Menopause

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During early menopause transition, the menstrual cycles remain regular but the interval between cycles begins to lengthen. Hormone levels begin to fluctuate. Ovulation may not occur with each cycle.{{cite book |title=Williams Gynecology |vauthors=Hoffman B |publisher=McGraw-Hill Medical |year=2012 |isbn=9780071716727 |location=New York |pages=555–56}}

The term menopause refers to a point in time that follows one year after the last menstruation. During the menopausal transition and after menopause, women can experience a wide range of symptoms. However, for women who enter the menopause transition without having regular menstrual cycles (due to prior surgery, other medical conditions or ongoing hormonal contraception) the menopause cannot be identified by bleeding patterns and is defined as the permanent loss of ovarian function.

File:Vaginal_Canal_Normal_vs._Menopause.png before and after menopause, demonstrating vaginal atrophy]]

During the transition to menopause, menstrual patterns can show shorter cycling (by 2–7 days); longer cycles remain possible. There may be irregular bleeding (lighter, heavier, spotting). Dysfunctional uterine bleeding is often experienced by women approaching menopause due to the hormonal changes that accompany the menopause transition. Spotting or bleeding may simply be related to vaginal atrophy, a benign sore (polyp or lesion), or may be a functional endometrial response. The European Menopause and Andropause Society has released guidelines for assessment of the endometrium, which is usually the main source of spotting or bleeding.{{cite journal |vauthors=Dreisler E, Poulsen LG, Antonsen SL, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, Pérez-López FR, Simoncini T, Tremollieres F, Rees M, Ulrich LG |date=June 2013 |title=EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women |journal=Maturitas |volume=75 |issue=2 |pages=181–90 |doi=10.1016/j.maturitas.2013.03.011 |pmid=23619009}}

In post-menopausal women, however, any unscheduled vaginal bleeding is of concern and requires an appropriate investigation to rule out the possibility of malignant diseases.

Urogenital symptoms may appear during menopause and continue through postmenopause and include painful intercourse, vaginal dryness and atrophic vaginitis (thinning of the membranes of the vulva, the vagina, the cervix and the outer urinary tract). There may also be considerable shrinking and loss in elasticity of all of the outer and inner genital areas. Urinary urgency may also occur and urinary incontinence in some women.{{Cite journal |last1=Allafi |first1=Ahmad Hasan |last2=Al-Johani |first2=Amal Saleem |last3=Babukur |first3=Raed M. |last4=Fikri |first4=Jehad |last5=Alanazi |first5=Raneem Rashed |last6=Ali |first6=Sara Dafaalla Mohamed Hag |last7=Alkathiry |first7=Abdulrahman |last8=Alfozan |first8=Abdalmelk Mohmed |last9=Mayoof |first9=Kawthar Ishaq Ahmed Ali Husain |last10=Abualhamael |first10=Maya Ahmad |date=2024 |title=The Link Between Menopause and Urinary Incontinence: A Systematic Review |journal=Cureus |volume=16 |issue=10 |pages=e71260 |doi=10.7759/cureus.71260 |doi-access=free |issn=2168-8184 |pmc=11550778 |pmid=39525118}}

File:Menopause - Osteoporosis -- Smart-Servier (cropped).jpg

The most common physical symptoms of menopause are heavy night sweats, and hot flashes (also known as vasomotor symptoms).{{cite journal | vauthors = Crandall CJ, Mehta JM, Manson JE | title = Management of Menopausal Symptoms: A Review | journal = JAMA | volume = 329 | issue = 5 | pages = 405–420 | date = February 2023 | pmid = 36749328 | doi = 10.1001/jama.2022.24140 | s2cid = 256628900 }} Sleeping problems and insomnia are also common.{{cite journal | vauthors = Santoro N, Epperson CN, Mathews SB | title = Menopausal Symptoms and Their Management | journal = Endocrinology and Metabolism Clinics of North America | volume = 44 | issue = 3 | pages = 497–515 | date = September 2015 | pmid = 26316239 | pmc = 4890704 | doi = 10.1016/j.ecl.2015.05.001 }} Other physical symptoms may be reported that are not specific to menopause but may be exacerbated by it, such as lack of energy, joint soreness, stiffness, back pain, breast enlargement, breast pain, heart palpitations, headache, dizziness, dry, itchy skin, thinning of the skin, tingling skin, rosacea, weight gain.{{Cite web |date=27 June 2017 |title=Red in the Face |url=https://newsinhealth.nih.gov/2012/08/red-face |access-date=31 March 2021 |website=NIH News in Health |language=en}}

Psychological symptoms are often reported but they are not specific to menopause and can be caused by other factors.{{Cite journal |last1=Hogervorst |first1=Eef |last2=Craig |first2=Jen |last3=O'Donnell |first3=Emma |date=2022-05-01 |title=Cognition and mental health in menopause: A review |url=https://www.sciencedirect.com/science/article/pii/S1521693421001644 |journal=Best Practice & Research Clinical Obstetrics & Gynaecology |series=Menopause Management |language=en |volume=81 |pages=69–84 |doi=10.1016/j.bpobgyn.2021.10.009 |issn=1521-6934 |pmid=34969617|s2cid=244805452 }}{{Cite journal |last1=Kilpi |first1=Fanny |last2=Soares |first2=Ana Luiza G. |last3=Fraser |first3=Abigail |last4=Nelson |first4=Scott M. |last5=Sattar |first5=Naveed |last6=Fallon |first6=Sean James |last7=Tilling |first7=Kate |last8=Lawlor |first8=Deborah A. |date=14 August 2020 |title=Changes in six domains of cognitive function with reproductive and chronological ageing and sex hormones: a longitudinal study in 2411 UK mid-life women |journal=BMC Women's Health |language=en |volume=20 |issue=1 |page=177 |doi=10.1186/s12905-020-01040-3 |issn=1472-6874 |pmc=7427852 |pmid=32795281 |doi-access=free }} They include anxiety, poor memory, inability to concentrate, depressive mood, irritability, mood swings, and less interest in sexual activity.{{cite journal |vauthors=Llaneza P, García-Portilla MP, Llaneza-Suárez D, Armott B, Pérez-López FR |date=February 2012 |title=Depressive disorders and the menopause transition |journal=Maturitas |volume=71 |issue=2 |pages=120–30 |doi=10.1016/j.maturitas.2011.11.017 |pmid=22196311|hdl=10651/6519 |hdl-access=free }}

Menopause-related cognitive impairment can be confused with the mild cognitive impairment that precedes dementia.{{Cite book |title=Managing the Menopause: 21st Century Solutions |vauthors=Panay N, Briggs P, Kovacs G |date=20 August 2015 |publisher=Cambridge University Press |isbn=9781316352717 |chapter=Memory and Mood in the Menopause |chapter-url=https://books.google.com/books?id=UZ9rCgAAQBAJ&pg=PA91}} There is evidence of small decreases in verbal memory, on average, which may be caused by the effects of declining estrogen levels on the brain,{{Cite book |url=https://books.google.com/books?id=JtBJDwAAQBAJ&pg=PA38 |title=Pre-Menopause, Menopause and Beyond: Volume 5: Frontiers in Gynecological Endocrinology |vauthors=Birkhaeuser M, Genazzani AR |date=30 January 2018 |publisher=Springer |isbn=9783319635408 |pages=38–39}} or perhaps by reduced blood flow to the brain during hot flashes.{{Cite book |url=https://books.google.com/books?id=xTExDwAAQBAJ |title=Current Medical Diagnosis and Treatment 2018, 57th Edition |vauthors=Papadakis MA, McPhee SJ, Rabow MW |date=11 September 2017 |publisher=McGraw Hill Professional |isbn=9781259861499 |pages=1212}} However, these tend to resolve for most women during the postmenopause. Subjective reports of memory and concentration problems are associated with several factors, such as lack of sleep, and stress.

