Menopause

What Is Menopause?

Menopause is a natural life transition that occurs when people who are assigned female at birth do not have a menstrual period for 12 consecutive months.¹ Menopause is a natural part of the aging process, occurring typically between the ages of 45 and 55.¹ The average age of menopause in the United States is 51 years.²

Perimenopause is a period of time prior to menopause during which a person assigned female at birth may begin to experience changes in their periods, hot flashes, or other symptoms such as sleep disturbances, urinary urgency, and others. During perimenopause, the ovaries start to produce varying levels of the hormones estrogen and progesterone, which may give rise to these symptoms. But perimenopause affects bodies differently. Some people assigned female at birth may experience symptoms, but others may not.¹

Perimenopause typically lasts about seven years, but it can be as long as 14 years. Race, ethnicity, age of onset of menopausal/hormonal changes, and smoking history can all influence the duration of perimenopause.¹

Prevalence of Menopause

An estimated 1.3 million people assigned female at birth reach menopause annually in the U.S.²

About 10% of people assigned female at birth will reach menopause before age 45. If menopause occurs between ages 40-45, it is considered early. About 2% of people assigned female at birth experience menopause before age 40.³ Medical professionals call this premature menopause, and it may occur due to genetics or other causes of ovarian failure.^2,3

A person’s ethnic or racial background also may affect menopause. For example:

• Black or Native American people assigned female at birth tend to have more hot flashes that are more intense, compared with other ethnicities.⁴
• People assigned female at birth who are Hispanic have a rate of hot flashes that is similar to those who are white but less than those who are Black.⁴
• Hispanic and Black people assigned female at birth experience more menopause-related sleep disruptions compared with those who are white.⁵
• Among people assigned female at birth, Black, Japanese, and Chinese people had poorer and shorter sleep related to menopause, compared with those who are white.⁵
• Black and Hispanic people assigned female at birth indicate that urinary incontinence worsens during and after menopause more than those who are white.⁶

Causes and Risk Factors

What Causes Menopause?

Menopause is a normal part of aging for people assigned female at birth, not a sickness or disorder.¹ Menopause occurs when the ovaries no longer release eggs or produce the hormones progesterone and estrogen.⁷

In the time leading up to menopause, called perimenopause, declining levels of these hormones may lead to symptoms such as hot flashes, sleep disturbances, and others.^1,8 Menstrual periods also may occur less regularly and then stop.⁸

Menopause can occur abruptly. For example, if a person assigned female at birth has their ovaries removed, the surgery will lead to menopause.⁷ Chemotherapy and hormone therapy for cancer may also lead to menopause.⁹

Menopause Symptoms

Menopause symptoms may vary among people assigned female at birth, and they may last for five or more years. Additionally, surgical menopause symptoms can be intense and have a sudden onset.⁸

People assigned female at birth first may notice changes in their periods, which may occur more or less often. For example, they may get a period every three weeks and then start to miss periods. In other cases, people assigned female at birth may experience irregular periods for one to three years before periods cease.⁸

Other menopause symptoms can include:

• Hot flashes,¹ which may be more intense in the first one to two years⁸
• Night sweats,⁸ which are hot flashes that occur at night¹⁷
• Sleep difficulties, which can include trouble falling asleep, trouble staying asleep, or waking earlier than planned¹
• Depression or anxiety^1,8
• Painful intercourse¹
• Irritability, moodiness, and mood swings^1,18
• Racing or pounding heart⁸
• Heart palpitations⁸
• Flushing of the skin⁸
• Decreased libido⁸
• Vaginal dryness/itchiness⁸
• Vaginal infections⁸
• Forgetfulness or brain fog or difficulty concentrating^8,19
• Pain and aches in the joints⁸
• Headache⁸
• Leakage of urine or a sudden need to urinate^1,8
• Weight gain¹

Menopause Complications

Menopause complications can stem from dips in the level of the hormone estrogen. One of the leading menopause complications is osteoporosis, a condition that affects the density and strength of bone.²

Declining estrogen levels during menopause can lead to lower bone density. It’s estimated that osteoporosis affects more than 250,000 people assigned female at birth who are menopausal or postmenopausal. At the age of 40, women begin to lose bone at a rate of 0.3% to 0.5% per year. The rate of bone loss increases in menopause to 3% to 5% per year for the first five to seven years.²

Cardiovascular disease (CVD) is another common menopause complication. Declining estrogen levels can lead to vasoconstriction (narrowing of blood vessels) and changes to cholesterol.^2,20 This elevates CVD risk, including coronary artery disease and stroke.^2,3 The risk of coronary heart disease is two to three times higher after reaching menopause than it is for people assigned female at birth who have not reached menopause at the same age. Diet and exercise may lower CVD risk.²

