51 years in the United States. If a woman goes through menopause before age 40 it is called premature menopause, and early menopause between 40-45.

What are the 3 stages of menopause?

Stage 1: Perimenopause

Perimenopause is the transitional stage when a woman is moving towards menopause. During perimenopause:

• Ovaries begin to release eggs irregularly and gradually stop working.

• The body makes less estrogen and other reproductive hormones.

• Fertility decreases.

• Menstrual cycles become more irregular (longer or shorter).

• Noticeable symptoms of menopause develop.

Symptoms of Perimenopause include:

• Irregular periods (shorter or longer, heavier or lighter than usual)

• Hot flashes (a sudden feeling of warmth that spreads throughout the body)

• Night sweats (excessive sweating at night time)

• Vaginal dryness and discomfort during sexual intercourse

• Headaches

• Sleep problems such as insomnia

• Mood changes or swings such as irritability, anxiety, depression

• Memory problems and trouble concentrating (brain fog)

• Changes in libido (sexual desire)

• Urinary urgency and frequency (needing to use the bathroom more often and urgently) and urinary incontinence (not getting to the bathroom on time)

• Joint pains and muscle aches

• Racing heartbeat

• Dry skin, dry mouth, dry eyes

• Excessive sweating

• Breast tenderness

• Weight gain

• Hair thinning or hair loss

• Symptoms similar to PMS (premenstrual syndrome)

How Long Does Perimenopause Last?

Perimenopause can last for 2 to 8 years. However, each woman is unique, and each experience will be different. 

What Does Perimenopause Feel Like?

During perimenopause, hormones fluctuate quite a lot. Low estrogen levels can cause vasomotor symptoms such as hot flashes and night sweats, while high estrogen levels can cause symptoms similar to PMS (premenstrual syndrome).

These changing levels of hormones can cause the menstrual cycle to become shorter or longer and the menstrual flow to become irregular before the final menstrual period. These changes may occur with regular menstrual cycles at times.

Emotional and Psychological Impacts of Perimenopause

In addition to common symptoms of menopause, such as hot flashes and vaginal dryness, changing levels of reproductive hormones can also impact mental health. You may experience symptoms such as stress, anxiety, and depression. Mood changes can include anger, frustration, and irritability. Many women report memory problems and trouble concentrating (“brain fog”). Problems with sleeping can lead to tiredness, poor concentration, and irritability. The emotional and psychological impact of menopause can result in loss of confidence and self-esteem.

Stage 2: Menopause

As noted above, a woman is diagnosed with menopause when she has gone 12 consecutive months without having a menstrual period. In other words, menopause is diagnosed after it has already occurred. Your healthcare provider may also order blood tests like follicle-stimulating hormone (FSH) to check levels for confirmation. 

Key physiological changes and symptoms of perimenopause are the same symptoms described above. They can occur for up to 10 years before menopause is officially diagnosed with the absence of menstrual periods for 12 consecutive months.

Stage 3: Postmenopause

Postmenopause refers to the time after menopause when your menstrual period has stopped for 12 months or longer. At this stage, you are no longer ovulating (your ovaries are not releasing eggs each month). Your reproductive years are behind you, and you cannot become pregnant. Once you enter postmenopause, it lasts for the rest of your life.

The symptoms experienced during perimenopause and menopause typically become milder or go away during post-menopause. However, for some women, symptoms of menopause can last for 10 years or more after menopause.

Long-Term Health Considerations

Postmenopausal women are at an increased risk of several health conditions:

• Osteoporosis (bone loss) after menopause occurs more quickly due to decreased estrogen levels. This is associated with an increased risk of bone fractures, especially in the spine, hips, and wrists. Osteopenia (low bone density) can develop first and quickly progress to osteoporosis.

• Cardiovascular disease (heart disease, heart attack, stroke) can occur due to the loss of the protective effect of estrogen. Additionally, women in postmenopause often exercise less, leading to cardiovascular risk factors like high cholesterol and high blood pressure. 

• Vaginal atrophy (thinning of the vaginal tissues) occurs due to decreased estrogen in the body. This can cause vaginal dryness and discomfort during sex for many years after menopause. 