Exposure to endogenous estrogen during reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. The menopausal transition is associated with an increase in fat mass (predominantly in visceral fat), an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction.{{cite journal |vauthors=Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T |date=June 2022 |title=Menopause: a cardiometabolic transition |journal=The Lancet. Diabetes & Endocrinology |language=English |volume=10 |issue=6 |pages=442–456 |doi=10.1016/S2213-8587(22)00076-6 |pmid=35525259 |s2cid=248561432}} Women with vasomotor symptoms during menopause seem to have an especially unfavorable cardiometabolic profile,{{cite journal |vauthors=Thurston RC |date=April 2018 |title=Vasomotor symptoms: natural history, physiology, and links with cardiovascular health |journal=Climacteric |volume=21 |issue=2 |pages=96–100 |doi=10.1080/13697137.2018.1430131 |pmc=5902802 |pmid=29390899}} as well as women with premature onset of menopause (before 45 years of age).{{cite journal |vauthors=Stevenson JC, Collins P, Hamoda H, Lambrinoudaki I, Maas AH, Maclaran K, Panay N |date=October 2021 |title=Cardiometabolic health in premature ovarian insufficiency |journal=Climacteric |volume=24 |issue=5 |pages=474–480 |doi=10.1080/13697137.2021.1910232 |pmid=34169795 |s2cid=235634591 |doi-access=free|hdl=2066/238753 |hdl-access=free }} These risks can be reduced by managing risk factors, such as tobacco smoking, hypertension, increased blood lipids and body weight.{{cite journal |vauthors=Souza HC, Tezini GC |date=September 2013 |title=Autonomic Cardiovascular Damage during Post-menopause: the Role of Physical Training |journal=Aging and Disease |volume=4 |issue=6 |pages=320–328 |doi=10.14336/AD.2013.0400320 |pmc=3843649 |pmid=24307965}}{{cite journal |author1=ESHRE Capri Workshop Group |year=2011 |title=Perimenopausal risk factors and future health |journal=Human Reproduction Update |volume=17 |issue=5 |pages=706–717 |doi=10.1093/humupd/dmr020 |pmid=21565809|hdl=11380/665246 |hdl-access=free }}

The annual rates of bone mineral density loss are highest starting one year before the final menstrual period and continuing through the two years after it.{{cite journal |vauthors=Warming L, Hassager C, Christiansen C |date=2002-02-01 |title=Changes in bone mineral density with age in men and women: a longitudinal study |journal=Osteoporosis International |volume=13 |issue=2 |pages=105–112 |doi=10.1007/s001980200001 |pmid=11905520 |s2cid=618576}} Thus, post menopausal women are at increased risk of osteopenia, osteoporosis and fractures.

Menopause is a normal event in a woman's life and a natural part of aging. Menopause can also be induced early.{{Cite web |title=Early or premature menopause {{!}} Office on Women's Health |url=https://www.womenshealth.gov/menopause/early-or-premature-menopause |access-date=2022-10-21 |website=www.womenshealth.gov}} Induced menopause occurs as a result of medical treatment such as chemotherapy, radiotherapy, oophorectomy, or complications of tubal ligation, hysterectomy, unilateral or bilateral salpingo-oophorectomy or leuprorelin usage.{{cite web |title=Gynaecologic Problems: Menopausal Problems |url=http://www.hon.ch/Dossier/MotherChild/gynae_problems/menopausal.html |url-status=dead |archive-url=https://web.archive.org/web/20210225095037/https://www.hon.ch/Dossier/MotherChild/gynae_problems/menopausal.html |archive-date=25 February 2021 |access-date=22 February 2012 |publisher=Health on the Net Foundation}}

Menopause typically occurs at some point between 47 and 54 years of age. According to various data, more than 95% of women have their last period between the ages of 44–56 (median 49–50). 2% of women under the age of 40, 5% between the ages of 40–45 and the same number between the ages of 55–58 have their last bleeding.{{cite journal |vauthors=Morabia A, Costanza MC |date=December 1998 |title=International variability in ages at menarche, first livebirth, and menopause. World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives |journal=American Journal of Epidemiology |volume=148 |issue=12 |pages=1195–205 |doi=10.1093/oxfordjournals.aje.a009609 |pmid=9867266 |doi-access=free}} The average age of the last period in the United States is 51 years, in Russia is 50 years, in Greece is 49 years, in Turkey is 47 years, in Egypt is 47 years and in India is 46 years.{{cite journal |vauthors=Ringa V |year=2000 |title=Menopause and treatments |journal=Quality of Life Research |volume=9 |issue=6 |pages=695–707 |doi=10.1023/A:1008913605129 |jstor=4036942 |s2cid=22496307}} Beyond the influence of genetics, these differences are also due to early-life environmental conditions{{Cite journal |last1=Begum |first1=Khurshida |last2=Muttukrishna |first2=Shanthi |last3=Sievert |first3=Lynnette Leidy |last4=Sharmeen |first4=Taniya |last5=Murphy |first5=Lorna |last6=Chowdhury |first6=Osul |last7=Kasim |first7=Adetayo |last8=Gunu |first8=Richard |last9=Bentley |first9=Gillian R. |date=March 2016 |title=Ethnicity or environment: effects of migration on ovarian reserve among Bangladeshi women in the United Kingdom |url=https://linkinghub.elsevier.com/retrieve/pii/S0015028215021081 |journal=Fertility and Sterility |language=en |volume=105 |issue=3 |pages=744–754.e1 |doi=10.1016/j.fertnstert.2015.11.024|pmid=26706133 }} and associated with epigenetic effects.{{Cite journal |last1=Bar-Sadeh |first1=Ben |last2=Rudnizky |first2=Sergei |last3=Pnueli |first3=Lilach |last4=Bentley |first4=Gillian R. |last5=Stöger |first5=Reinhard |last6=Kaplan |first6=Ariel |last7=Melamed |first7=Philippa |date=2020-09-15 |title=Unravelling the role of epigenetics in reproductive adaptations to early-life environment |url=https://www.nature.com/articles/s41574-020-0370-8 |journal=Nature Reviews Endocrinology |language=en |volume=16 |issue=9 |pages=519–533 |doi=10.1038/s41574-020-0370-8 |issn=1759-5029}} The menopausal transition or perimenopause leading up to menopause usually lasts 3–4 years (sometimes as long as 5–14 years).

Undiagnosed and untreated coeliac disease is a risk factor for early menopause. Coeliac disease can present with several non-gastrointestinal symptoms, in the absence of gastrointestinal symptoms, and most cases escape timely recognition and go undiagnosed, leading to a risk of long-term complications. A strict gluten-free diet reduces the risk. Women with early diagnosis and treatment of coeliac disease present a normal duration of fertile life span.{{cite journal |vauthors=Tersigni C, Castellani R, de Waure C, Fattorossi A, De Spirito M, Gasbarrini A, Scambia G, Di Simone N |year=2014 |title=Celiac disease and reproductive disorders: meta-analysis of epidemiologic associations and potential pathogenic mechanisms |journal=Human Reproduction Update |volume=20 |issue=4 |pages=582–93 |doi=10.1093/humupd/dmu007 |pmid=24619876 |doi-access=free|hdl=10807/56796 |hdl-access=free }}{{cite journal |vauthors=Lasa JS, Zubiaurre I, Soifer LO |year=2014 |title=Risk of infertility in patients with celiac disease: a meta-analysis of observational studies |journal=Arquivos de Gastroenterologia |volume=51 |issue=2 |pages=144–50 |doi=10.1590/S0004-28032014000200014 |pmid=25003268 |doi-access=free}}

Women who have undergone hysterectomy with ovary conservation go through menopause on average 1.5 years earlier than the expected age.

In rare cases, a woman's ovaries stop working at a very early age, ranging anywhere from the age of puberty to age 40. This is known as premature ovarian failure or premature ovarian insufficiency (POI) and affects 1 to 2% of women by age 40.{{cite journal |vauthors=Podfigurna-Stopa A, Czyzyk A, Grymowicz M, Smolarczyk R, Katulski K, Czajkowski K, Meczekalski B |date=September 2016 |title=Premature ovarian insufficiency: the context of long-term effects |journal=Journal of Endocrinological Investigation |volume=39 |issue=9 |pages=983–90 |doi=10.1007/s40618-016-0467-z |pmc=4987394 |pmid=27091671}}{{cite journal |vauthors=Laissue P |date=August 2015 |title=Aetiological coding sequence variants in non-syndromic premature ovarian failure: From genetic linkage analysis to next generation sequencing |journal=Molecular and Cellular Endocrinology |type=Review |volume=411 |pages=243–57 |doi=10.1016/j.mce.2015.05.005 |pmid=25960166 |doi-access=free}}{{cite journal |vauthors=Fenton AJ |year=2015 |title=Premature ovarian insufficiency: Pathogenesis and management |journal=Journal of Mid-Life Health |type=Review |volume=6 |issue=4 |pages=147–53 |doi=10.4103/0976-7800.172292 |pmc=4743275 |pmid=26903753 |doi-access=free }} It is diagnosed or confirmed by high blood levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) on at least three occasions at least four weeks apart.{{cite journal |vauthors=Kalantaridou SN, Davis SR, Nelson LM |date=December 1998 |title=Premature ovarian failure |journal=Endocrinology and Metabolism Clinics of North America |volume=27 |issue=4 |pages=989–1006 |doi=10.1016/s0889-8529(05)70051-7 |pmid=9922918}}

Premature ovarian insufficiency may be related to an auto immune disorder and therefore might co-occur with other autoimmune disorders such as thyroid disease, [adrenal insufficiency], and diabetes mellitus. Other causes include chemotherapy, being a carrier of the fragile X syndrome gene, and radiotherapy. However, in about 50–80% of cases of premature ovarian insufficiency, the cause is unknown, i.e., it is generally idiopathic.