Diagnosis and Treatment

Menopause Diagnosis

Formally, menopause is the day on which a person assigned female at birth has gone 12 consecutive months without a period.¹ Typically, the emergence of symptoms and signs notify a person assigned female at birth that they’re approaching menopause. Healthcare providers do not typically diagnose it.^2,21

When a person assigned female at birth talks to a healthcare provider about their symptoms, the healthcare provider typically identifies the symptoms, rules out other conditions for people over the age of 45, and factors in the patient’s age.² Two of the more common symptoms that a healthcare provider will look for are changes to the patient’s periods and the presence of hot flashes.^2,8 Other common symptoms may include night sweats,⁸ which are hot flashes that occur at night,¹⁷ trouble sleeping,¹ and irritability, moodiness, and mood swings.^1,18

In addition to looking for these and other symptoms, healthcare providers can also perform urine or blood tests to evaluate hormone levels, which may indicate perimenopause or postmenopause.^21,8

Menopause Symptom Management

Healthcare providers tend to focus on managing menopause symptoms that affect quality of life and strive to help patients avoid long-term complications.² Hormonal treatments may help achieve both objectives.²

Certain hormonal treatments have been approved by the U.S. Food and Drug Administration (FDA) to treat moderate to severe hot flashes due to menopause.^2,22 Additionally, the FDA has approved hormonal treatments to address vaginal changes due to menopause, including painful sex.²² And finally, the FDA has approved hormonal treatments to prevent postmenopausal osteoporosis.²² Hormone therapy comes with risks, which should be weighed with a healthcare provider.²

Healthcare providers may also prescribe selective estrogen receptor modulators (SERMs), but not all SERMs work the same way or have the same effects. One SERM may help prevent or treat postmenopausal osteoporosis. Another SERM is combined with estrogens into one medication to treat moderate to severe hot flashes and prevent postmenopausal osteoporosis.^2,23 Another SERM can treat moderate to severe painful sex due to menopause.²²

Additionally, healthcare providers may turn to non-hormonal treatments to help with menopause. The FDA has approved one selective serotonin reuptake inhibitor (SSRI) to treat hot flashes.² SSRIs increase serotonin, a neurotransmitter.²⁴ And in May 2023, the FDA approved a neurokinin 3 receptor agonist to help with moderate to severe hot flashes.²⁵ This type of medication targets a specific neural pathway that has been linked to hot flashes.²⁶

To help manage osteoporosis, healthcare providers may also recommend calcium and vitamin D supplementation, along with other vitamins and minerals critical for bone health, such as vitamin K2 and magnesium.²⁷ Physical activity and quitting smoking may also lessen osteoporosis risk.²

According to the National Library of Medicine, certain lifestyle changes may also help with menopause management. Identifying symptom triggers such as spicy foods, caffeine, or alcohol may be helpful. Additionally, physical exercise, intentional breathing exercises during hot flashes, and Kegel exercises may help. Other ways to help manage symptoms may include acupuncture, dressing in layers to deal with hot flashes, remaining sexually active, and using lubricants and vaginal moisturizer during sex.⁸

Global Impact of Menopause

Researchers estimate that by 2050 there will be 1.6 billion people assigned female at birth who have reached menopause worldwide. In 2020, there were a billion people worldwide who had reached menopause. Up to 75% of people in menopause experience hot flashes, night sweats, and other symptoms.²⁸

Despite the common nature of menopause, many people assigned female at birth do not discuss it with a healthcare provider. Research in the U.K. indicated that 45% of people assigned female at birth had not talked to a healthcare provider about their menopause symptoms.²⁹

This has implications for how people assigned female at birth live and work. In 2020, an estimated 657 million people assigned female at birth were between the ages of 45 and 59 across the globe, and about half of these were in the workforce.³⁰ Research in the U.K. indicated that one out of 10 people assigned female at birth have left the U.K. workforce due to menopause.²⁹ In a 2022 survey of 1,045 people assigned female at birth aged 40 to 64 in the U.S., who all reported experiencing at least one instance of hot flashes or night sweats in the past month, 12% said menopause affected their performance at work.³¹

Education surrounding menopause is also lacking. Around the world, many communities, families, workplaces, and even healthcare settings may not discuss menopause. People assigned female at birth may not know their symptoms are due to menopause, or what treatment options they have. Healthcare providers may not be adequately trained in how to help. Menopausal symptoms such as vaginal dryness and painful intercourse go unaddressed because sexual wellbeing is overlooked. Moreover, many menopause health services receive inadequate funding.³²