• Non-alcoholic fatty liver disease (NAFLD) is a risk due to deposition of fat in the liver. It is more common in post-menopausal women and can increase the risk of cirrhosis and liver cancer.

• Mental health issues (mood swings, anxiety, and depression) are common in postmenopausal women. These may be explained by the stress of life changes, sexual tensions, relationship problems, sadness over the loss of reproductive function, and decreased hormone levels. 

Managing Postmenopausal Life

If bone mineral density (bone densitometry) shows bone loss or thinning bones (osteoporosis), your doctor can prescribe treatments to improve bone density and lower your risk of fractures. Estrogen therapy has also been shown to prevent osteoporosis. Regular exercise can strengthen your bones and improve balance and flexibility, lowering the risk of falls and related fractures.

A healthy diet, regular exercise, and smoking cessation (if you smoke) can lower your risk of coronary artery disease and help you maintain a healthy body weight. It is also important to take prescription medications for hypertension, high cholesterol, and diabetes, which are risk factors for heart disease. 

For symptoms related to vaginal atrophy, lubricants can help with vaginal dryness and discomfort during sexual intercourse. Urinary frequency and urgency and urinary incontinence (loss of bladder control) can also be relieved by estrogens, anticholinergics, and pelvic floor strengthening exercises.

Mental health symptoms during postmenopausal life can be managed by medication or by talking to a counselor or therapist.

How to Identify Your Stage of Menopause

Recognizing Symptoms of Each Stage

• Early perimenopause: Regular menstrual cycles with some menopausal symptoms like hot flashes, night sweats, and vaginal dryness due to hormonal changes.

• Late perimenopause: Irregular menstrual cycles and worsening symptoms of menopause.

• Menopause: Complete cessation of menstruation for at least 12 months continuously and gradual lessening of menopausal symptoms.

• Post-menopause: Some symptoms of menopause continue. Health risks such as osteoporosis, cardiovascular disease, vaginal atrophy, and mental health problems are present in this stage of menopause.

Note: Menopause symptoms may overlap during the three stages. 

Tools and Tests for Diagnosing Menopausal Stages

Diagnosis of Perimenopause

Perimenopause is diagnosed if you are in your late 40s or early 50s and have hot flashes and other menopausal symptoms. It is important to note that blood tests to check hormone levels during perimenopause can yield misleading results because of hormonal fluctuations.

Diagnosis of Menopause and Postmenopause

Aside from the 12-month criteria, blood tests to check hormone levels can be done and are more accurate when confirming menopause. Once menopause has officially occurred, post-menopause is diagnosed and lasts for the rest of a woman’s life.

When To See a Healthcare Provider

See your healthcare provider if the symptoms of menopause are bothersome and affect your ability to function in daily life. Your provider can prescribe treatments to ease menopausal symptoms. 

It is also important to see your healthcare provider if you have irregular vaginal bleeding. This can be a sign of other health conditions, and your doctor can make sure that menopause is the true cause of your symptoms. 

In addition, seek professional medical care if you have: 

• Heavy bleeding with periods.

• Passage of large blood clots in menstrual blood (clots bigger than a quarter).

• Periods lasting more than 7 days.

• Less than 21 days between menstrual periods.

• Bleeding or spotting between periods.

• Bleeding after sex.

• Skipped periods before age 45.

Common Questions About the Stages of Menopause

How Do You Know What Stage of Menopause You Are In?

If you are still getting your periods but have symptoms of menopause, you are in perimenopause. If you have not had a menstrual period for 12 consecutive months, you have officially reached menopause. After menopause, you remain in post-menopause for the rest of your life.

At What Stage of Menopause Are Symptoms Worst?

Menopause symptoms are usually the worst in late perimenopause, but every woman’s experience is different. Generally speaking, symptoms are mild in early perimenopause. They worsen progressively during late perimenopause when menopause is imminent. After menopause occurs, symptoms usually improve. 

Coping Strategies and Treatments

Many women go through menopause without needing any treatment. Others experience severe symptoms and require treatment. 

The treatment for menopause depends on the most significant symptoms that are bothersome and disruptive to daily life. Treatment options include:

Hormone Therapy

The ovaries stop making estrogen and progesterone in menopausal women. Hormone therapy refers to hormones given to women going through natural menopause after age 45. The term hormone replacement therapy is used when menopause is early (before age 45) or premature (before age 40). Taking menopausal hormone therapy can help with menopausal symptoms and help prevent osteoporosis.