Early menopause can be related to cigarette smoking, higher body mass index, racial and ethnic factors, illnesses, and the removal of the uterus.Bucher, et al. 1930

Menopause can be surgically induced by bilateral oophorectomy (removal of ovaries), which is often, but not always, done in conjunction with removal of the fallopian tubes (salpingo-oophorectomy) and uterus (hysterectomy).{{cite journal |vauthors=Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ |date=April 2012 |title=Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging |journal=Fertility and Sterility |volume=97 |issue=4 |pages=843–51 |doi=10.1016/j.fertnstert.2012.01.128 |pmc=3340904 |pmid=22341880}} Cessation of menses as a result of removal of the ovaries is called "surgical menopause". Surgical treatments, such as the removal of ovaries, might cause periods to stop altogether.{{Cite web |date=12 July 2017 |title=Early or premature menopause |url=https://www.womenshealth.gov/menopause/early-or-premature-menopause |access-date=7 November 2018 |work=Womenshealth.gov}} The sudden and complete drop in hormone levels may produce extreme withdrawal symptoms such as hot flashes, etc. The symptoms of early menopause may be more severe.

Removal of the uterus without removal of the ovaries does not directly cause menopause, although pelvic surgery of this type can often precipitate a somewhat earlier menopause, perhaps because of a compromised blood supply to the ovaries.{{medical citation needed|date=February 2015}} The time between surgery and possible early menopause is due to the fact that ovaries are still producing hormones.

File:615_Age_and_Bone_Mass.jpg due to menopause occurs due to changes in a woman's hormone levels.]]

The menopausal transition, and postmenopause itself, is a natural change, not usually a disease state or a disorder. The main cause of this transition is the natural depletion and aging of the finite amount of oocytes (ovarian reserve). This process is sometimes accelerated by other conditions and is known to occur earlier after a wide range of gynecologic procedures such as hysterectomy (with and without ovariectomy), endometrial ablation and uterine artery embolisation. The depletion of the ovarian reserve causes an increase in circulating follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels because there are fewer oocytes and follicles responding to these hormones and producing estrogen.{{Citation needed|date=November 2024}}

The transition has a variable degree of effects.{{cite journal |vauthors=Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL |date=April 2006 |title=Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles |journal=Archives of General Psychiatry |volume=63 |issue=4 |pages=385–90 |doi=10.1001/archpsyc.63.4.385 |pmid=16585467 |doi-access=free}}

The stages of the menopause transition have been classified according to a woman's reported bleeding pattern, supported by changes in the pituitary follicle-stimulating hormone (FSH) levels.{{cite journal |vauthors=Soules MR, Sherman S, Parrott E, Rebar R, Santoro N, Utian W, Woods N |date=December 2001 |title=Executive summary: Stages of Reproductive Aging Workshop (STRAW) |journal=Climacteric |volume=4 |issue=4 |pages=267–72 |doi=10.1080/cmt.4.4.267.272 |pmid=11770182 |s2cid=28673617}}

In younger women, during a normal menstrual cycle the ovaries produce estradiol, testosterone and progesterone in a cyclical pattern under the control of FSH and luteinizing hormone (LH), which are both produced by the pituitary gland. During perimenopause (approaching menopause), estradiol levels and patterns of production remain relatively unchanged or may increase compared to young women, but the cycles become frequently shorter or irregular.{{cite journal |vauthors=Prior JC |date=August 1998 |title=Perimenopause: the complex endocrinology of the menopausal transition |journal=Endocrine Reviews |volume=19 |issue=4 |pages=397–428 |doi=10.1210/edrv.19.4.0341 |pmid=9715373 |doi-access=free}} The often observed increase in estrogen is presumed to be in response to elevated FSH levels that, in turn, is hypothesized to be caused by decreased feedback by inhibin.{{cite journal |vauthors=Burger HG |date=January 1994 |title=Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition—an analysis of FSH, oestradiol and inhibin |journal=European Journal of Endocrinology |volume=130 |issue=1 |pages=38–42 |doi=10.1530/eje.0.1300038 |pmid=8124478}} Similarly, decreased inhibin feedback after hysterectomy is hypothesized to contribute to increased ovarian stimulation and earlier menopause.{{cite journal |vauthors=Nahás E, Pontes A, Traiman P, NahásNeto J, Dalben I, De Luca L |date=April 2003 |title=Inhibin B and ovarian function after total abdominal hysterectomy in women of reproductive age |journal=Gynecological Endocrinology |volume=17 |issue=2 |pages=125–31 |doi=10.1080/713603218 |pmid=12737673}}{{cite journal |vauthors=Petri Nahás EA, Pontes A, Nahas-Neto J, Borges VT, Dias R, Traiman P |date=February 2005 |title=Effect of total abdominal hysterectomy on ovarian blood supply in women of reproductive age |journal=Journal of Ultrasound in Medicine |volume=24 |issue=2 |pages=169–74 |doi=10.7863/jum.2005.24.2.169 |pmid=15661947 |s2cid=30259666|hdl=11449/224482 |hdl-access=free }}

The menopausal transition is characterized by marked, and often dramatic, variations in FSH and estradiol levels. Because of this, measurements of these hormones are not considered to be reliable guides to a woman's exact menopausal status.

Menopause occurs because of the sharp decrease of estradiol and progesterone production by the ovaries. After menopause, estrogen continues to be produced mostly by aromatase in fat tissues and is produced in small amounts in many other tissues such as ovaries, bone, blood vessels, and the brain where it acts locally.{{cite journal |vauthors=Simpson ER, Davis SR |date=November 2001 |title=Minireview: aromatase and the regulation of estrogen biosynthesis—some new perspectives |journal=Endocrinology |volume=142 |issue=11 |pages=4589–94 |doi=10.1210/endo.142.11.8547 |pmid=11606422 |doi-access=free}} The substantial fall in circulating estradiol levels at menopause impacts many tissues, from brain to skin.

In contrast to the sudden fall in estradiol during menopause, the levels of total and free testosterone, as well as dehydroepiandrosterone sulfate (DHEAS) and androstenedione appear to decline more or less steadily with age. An effect of natural menopause on circulating androgen levels has not been observed.{{cite journal |vauthors=Davison SL, Bell R, Donath S, Montalto JG, Davis SR |date=July 2005 |title=Androgen levels in adult females: changes with age, menopause, and oophorectomy |journal=The Journal of Clinical Endocrinology and Metabolism |volume=90 |issue=7 |pages=3847–53 |doi=10.1210/jc.2005-0212 |pmid=15827095 |doi-access=free}} Thus specific tissue effects of natural menopause cannot be attributed to loss of androgenic hormone production.{{cite journal |vauthors=Fogle RH, Stanczyk FZ, Zhang X, Paulson RJ |date=August 2007 |title=Ovarian androgen production in postmenopausal women |journal=The Journal of Clinical Endocrinology and Metabolism |volume=92 |issue=8 |pages=3040–3 |doi=10.1210/jc.2007-0581 |pmid=17519304 |doi-access=free}}

Hot flashes and other vasomotor and body symptoms accompanying the menopausal transition are associated with estrogen insufficiency and changes that occur in the brain, primarily the hypothalamus and involve complex interplay between the neurotransmitters kisspeptin, neurokinin B, and dynorphin, which are found in KNDy neurons in the infundibular nucleus.{{cite journal |vauthors=Skorupskaite K, George JT, Anderson RA |year=2014 |title=The kisspeptin-GnRH pathway in human reproductive health and disease |journal=Human Reproduction Update |volume=20 |issue=4 |pages=485–500 |doi=10.1093/humupd/dmu009 |pmc=4063702 |pmid=24615662}}

Decreased inhibin feedback after hysterectomy is hypothesized to contribute to increased ovarian stimulation and earlier menopause. Hastened ovarian aging has been observed after endometrial ablation. While it is difficult to prove that these surgeries are causative, it has been hypothesized that the endometrium may be producing endocrine factors contributing to the endocrine feedback and regulation of the ovarian stimulation. Elimination of these factors contributes to faster depletion of the ovarian reserve. Reduced blood supply to the ovaries that may occur as a consequence of hysterectomy and uterine artery embolisation has been hypothesized to contribute to this effect.

Impaired DNA repair mechanisms may contribute to earlier depletion of the ovarian reserve during aging.{{cite journal |vauthors=Titus S, Li F, Stobezki R, Akula K, Unsal E, Jeong K, Dickler M, Robson M, Moy F, Goswami S, Oktay K |date=February 2013 |title=Impairment of BRCA1-related DNA double-strand break repair leads to ovarian aging in mice and humans |journal=Science Translational Medicine |volume=5 |issue=172 |pages=172ra21 |doi=10.1126/scitranslmed.3004925 |pmc=5130338 |pmid=23408054}} As women age, double-strand breaks accumulate in the DNA of their primordial follicles. Primordial follicles are immature primary oocytes surrounded by a single layer of granulosa cells. An enzyme system is present in oocytes that ordinarily accurately repairs DNA double-strand breaks. This repair system is called "homologous recombinational repair", and it is especially effective during meiosis. Meiosis is the general process by which germ cells are formed in all sexual eukaryotes; it appears to be an adaptation for efficiently removing damages in germ line DNA.{{cite journal |vauthors=Brandl E, Mirzaghaderi G |date=September 2016 |title=The evolution of meiotic sex and its alternatives |journal=Proceedings of the Royal Society B: Biological Sciences |publisher=Proc Biol Sci |volume=283 |issue=1838 |doi=10.1098/rspb.2016.1221 |pmc=5031655 |pmid=27605505 |doi-access=free}}

Human primary oocytes are present at an intermediate stage of meiosis, termed prophase I (see Oogenesis). Expression of four key DNA repair genes that are necessary for homologous recombinational repair during meiosis (BRCA1, MRE11, Rad51, and ATM) decline with age in oocytes. This age-related decline in ability to repair DNA double-strand damages can account for the accumulation of these damages, that then likely contributes to the depletion of the ovarian reserve.

Ways of assessing the impact on women of some of these menopause effects, include the Greene climacteric scale questionnaire,{{cite journal |vauthors=Greene JG |date=May 1998 |title=Constructing a standard climacteric scale |journal=Maturitas |volume=29 |issue=1 |pages=25–31 |doi=10.1016/s0378-5122(98)00025-5 |pmid=9643514}} the Cervantes scale{{cite journal |vauthors=Monterrosa-Castro A, Romero-Pérez I, Marrugo-Flórez M, Fernández-Alonso AM, Chedraui P, Pérez-López FR |date=August 2012 |title=Quality of life in a large cohort of mid-aged Colombian women assessed using the Cervantes Scale |journal=Menopause |volume=19 |issue=8 |pages=924–30 |doi=10.1097/gme.0b013e318247908d |pmid=22549166 |s2cid=19201297}} and the Menopause rating scale.{{cite journal |vauthors=Chedraui P, Pérez-López FR, Mendoza M, Leimberg ML, Martínez MA, Vallarino V, Hidalgo L |date=January 2010 |title=Factors related to increased daytime sleepiness during the menopausal transition as evaluated by the Epworth sleepiness scale |journal=Maturitas |volume=65 |issue=1 |pages=75–80 |doi=10.1016/j.maturitas.2009.11.003 |pmid=19945237}}

The term "perimenopause", which literally means "around the menopause", refers to the menopause transition years before the date of the final episode of flow.{{Cite news |title=What Is Perimenopause? |work=WebMD |url=https://www.webmd.com/menopause/guide/guide-perimenopause#1 |access-date=6 October 2018}}{{Cite news |title=Perimenopause – Symptoms and causes |work=Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666 |access-date=6 October 2018}} According to the North American Menopause Society, this transition can last for four to eight years.{{cite web |title=Menopause 101 |url=http://www.menopause.org/for-women/menopauseflashes/menopause-101-a-primer-for-the-perimenopausal |url-status=live |archive-url=https://web.archive.org/web/20130410111346/http://www.menopause.org/for-women/menopauseflashes/menopause-101-a-primer-for-the-perimenopausal |archive-date=10 April 2013 |access-date=11 April 2013 |work=A primer for the perimenopausal |publisher=The North American Menopause Society}} The Centre for Menstrual Cycle and Ovulation Research describes it as a six- to ten-year phase ending 12 months after the last menstrual period.{{cite web |title=Perimenopause |url=http://www.cemcor.ca/help_yourself/perimenopause |url-status=live |archive-url=https://web.archive.org/web/20130225055347/http://cemcor.ca/help_yourself/perimenopause |archive-date=25 February 2013 |access-date=10 May 2013 |publisher=Centre for Menstrual Cycle and Ovulation Research (CeMCOR) |vauthors=Prior J}}

During perimenopause, estrogen levels average about 20–30% higher than during premenopause, often with wide fluctuations. These fluctuations cause many of the physical changes during perimenopause as well as menopause, especially during the last 1–2 years of perimenopause (before menopause).{{cite journal |vauthors=Chichester M, Ciranni P |date=August–September 2011 |title=Approaching menopause (but not there yet!): caring for women in midlife |journal=Nursing for Women's Health |volume=15 |issue=4 |pages=320–4 |doi=10.1111/j.1751-486X.2011.01652.x |pmid=21884497}} Some of these changes are hot flashes, night sweats, difficulty sleeping, mood swings, vaginal dryness or atrophy, incontinence, osteoporosis, and heart disease. Perimenopause is also associated with a higher likelihood of depression (affecting from 45 percent to 68 percent of perimenopausal women), which is twice as likely to affect those with a history of depression.{{Cite web |last=Silver |first=Dr. Nazanin E. |date=2023 |title=Mood Changes During Perimenopause Are Real. Here’s What to Know. |url=https://www.acog.org/womens-health/experts-and-stories/the-latest/mood-changes-during-perimenopause-are-real-heres-what-to-know |access-date=2025-03-27 |website=www.acog.org |language=en}}{{cite journal |vauthors=Gilbert N |date=27 January 2022 |title=When depression sneaks up on menopause |url=https://knowablemagazine.org/article/mind/2022/when-depression-sneaks-menopause |journal=Knowable Magazine |doi=10.1146/knowable-012722-1 |access-date=17 May 2022 |doi-access=free}}

During this period, fertility diminishes but is not considered to reach zero until the official date of menopause. The official date is determined retroactively, once 12 months have passed after the last appearance of menstrual blood.

The menopause transition typically begins between 40 and 50 years of age (average 47.5).{{cite book |url=https://books.google.com/books?id=wVkKVsCdNIkC&pg=PT247 |title=Disorders of menstruation |vauthors=Hurst BS |date=2011 |publisher=Wiley-Blackwell |isbn=9781444391817 |location=Chichester, West Sussex}}{{cite journal |vauthors=McNamara M, Batur P, DeSapri KT |date=February 2015 |title=In the clinic. Perimenopause |journal=Annals of Internal Medicine |volume=162 |issue=3 |pages=ITC1–15 |doi=10.7326/AITC201502030 |pmid=25643316|s2cid=216041116 }} The duration of perimenopause may be for up to eight years. Women will often, but not always, start these transitions (perimenopause and menopause) about the same time as their mother did.{{cite web |title=Inevitable Menopause |url=http://ce.nurse.com/course/CE232-60/inevitable-menopause/ |url-status=live |archive-url=https://web.archive.org/web/20131102015353/http://ce.nurse.com/course/ce232-60/inevitable-menopause |archive-date=2 November 2013 |access-date=11 April 2013 |vauthors=Kessenich C}}

Some research appears to show that melatonin supplementation in perimenopausal women can improve thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing depression associated with menopause.{{cite journal |vauthors=Bellipanni G, DI Marzo F, Blasi F, Di Marzo A |date=December 2005 |title=Effects of melatonin in perimenopausal and menopausal women: our personal experience |journal=Annals of the New York Academy of Sciences |volume=1057 |issue=1 |pages=393–402 |bibcode=2005NYASA1057..393B |doi=10.1196/annals.1356.030 |pmid=16399909 |s2cid=25213110}}

The term "postmenopausal" describes women who have not experienced any menstrual flow for a minimum of 12 months, assuming that they have a uterus and are not pregnant or lactating. The reason for this delay in declaring postmenopause is that periods are usually erratic during menopause. Therefore, a reasonably long stretch of time is necessary to be sure that the cycling has ceased. At this point a woman is considered infertile; however, the possibility of becoming pregnant has usually been very low (but not quite zero) for a number of years before this point is reached.{{citation needed|date=January 2024}}

In women with or without a uterus, menopause or postmenopause can also be identified by a blood test showing a very high follicle-stimulating hormone level, greater than 25 IU/L in a random blood draw; it rises as ovaries become inactive. FSH continues to rise, as its counterpart estradiol continues to drop for about 2 years after the last menstrual period, after which the levels of each of these hormones stabilize. The stabilization period after the begin of early postmenopause has been estimated to last 3 to 6 years, so early postmenopause lasts altogether about 5 to 8 years, during which hormone withdrawal effects such as hot flashes disappear. Finally, late postmenopause has been defined as the remainder of a woman's lifespan, when reproductive hormones do not change any more.{{citation needed|date=January 2024}}

A period-like flow during postmenopause, even spotting, may be a sign of endometrial cancer.

Perimenopause is a natural stage of life. It is not a disease or a disorder. Therefore, it does not automatically require any kind of medical treatment. However, in those cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the life of the woman experiencing them, palliative medical therapy may sometimes be appropriate.