• Estrogen-only therapy involves taking estrogen only. Estrogen comes in various forms, such as pills, patches, creams, gels, sprays, and vaginal rings. This type of hormone therapy is best for women who have had a hysterectomy (surgery to remove the uterus). 

• Estrogen progestogen therapy (EPT) is a combination hormone therapy for women who have not had a hysterectomy.

• Birth control pills to balance hormone levels.

Prescription Medications for Menopause

Non-hormonal prescription medicines for menopause symptoms include the following: 

• Antidepressants such as SSRIs or SNRIs improve mood swings and hot flashes.

• Anti-seizure/nerve pain medicine, gabapentin for hot flashes.

• Fezolinetant (Veozah) for vasomotor symptoms.

• Oxybutynin (Ditropan) for overactive bladder and hot flashes.

• Vaginal creams for lubrication to reduce vaginal dryness.

• Bisphosphonates such as alendronate (Fosamax) to improve bone health.

Lifestyle Changes and Their Impact

Hormone therapy and non-hormone prescription medications can relieve hot flashes and other symptoms. However, some women cannot take hormones for reasons such as a history of blood clots or breast cancer. In such women, a healthy lifestyle can help. Here are some tips to help you cope:

Focus on Your Diet

Dietary modifications can help to relieve menopausal symptoms. For example, limiting caffeine, excessive alcohol consumption, and spicy foods can decrease the severity of hot flashes. Eating foods that contain phytoestrogens (plant estrogen) may also help. Examples include soybeans, lentils, chickpeas, beans, whole grains, flaxseed, and fruits and vegetables. 

Avoid Triggers for Hot Flashes

Keeping a diary of your episodes of hot flashes can help you identify the things that trigger them. Common triggers include warm temperatures, wearing too many layers, being overweight or obese, smoking, and eating spicy food or drinking caffeinated beverages. 

Get Regular Exercise

Regular physical activity can relieve many of the common symptoms of menopause. Activities such as swimming are especially helpful as they also keep you cool. Yoga and tai-chi can help in relieving anxiety and managing stress. 

Stress Management Techniques

The emotional and psychological symptoms of menopause can be managed with activities such as yoga, meditation, mindfulness, deep breathing exercises, listening to music, or taking art classes. If your symptoms are severe, consider consulting a mental health professional who can offer cognitive behavioral therapy (CBT) or hypnotherapy.

Alternative Therapies and Herbal Supplements for Menopausal Symptoms

Some of the supplements that may help women with mild menopausal symptoms include black cohosh, flaxseed and flaxseed oil, wild yam, and red clover. Your provider may also recommend calcium and vitamin D supplements to prevent osteoporosis. However, the safety and efficacy of many supplements are not supported by robust scientific evidence and are not regulated by the U.S. Food and Drug Administration (FDA). Always check with your healthcare provider before taking any dietary supplements. 

Resources for Women Experiencing Menopause

Support Networks and Communities

Talking to other women who are also going through the transition and symptoms of menopause helps many women feel less overwhelmed by the changes. Support groups also provide an outlet for emotions and answers to common questions. However, it’s important to choose groups that are moderated by medical professionals to avoid any misinformation. 

Educational Materials and Courses

Here are some links for further reading:

• Menopause (MedlinePlus)

• Hormone therapy and cancer risk (National Cancer Institute)

• Hot Flashes (National Institute on Aging)

Final Thoughts on Stages of Menopause

The pre-menopause stage of a woman’s life is when she has regular menstrual periods and can become pregnant. Menopause is a natural transition in which the ovaries stop releasing eggs and making hormones, and it marks the end of a woman’s reproductive years. 

Most women go through menopause in their early 50s. You reach menopause 12 months after your final menstrual period, i.e., when you have not had a menstrual period for 12 consecutive months. Doctors can also do blood tests for hormones such as FSH to confirm a diagnosis of menopause.

Seek Help for Menopause-Related Symptoms

If you have severe symptoms of menopause, you don’t have to suffer in silence. Many effective treatments are available to help you go through this natural transition.