{{Main|Hormone replacement therapy}}

In the context of the menopause, menopausal hormone therapy (MHT) is the use of estrogen in women without a uterus and estrogen plus progestogen in women who have an intact uterus.The Woman's Health Program Monash University, [http://med.monash.edu.au/sphpm/womenshealth/docs/postmenopausal-hormone-therapy.pdf Oestrogen and Progestin as Hormone Therapy] {{webarchive|url=https://web.archive.org/web/20120711003526/http://med.monash.edu.au/sphpm/womenshealth/docs/postmenopausal-hormone-therapy.pdf|date=11 July 2012}}

MHT may be reasonable for the treatment of menopausal symptoms, such as hot flashes.{{cite journal |author=North American Menopause Society |date=March 2010 |title=Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society |journal=Menopause |volume=17 |issue=2 |pages=242–255 |doi=10.1097/gme.0b013e3181d0f6b9 |pmid=20154637 |s2cid=24806751}} It is the most effective treatment option, especially when delivered as a skin patch.{{cite journal |author1=North American Menopause Society |date=March 2012 |title=The 2012 hormone therapy position statement of: The North American Menopause Society |journal=Menopause |volume=19 |issue=3 |pages=257–71 |doi=10.1097/GME.0000000000000921 |pmc=3443956 |pmid=22367731}}{{cite journal |vauthors=Sarri G, Pedder H, Dias S, Guo Y, Lumsden MA |date=September 2017 |title=Vasomotor symptoms resulting from natural menopause: a systematic review and network meta-analysis of treatment effects from the National Institute for Health and Care Excellence guideline on menopause |url=http://eprints.gla.ac.uk/138525/7/138525.pdf |journal=BJOG |volume=124 |issue=10 |pages=1514–1523 |doi=10.1111/1471-0528.14619 |pmid=28276200 |s2cid=206909766}} Its use, however, appears to increase the risk of strokes and blood clots.{{cite journal |vauthors=Boardman HM, Hartley L, Eisinga A, Main C, Roqué i Figuls M, Bonfill Cosp X, Gabriel Sanchez R, Knight B |date=March 2015 |title=Hormone therapy for preventing cardiovascular disease in post-menopausal women |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=3 |pages=CD002229 |doi=10.1002/14651858.CD002229.pub4 |pmid=25754617 |pmc=10183715 |hdl-access=free |hdl=20.500.12105/9999}} When used for menopausal symptoms the global recommendation is MHT should be prescribed for a long as there are defined treatment effects and goals for the individual woman.

MHT is also effective for preventing bone loss and osteoporotic fracture,{{cite journal |vauthors=de Villiers TJ, Stevenson JC |date=June 2012 |title=The WHI: the effect of hormone replacement therapy on fracture prevention |journal=Climacteric |volume=15 |issue=3 |pages=263–6 |doi=10.3109/13697137.2012.659975 |pmid=22612613 |s2cid=40340985}} but it is generally recommended only for women at significant risk for whom other therapies are unsuitable.{{cite journal |vauthors=Marjoribanks J, Farquhar C, Roberts H, Lethaby A, Lee J |date=January 2017 |title=Long-term hormone therapy for perimenopausal and postmenopausal women |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD004143 |doi=10.1002/14651858.CD004143.pub5 |pmc=6465148 |pmid=28093732}}

MHT may be unsuitable for some women, including those at increased risk of cardiovascular disease, increased risk of thromboembolic disease (such as those with obesity or a history of venous thrombosis) or increased risk of some types of cancer. There is some concern that this treatment increases the risk of breast cancer.{{cite journal |vauthors=Chlebowski RT, Anderson GL |date=April 2015 |title=Menopausal hormone therapy and breast cancer mortality: clinical implications |journal=Therapeutic Advances in Drug Safety |volume=6 |issue=2 |pages=45–56 |doi=10.1177/2042098614568300 |pmc=4406918 |pmid=25922653}} Women at increased risk of cardiometabolic disease and VTE may be able to use transdermal estradiol which does not appear to increase risks in low to moderate doses.

Adding testosterone to hormone therapy has a positive effect on sexual function in postmenopausal women, although it may be accompanied by hair growth or acne if used in excess. Transdermal testosterone therapy in appropriate dosing is generally safe.{{cite journal |display-authors=6 |vauthors=Davis SR, Baber R, Panay N, Bitzer J, Cerdas Perez S, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME |date=October 2019 |title=Global Consensus Position Statement on the Use of Testosterone Therapy for Women |journal=Climacteric |volume=22 |issue=5 |pages=429–434 |doi=10.1080/13697137.2019.1637079 |pmid=31474158 |s2cid=201713094 |doi-access=free|hdl=2158/1176450 |hdl-access=free }}

SERMs are a category of drugs, either synthetically produced or derived from a botanical source, that act selectively as agonists or antagonists on the estrogen receptors throughout the body. The most commonly prescribed SERMs are raloxifene and tamoxifen. Raloxifene exhibits oestrogen agonist activity on bone and lipids, and antagonist activity on breast and the endometrium.{{cite journal |vauthors=Davis SR, Dinatale I, Rivera-Woll L, Davison S |date=May 2005 |title=Postmenopausal hormone therapy: from monkey glands to transdermal patches |journal=The Journal of Endocrinology |volume=185 |issue=2 |pages=207–22 |doi=10.1677/joe.1.05847 |pmid=15845914 |doi-access=free}} Tamoxifen is in widespread use for treatment of hormone sensitive breast cancer. Raloxifene prevents vertebral fractures in postmenopausal, osteoporotic women and reduces the risk of invasive breast cancer.{{cite journal |vauthors=Bevers TB |date=September 2007 |title=The STAR trial: evidence for raloxifene as a breast cancer risk reduction agent for postmenopausal women |journal=Journal of the National Comprehensive Cancer Network |volume=5 |issue=8 |pages=719–24 |doi=10.6004/jnccn.2007.0073 |pmid=17927929 |doi-access=free}}

Some of the SSRIs and SNRIs appear to provide some relief from vasomotor symptoms. The most effective SSRIs and SNRIs are paroxetine, escitalopram, citalopram, venlafaxine, and desvenlafaxine. They may, however, be associated with appetite and sleeping problems, constipation and nausea.{{cite journal |vauthors=Potter B, Schrager S, Dalby J, Torell E, Hampton A |date=December 2018 |title=Menopause |journal=Primary Care |series=Women's Health |volume=45 |issue=4 |pages=625–641 |doi=10.1016/j.pop.2018.08.001 |pmid=30401346 |s2cid=239485855}}

Gabapentin or fezolinetant can also improve the frequency and severity of vasomotor symptoms. Side effects of using gabapentin include drowsiness and headaches.

Cognitive behavioural therapy and clinical hypnosis can decrease the amount women are affected by hot flashes. Mindfulness is not yet proven to be effective in easing vasomotor symptoms.{{cite journal |display-authors=6 |vauthors=Goldstein KM, Shepherd-Banigan M, Coeytaux RR, McDuffie JR, Adam S, Befus D, Goode AP, Kosinski AS, Masilamani V, Williams JW |date=April 2017 |title=Use of mindfulness, meditation and relaxation to treat vasomotor symptoms |journal=Climacteric |volume=20 |issue=2 |pages=178–182 |doi=10.1080/13697137.2017.1283685 |pmid=28286985 |s2cid=10446084}}{{cite journal |vauthors=van Driel CM, Stuursma A, Schroevers MJ, Mourits MJ, de Bock GH |date=February 2019 |title=Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis |journal=BJOG |volume=126 |issue=3 |pages=330–339 |doi=10.1111/1471-0528.15153 |pmc=6585818 |pmid=29542222}}

Exercise has been thought to reduce postmenopausal symptoms through the increase of endorphin levels, which decrease as estrogen production decreases.{{cite journal |vauthors=Hickey M, Szabo RA, Hunter MS |date=November 2017 |title=Non-hormonal treatments for menopausal symptoms |journal=BMJ |volume=359 |pages=j5101 |doi=10.1136/bmj.j5101 |pmid=29170264 |s2cid=46856968}} However, there is insufficient evidence to suggest that exercise helps with the symptoms of menopause. Similarly, yoga has not been shown to be useful as a treatment for vasomotor symptoms.

However a high BMI is a risk factor for vasomotor symptoms in particular. Weight loss may help with symptom management.{{cite journal |vauthors=Moore TR, Franks RB, Fox C |date=May 2017 |title=Review of Efficacy of Complementary and Alternative Medicine Treatments for Menopausal Symptoms |journal=Journal of Midwifery & Women's Health |volume=62 |issue=3 |pages=286–297 |doi=10.1111/jmwh.12628 |pmid=28561959 |s2cid=4756342}}

There is no strong evidence that cooling techniques such as using specific clothing or environment control tools (for example fans) help with symptoms. Paced breathing and relaxation are not effective in easing symptoms.

There is no evidence of consistent benefit of taking any dietary supplements or herbal products for menopausal symptoms.{{cite journal |vauthors=Clement YN, Onakpoya I, Hung SK, Ernst E |date=March 2011 |title=Effects of herbal and dietary supplements on cognition in menopause: a systematic review |journal=Maturitas |volume=68 |issue=3 |pages=256–63 |doi=10.1016/j.maturitas.2010.12.005 |pmid=21237589}}{{cite journal |vauthors=Nedrow A, Miller J, Walker M, Nygren P, Huffman LH, Nelson HD |date=July 2006 |title=Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review |journal=Archives of Internal Medicine |volume=166 |issue=14 |pages=1453–65 |doi=10.1001/archinte.166.14.1453 |pmid=16864755 |doi-access=free}} These widely marketed but ineffective supplements include soy isoflavones, pollen extracts, black cohosh, omega-3 among many others.{{cite journal |display-authors=6 |vauthors=Franco OH, Chowdhury R, Troup J, Voortman T, Kunutsor S, Kavousi M, Oliver-Williams C, Muka T |date=June 2016 |title=Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis |journal=JAMA |volume=315 |issue=23 |pages=2554–2563 |doi=10.1001/jama.2016.8012 |pmid=27327802 |doi-access=free}}{{cite journal |vauthors=Leach MJ, Moore V |date=September 2012 |title=Black cohosh (Cimicifuga spp.) for menopausal symptoms |journal=The Cochrane Database of Systematic Reviews |volume=9 |issue=9 |pages=CD007244 |doi=10.1002/14651858.CD007244.pub2 |pmc=6599854 |pmid=22972105}}

There is no evidence of consistent benefit of alternative therapies for menopausal symptoms despite their popularity.

As of 2023, there is no evidence to support the efficacy of acupuncture as a management for menopausal symptoms.{{cite journal |vauthors=Dodin S, Blanchet C, Marc I, Ernst E, Wu T, Vaillancourt C, Paquette J, Maunsell E |date=July 2013 |title=Acupuncture for menopausal hot flushes |journal=The Cochrane Database of Systematic Reviews |volume=7 |issue=7 |pages=CD007410 |doi=10.1002/14651858.CD007410.pub2 |pmc=6544807 |pmid=23897589}} The Cochrane review found not enough evidence in 2016 to show a difference between Chinese herbal medicine and placebo for the vasomotor symptoms.{{cite journal |vauthors=Zhu X, Liew Y, Liu ZL |date=March 2016 |title=Chinese herbal medicine for menopausal symptoms |journal=The Cochrane Database of Systematic Reviews |volume=3 |issue=5 |pages=CD009023 |doi=10.1002/14651858.CD009023.pub2 |pmc=4951187 |pmid=26976671}}

• Lack of lubrication is a common problem during and after perimenopause. Vaginal moisturizers can help women with overall dryness, and lubricants can help with lubrication difficulties that may be present during intercourse. It is worth pointing out that moisturizers and lubricants are different products for different issues: some women complain that their genitalia are uncomfortably dry all the time, and they may do better with moisturizers. Those who need only lubricants do well using them only during intercourse.
• Low-dose prescription vaginal estrogen products such as estrogen creams are generally a safe way to use estrogen topically, to help vaginal thinning and dryness problems (see vaginal atrophy) while only minimally increasing the levels of estrogen in the bloodstream.
• Individual counseling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time.
• Osteoporosis can be minimized by smoking cessation, adequate vitamin D intake and regular weight-bearing exercise. The bisphosphonate drug alendronate may decrease the risk of a fracture, in women that have both bone loss and a previous fracture and less so for those with just osteoporosis.{{cite journal |vauthors=Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P |date=January 2008 |title=Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women |journal=The Cochrane Database of Systematic Reviews |issue=1 |pages=CD001155 |doi=10.1002/14651858.CD001155.pub2 |pmid=18253985}}
• A surgical procedure where a part of one of the ovaries is removed earlier in life and frozen and then over time thawed and returned to the body (ovarian tissue cryopreservation) has been tried. While at least 11 women have undergone the procedure and paid over £6,000, there is no evidence it is safe or effective.{{Cite web |date=28 January 2020 |title=Concerns over new 'menopause delay' procedure |url=https://www.bbc.com/news/health-51269237 |website=BBC News}}

The menopause transition is a process, involving hormonal, menstrual, and typically vasomotor changes. However, the experience of the menopause as a whole is very much influenced by psychological and social factors, such as past experience, lifestyle, social and cultural meanings of menopause, and a woman's social and material circumstances. Menopause has been described as a biopsychosocial experience, with social and cultural factors playing a prominent role in the way menopause is experienced and perceived.{{citation needed|date=January 2024}}

The paradigm within which a woman considers menopause influences the way she views it: women who understand menopause as a medical condition rate it significantly more negatively than those who view it as a life transition or a symbol of aging.{{cite journal |vauthors=Gannon L, Ekstrom B |year=1993 |title=Attitudes toward menopause: The influence of sociocultural paradigms |journal=Psychology of Women Quarterly |volume=17 |issue=3 |pages=275–88 |doi=10.1111/j.1471-6402.1993.tb00487.x |s2cid=144546258 |hdl-access=free |hdl=2286/R.I.44298}} There is some evidence that negative attitudes and expectations, held before the menopause, predict symptom experience during the menopause, and beliefs and attitudes toward menopause tend to be more positive in postmenopausal than in premenopausal women.{{Cite journal |last1=Brown |first1=Lydia |last2=Brown |first2=Valerie |last3=Judd |first3=Fiona |last4=Bryant |first4=Christina |date=2018-10-02 |title=It's not as bad as you think: menopausal representations are more positive in postmenopausal women |url=https://www.tandfonline.com/doi/full/10.1080/0167482X.2017.1368486 |journal=Journal of Psychosomatic Obstetrics & Gynecology |language=en |volume=39 |issue=4 |pages=281–288 |doi=10.1080/0167482X.2017.1368486 |pmid=28937311 |s2cid=24085899 |issn=0167-482X|url-access=subscription }} Women with more negative attitudes towards the menopause report more symptoms during this transition.{{cite journal | vauthors = Ayers B, Forshaw M, Hunter MS | title = The impact of attitudes towards the menopause on women's symptom experience: a systematic review | journal = Maturitas | volume = 65 | issue = 1 | pages = 28–36 | date = January 2010 | pmid = 19954900 | doi = 10.1016/j.maturitas.2009.10.016 | s2cid = 486661 }}

Menopause is a stage of life experienced in different ways. It can be characterized by personal challenges, changes in personal roles within the family and society. Women's approaches to changes during menopause are influenced by their personal, family and sociocultural background.{{cite journal | vauthors = Hoga L, Rodolpho J, Gonçalves B, Quirino B | title = Women's experience of menopause: a systematic review of qualitative evidence | journal = JBI Database of Systematic Reviews and Implementation Reports | volume = 13 | issue = 8 | pages = 250–337 | date = September 2015 | pmid = 26455946 | doi = 10.11124/jbisrir-2015-1948 | s2cid = 21908463 }} Women from different regions and countries also have different attitudes. Postmenopausal women had more positive attitudes toward menopause compared with peri- or premenopausal women. Other influencing factors of attitudes toward menopause include age, menopausal symptoms, psychological and socioeconomical status, and profession and ethnicity.{{cite journal | vauthors = Dashti S, Bahri N, Fathi Najafi T, Amiridelui M, Latifnejad Roudsari R | title = Influencing factors on women's attitudes toward menopause: a systematic review | journal = Menopause | volume = 28 | issue = 10 | pages = 1192–1200 | date = September 2021 | pmid = 34520416 | doi = 10.1097/GME.0000000000001833 | s2cid = 237516036 }}

Ethnicity and geography play roles in the experience of menopause. American women of different ethnicities report significantly different types of menopausal effects. One major study found Caucasian women most likely to report what are sometimes described as psychosomatic symptoms, while African-American women were more likely to report vasomotor symptoms.{{cite journal |vauthors=Avis N, Stellato RC, Bromberger J, Gan P, Cain V, Kagawa-Singer M |year=2001 |title=Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic group |journal=Social Science & Medicine |volume=52 |issue=3 |pages=345–56 |doi=10.1016/S0277-9536(00)00147-7 |pmid=11330770}}

There may be variations in experiences of women from different ethnic backgrounds regarding menopause and care. Immigrant women reported more vasomotor symptoms and other physical symptoms and poorer mental health than non-immigrant women and were mostly dissatisfied with the care they had received. Self-management strategies for menopausal symptoms were also influenced by culture.{{cite journal | vauthors = Stanzel KA, Hammarberg K, Fisher J | title = Experiences of menopause, self-management strategies for menopausal symptoms and perceptions of health care among immigrant women: a systematic review | journal = Climacteric | volume = 21 | issue = 2 | pages = 101–110 | date = April 2018 | pmid = 29345497 | doi = 10.1080/13697137.2017.1421922 | s2cid = 3653549 }}

Two multinational studies of Asian women, found that hot flushes were not the most commonly reported symptoms, instead body and joint aches, memory problems, sleeplessness, irritability and migraines were.{{cite journal | vauthors = Haines CJ, Xing SM, Park KH, Holinka CF, Ausmanas MK | title = Prevalence of menopausal symptoms in different ethnic groups of Asian women and responsiveness to therapy with three doses of conjugated estrogens/medroxyprogesterone acetate: the Pan-Asia Menopause (PAM) study | journal = Maturitas | volume = 52 | issue = 3–4 | pages = 264–276 | date = November 2005 | pmid = 15921865 | doi = 10.1016/j.maturitas.2005.03.012 }} In another study comparing experiences of menopause amongst White Australian women and women in Laos, Australian women reported higher rates of depression, as well as fears of aging, weight gain and cancer – fears not reported by Laotian women, who positioned menopause as a positive event.{{cite journal | vauthors = Sayakhot P, Vincent A, Teede H | title = Cross-cultural study: experience, understanding of menopause, and related therapies in Australian and Laotian women | journal = Menopause | volume = 19 | issue = 12 | pages = 1300–1308 | date = December 2012 | pmid = 22929035 | doi = 10.1097/gme.0b013e31825fd14e | s2cid = 205613667 }} Japanese women experience menopause effects, or kōnenki (更年期), in a different way from American women.{{cite journal |vauthors=Lock M |year=1998 |title=Menopause: lessons from anthropology |journal=Psychosomatic Medicine |volume=60 |issue=4 |pages=410–9 |doi=10.1097/00006842-199807000-00005 |pmid=9710286 |s2cid=38878080}} Japanese women report lower rates of hot flashes and night sweats; this can be attributed to a variety of factors, both biological and social. Historically, kōnenki was associated with wealthy middle-class housewives in Japan, i.e., it was a "luxury disease" that women from traditional, inter-generational rural households did not report. Menopause in Japan was viewed as a symptom of the inevitable process of aging, rather than a "revolutionary transition", or a "deficiency disease" in need of management. As of 2005, in Japanese culture, reporting of vasomotor symptoms has been on the increase, with research finding that of 140 Japanese participants, hot flashes were prevalent in 22.1%.{{cite journal |vauthors=Melby MK |year=2005 |title=Factor analysis of climacteric symptoms in Japan |journal=Maturitas |volume=52 |issue=3–4 |pages=205–22 |doi=10.1016/j.maturitas.2005.02.002 |pmid=16154301}} This was almost double that of 20 years prior.{{cite book |title=An Anthropology of Biomedicine |vauthors=Lock M, Nguyen V |date=2010 |publisher=Wiley-Blackwell |location=West Sussex |pages=84–89 |chapter=Chapter 4: Local Biologies and Human Difference}} Whilst the exact cause for this is unknown, possible contributing factors include dietary changes, increased medicalisation of middle-aged women and increased media attention on the subject. However, reporting of vasomotor symptoms is still "significantly" lower than in North America.{{cite journal |vauthors=Gold EB, Block G, Crawford S, Lachance L, FitzGerald G, Miracle H, Sherman S |date=June 2004 |title=Lifestyle and demographic factors in relation to vasomotor symptoms: baseline results from the Study of Women's Health Across the Nation |journal=American Journal of Epidemiology |volume=159 |issue=12 |pages=1189–99 |doi=10.1093/aje/kwh168 |pmid=15191936 |doi-access=free}}

Additionally, while most women in the United States apparently have a negative view of menopause as a time of deterioration or decline, some studies seem to indicate that women from some Asian cultures have an understanding of menopause that focuses on a sense of liberation and celebrates the freedom from the risk of pregnancy.{{cite journal |vauthors=Maoz B, Dowty N, Antonovsky A, Wisjenbeck H |year=1970 |title=Female attitudes to menopause |journal=Social Psychiatry |volume=5 |pages=35–40 |doi=10.1007/BF01539794 |s2cid=30147685}} Diverging from these conclusions, one study appeared to show that many American women "experience this time as one of liberation and self-actualization".{{cite journal |vauthors=Stotland NL |date=August 2002 |title=Menopause: social expectations, women's realities |journal=Archives of Women's Mental Health |volume=5 |issue=1 |pages=5–8 |doi=10.1007/s007370200016 |pmid=12503068 |s2cid=9248759}}

In some women, menopause may bring about a sense of loss related to the end of fertility. In addition, this change often aligns with other stressors, such as the responsibility of looking after elderly parents or dealing with the emotional challenges of "empty nest syndrome" when children move out of the family home. This situation can be accentuated in cultures where being older is negatively perceived.

{{Further|Menopause in the workplace}}

Midlife is typically a life stage when men and women may be dealing with demanding life events and responsibilities, such as work, health problems, and caring roles. For example, in 2018 in the UK women aged 45–54 report more work-related stress than men or women of any other age group.{{Cite web |date=31 October 2018 |title=Work related stress, depression or anxiety |url=http://greeningconsultants.co.uk/wp-content/uploads/2019/03/HSE-Stats-2018.pdf |journal= |publisher=Health and Safety Executive (HSE)}} Hot flashes are often reported to be particularly distressing at work and lead to embarrassment and worry about potential stigmatisation.{{Cite book |last1=Griffiths |first1=Amanda |url=https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/595439/CMO_annual_report_2014.pdf |title=Annual Report of the Chief Medical Officer, 2014, The Health of the 51%: Women |last2=S Hunter |first2=Myra |publisher=Department of Health |year=2015 |editor-last=C Davies |editor-first=Sally |chapter=Psychosocial factors and menopause: The impact of menopause on personal and working life}} A June 2023 study by the Mayo Clinic estimated an annual loss of $1.8 billion in the United States due to workdays missed as a result of menopause symptoms.{{Cite journal |last1=Faubion |first1=Stephanie S. |last2=Enders |first2=Felicity |last3=Hedges |first3=Mary S. |last4=Chaudhry |first4=Rajeev |last5=Kling |first5=Juliana M. |last6=Shufelt |first6=Chrisandra L. |last7=Saadedine |first7=Mariam |last8=Mara |first8=Kristin |last9=Griffin |first9=Joan M. |last10=Kapoor |first10=Ekta |date=2023-06-01 |title=Impact of Menopause Symptoms on Women in the Workplace |url=https://www.sciencedirect.com/science/article/pii/S002561962300112X |journal=Mayo Clinic Proceedings |volume=98 |issue=6 |pages=833–845 |doi=10.1016/j.mayocp.2023.02.025 |pmid=37115119 |s2cid=258367393 |issn=0025-6196|url-access=subscription }} This was one of the largest studies to date examining the impact of menopause symptoms on work outcomes. The research concluded there was a strong need to improve medical treatment for menopausal women and make the workplace environment more supportive to avoid such productivity losses.

Menopause literally means the "end of monthly cycles" (the end of monthly periods or menstruation), from the Greek word pausis ("pause") and mēn ("month"). This is a medical coinage; the Greek word for menses is actually different. In Ancient Greek, the menses were described in the plural, {{Transliteration|grc|ta emmēnia}} ("the monthlies"), and its modern descendant has been clipped to ta emmēna. The Modern Greek medical term is emmenopausis in Katharevousa or emmenopausi in Demotic Greek. The Ancient Greeks did not produce medical concepts about any symptoms associated with end of menstruation and did not use a specific word to refer to this time of a woman's life. The word menopause was invented by French doctors at the beginning of the nineteenth century. Greek etymology was reconstructed at this time and it was the Parisian student doctor Charles-Pierre-Louis de Gardanne who invented a variation of the word in 1812, which was edited to its final French form in 1821.Moore ADM |2022|The French Invention of Menopause and the Medicalisation of Women's Ageing, A History|Oxford University Press |page 85

Some of them noted that peasant women had no complaints about the end of menses, while urban middle-class women had many troubling symptoms. Doctors at this time considered the symptoms to be the result of urban lifestyles of sedentary behaviour, alcohol consumption, too much time indoors, and over-eating, with a lack of fresh fruit and vegetables.{{cite journal |vauthors=Moore AM |year=2018 |title=Conceptual Layers in the Invention of Menopause in Nineteenth-Century France |journal=French History |volume=32 |issue=2 |pages=226–248 |doi=10.1093/fh/cry006}}

The word "menopause" was coined specifically for female humans, where the end of fertility is traditionally indicated by the permanent stopping of monthly menstruations. However, menopause exists in some other animals, many of which do not have monthly menstruation;{{cite journal |vauthors=Walker ML, Herndon JG |date=September 2008 |title=Menopause in nonhuman primates? |journal=Biology of Reproduction |volume=79 |issue=3 |pages=398–406 |doi=10.1095/biolreprod.108.068536 |pmc=2553520 |pmid=18495681}} in this case, the term means a natural end to fertility that occurs before the end of the natural lifespan.

In the 21st century, celebrities have spoken out about their experiences of the menopause, which has led to it becoming less of a taboo as it has boosted awareness of the debilitating symptoms. Subsequently, TV shows have been running features on the menopause to help women experiencing symptoms. In the UK Lorraine Kelly has been an advocate for getting women to speak about their experiences including sharing her own. This has led to an increase in women seeking treatment such as HRT.{{Cite web |date=29 April 2022 |title='Breakthrough moment': how Lorraine Kelly helped shift the menopause debate |url=https://www.theguardian.com/society/2022/apr/29/breakthrough-moment-how-celebrities-helped-shift-the-menopause-debate |access-date=2 August 2022 |website=The Guardian |language=en}} Davina McCall also led an awareness campaign based on a documentary on Channel 4.{{Cite web |title=Davina McCall: Sex, Myths and the Menopause |url=https://www.channel4.com/programmes/davina-mccall-sex-myths-and-the-menopause |access-date=2023-07-03 |website=www.channel4.com |language=en}}

In the UK, Carolyn Harris sponsored the Menopause (Support and Services) Bill in June 2021. It was to exempt hormone replacement therapy from National Health Service prescription charges and to make provisions about menopause support and services, including public education and communication in supporting perimenopausal and post-menopausal women, and to raise awareness of menopause and its effects. The bill was withdrawn on 29 October 2021.{{Cite web |last=House of Commons |date= 27 October 2021 |title=Menopause (Support and Services) Bill, House of Commons, Session 2021-22 |url=https://bills.parliament.uk/bills/2897}}

In the US, David McKinley, Republican from West Virginia introduced the Menopause Research Act in September 2022 for $100 million in 2023 and 2024, but it stalled.{{Cite web |last=McKinley, David B. |date=September 6, 2022 |title=H.R.8774 - Menopause Research Act of 2022 |url=https://www.congress.gov/bill/117th-congress/house-bill/8774?s=1&r=13}}

The majority of mammal species reach menopause when they cease the production of ovarian follicles, which contain eggs (oocytes), between one-third and two-thirds of their maximum possible lifespan.doi.org/k233 However, few live long enough in the wild to reach this point. Humans are joined by a limited number of other species in which females live substantially longer than their ability to reproduce. Examples of others include cetaceans: beluga whales,{{cite journal |vauthors=Ellis S, Franks DW, Nattrass S, Currie TE, Cant MA, Giles D, Balcomb KC, Croft DP |date=August 2018 |title=Analyses of ovarian activity reveal repeated evolution of post-reproductive lifespans in toothed whales |journal=Scientific Reports |volume=8 |issue=1 |pages=12833 |bibcode=2018NatSR...812833E |doi=10.1038/s41598-018-31047-8 |pmc=6110730 |pmid=30150784}} narwhals, orcas,{{cite journal |vauthors=Brent LJ, Franks DW, Foster EA, Balcomb KC, Cant MA, Croft DP |date=March 2015 |title=Ecological knowledge, leadership, and the evolution of menopause in killer whales |journal=Current Biology |volume=25 |issue=6 |pages=746–750 |doi=10.1016/j.cub.2015.01.037 |pmid=25754636 |doi-access=free|bibcode=2015CBio...25..746B |hdl=10871/32919 |hdl-access=free }} false killer whalesArticle | Reuters - [https://www.reuters.com/science/why-did-menopause-evolve-new-study-whales-gives-some-clues-2024-03-13/ | Why did menopause evolve? New study of whales gives some clues] and short-finned pilot whales.{{cite web |year=1986 |title=Evidence for reproductive senescence in female cetaceans. |url=http://www.helenemarsh.com/publications/JournalPapers/1986/MarshKasuyaSenescence1986.pdf |url-status=dead |archive-url=https://web.archive.org/web/20200921150757/http://www.helenemarsh.com/publications/JournalPapers/1986/MarshKasuyaSenescence1986.pdf |archive-date=21 September 2020 |access-date=9 June 2018 |work=Reports of the International Whaling Commission. |pages=57–74 |vauthors=Marsh H, Kasuya T |volume=8}}

Menopause has been reported in a variety of other vertebrate species, but these examples tend to be from captive individuals, and thus are not necessarily representative of what happens in natural populations in the wild. Menopause in captivity has been observed in several species of nonhuman primates, including rhesus monkeys{{cite journal |vauthors=Walker ML |year=1995 |title=Menopause in female rhesus monkeys |journal=American Journal of Primatology |volume=35 |issue=1 |pages=59–71 |doi=10.1002/ajp.1350350106 |pmid=31924061 |pmc=10590078 |s2cid=83848539}} and chimpanzees.{{cite journal |vauthors=Bowden DM, Williams DD |date=1984 |title=Aging |journal=Advances in Veterinary Science and Comparative Medicine |volume=28 |issue= |pages=305–341 |doi=10.1016/b978-0-12-039228-5.50015-2 |isbn=9780120392285 |pmid=6395674}} Some research suggests that wild chimpanzees do not experience menopause, as their fertility declines are associated with declines in overall health.{{cite journal |display-authors=6 |vauthors=Emery Thompson M, Jones JH, Pusey AE, Brewer-Marsden S, Goodall J, Marsden D, Matsuzawa T, Nishida T, Reynolds V, Sugiyama Y, Wrangham RW |date=December 2007 |title=Aging and fertility patterns in wild chimpanzees provide insights into the evolution of menopause |journal=Current Biology |volume=17 |issue=24 |pages=2150–6 |doi=10.1016/j.cub.2007.11.033 |pmc=2190291 |pmid=18083515|bibcode=2007CBio...17.2150E }} Menopause has been reported in elephants in captivity{{cite book |url=https://books.google.com/books?id=95MoRwdQlcYC&q=elephant+menopause&pg=PA179 |title=The Asian Elephant |vauthors=Sukumar R |publisher=Cambridge University Press |year=1992 |isbn=9780521437585 |archive-url=https://web.archive.org/web/20160512173456/https://books.google.com/books?id=95MoRwdQlcYC&pg=PA179&lpg=PA179&dq=elephant+menopause&source=bl&ots=7aojlCdgn1&sig=4WnYMngrJYA_nhcEZHjvO4oZgQs&hl=en&ei=PkZGSs3uHd-MtgegtozbAw&sa=X&oi=book_result&ct=result&resnum=6 |archive-date=12 May 2016 |url-status=live}} and guppies.{{cite journal |vauthors=Reznick D, Bryant M, Holmes D |date=January 2006 |title=The evolution of senescence and post-reproductive lifespan in guppies (Poecilia reticulata) |journal=PLOS Biology |volume=4 |issue=1 |pages=e7 |doi=10.1371/journal.pbio.0040007 |pmc=1318473 |pmid=16363919 |doi-access=free}} Dogs do not experience menopause; the canine estrus cycle simply becomes irregular and infrequent. Although older female dogs are not considered good candidates for breeding, offspring have been produced by older animals, see Canine reproduction. Similar observations have been made in cats.{{Cite news |date=15 May 2012 |title=How long is a cat in heat? |work=Animal Planet |url=http://www.animalplanet.com/pets/how-long-is-a-cat-in-heat/ |access-date=12 June 2018 |url-status=dead |archive-url=https://web.archive.org/web/20151114211824/https://www.animalplanet.com/pets/how-long-is-a-cat-in-heat/ |archive-date=14 November 2015}}{{cbignore}}

Life histories show a varying degree of senescence; rapid senescing organisms (e.g., Pacific salmon and annual plants) do not have a post-reproductive life-stage. Gradual senescence is exhibited by all placental mammalian life histories.{{Original research inline|date=January 2024}}

{{Main|Evolution of menopause}}

There are various theories on the origin and process of the evolution of the menopause. These attempt to suggest evolutionary benefits to the human species stemming from the cessation of women's reproductive capability before the end of their natural lifespan. It is conjectured that in highly social groups natural selection favors females that stop reproducing and devote that post-reproductive life span to continuing to care for existing offspring, both their own and those of others to whom they are related, especially their granddaughters and grandsons.{{Cite web |last=Almansa |first=Juan Carranza |date=2022-11-16 |title=The evolutionary origins of menopause explained |url=http://theconversation.com/the-evolutionary-origins-of-menopause-explained-192543 |access-date=2023-09-20 |website=The Conversation |language=en}}

• European Menopause and Andropause Society
• Menopause in the workplace
• Menopause in incarceration
• Pregnancy over age 50
• Biological clock
• Evolution of menopause

{{Reflist}}

• Rebecca Mead, "If You Can't Stand the Heat: Why menopause never gets old", The New Yorker, 10 March 2025, pp. 28–31. "If you've got ovaries, you'll go through it. Why do so many feel so blindsided?" (p. 28.)

{{Commons}}

• [https://www.nlm.nih.gov/medlineplus/menopause.html Menopause: MedlinePlus]
• [https://www.nia.nih.gov/health/what-menopause What Is Menopause?], National Institute on Aging
• [https://www.menopause.org/for-women Menopause & Me], The North American Menopause Society

{{Medical resources

| DiseasesDB = 8034

| ICD11 = {{ICD11|GA30.0}}

| ICD10 = {{ICD10|N95.1}}

| ICD9 = {{ICD9|627.2}}

| ICDO =

| OMIM =

| MedlinePlus = 000894

| eMedicineSubj = article

| eMedicineTopic = 264088

| MeshID = D008593

}}

{{Reproductive physiology}}

{{Menstrual cycle}}

{{Authority control}}

Category:Developmental stages

Category:Endocrinology

Category:Gynaecological endocrinology

Category:Menstrual cycle

Category:Middle age

Category:Senescence

Category:Wikipedia medicine articles ready to translate

Category:Human female endocrine system