Menopause And Perimenopause


What Is It?

Most women think of menopause as the time of life when their menstrual periods end. This is true, but menopause broadly includes hormonal and physical changes that take place in the three to five years during middle age before the last menstrual period. For this reason, menopause sometimes is called the “change of life.”

While most women in the United States go through menopause around the age of 51, a small number will experience menopause as early as age 40, or as late as their late 50s. On rare occasions, menopause does not occur until the early 60s. When menopause is diagnosed prior to age 40, it is considered to be abnormal or premature.

Symptoms of menopause begin as the number of egg-producing follicles begins to shrink. The levels of both female hormones, estrogen and progesterone, begin to fall as the number of follicles decreases. The symptoms of menopause are mainly the result of falling levels of estrogen.

Generally, as hormone levels fall, a woman’s pattern of menstrual bleeding becomes irregular. Many women experience skipped, late or scanty periods for several months to a year before their periods stop altogether. Some women may experience heavier-than-normal bleeding. It is important to realize that until menopause is complete, a woman still can become pregnant even when periods are scanty or missed.

Perimenopause, also known as the climacteric, includes the time prior to menopause when hormonal and biological changes and physical symptoms begin to occur. This period lasts for an average of three to five years.


Some women don’t have any symptoms during menopause or only have a few symptoms. Others develop disturbing and even severe, disabling symptoms. Studies of women around the world suggest that differences in lifestyle, diet and activity may play a role in the severity and type of symptoms experienced by women during menopause. Symptoms can be noticed for several months to years before the last menstrual period when menopause begins.

Symptoms of menopause or perimenopause include:

  • Hot flashes — A hot flash is a feeling described as suddenly being hot, flushed and uncomfortable. Hot flashes come in bursts or flushes that generally last a few seconds to a few minutes. They are caused by changes in the way blood vessels relax and contract, and are thought to be related to the changes in a woman’s estrogen levels.

  • Vaginal drying — Secretions from the vagina decrease as estrogen levels fall. The lining of the vagina gradually becomes thinner, and elasticity is lost. These changes can cause sexual intercourse to be uncomfortable or painful. These changes also can lead to inflammation in the vagina known as atrophic vaginitis or vaginal infections from yeast or bacterial overgrowth.

  • Sleep disorders — Sleep often is disturbed by nighttime hot flashes. A long-term lack of sleep can lead to altered moods and emotions.

  • Depression — The physical changes of menopause do not appear to increase the risk of depression. However, major life changes affecting mood and emotion, such as menopause, increase the risk of developing depression.

  • Irritability — Some women report irritability or other emotional changes. Irritability commonly is caused by poor sleep resulting from nighttime hot flashes. A number of women, however, do not feel irritable.

  • Osteoporosis — This condition is a thinning of the bones that increases the risk of fracturing a bone, especially in the hips or spine. As estrogen levels drop and remain low during menopause, the risk of developing osteoporosis increases. The risk is greatest for slender, white or light-skinned women. Measures to prevent osteoporosis, including a diet rich in calcium and regular exercise, must start well before menopause begins. This is because women begin to lose bone mass as early as age 30 but fractures resulting from osteoporosis don’t occur until 10 to 15 years after menopause. It’s never too late to develop healthy habits, but starting early in life makes a big difference as you grow older. Osteoporosis is a major cause of disability in older women. It is estimated that osteoporosis causes over 1.5 million fractures each year and that 5 percent to 20 percent of women will die of complications from these fractures. Complications of major fractures include blood clots in the lungs, stroke and serious infection. Some women become incapacitated by hip or spine fractures and spend the rest of their lives bedridden or in nursing homes.

  • Cardiovascular disease — Prior to menopause women have lower rates of heart attack and stroke than men. Following menopause, however, the rate of heart disease in women continues to rise and equals that of men after age 65.


When your menstrual periods become irregular, infrequent or scant, your doctor first will determine whether you are pregnant. If not, then a blood test for levels of follicle-stimulating hormone (FSH) may be recommended. FSH levels normally rise to high levels at menopause and remain at high levels. High FSH levels can help to establish or confirm that menopause has occurred.

Other recommended screening tests, such as blood pressure, cholesterol level and thyroid function, a mammogram and a Pap test may be ordered if you are due for your routine health care exam.

At the time of menopause, some physicians recommend testing for bone density, and treating women who have osteoporosis and those who are at high risk of fracture. However, critics of this practice point out that test results can be inaccurate and do not always predict which women will have fractures. Because of this controversy, they recommend that all women who are at risk of osteoporosis should be treated regardless of bone density test results.

Another test not recommended routinely is endometrial biopsy. An endometrial biopsy is an office procedure in which a tiny piece of endometrial tissue from inside the uterus is taken and examined under a microscope for signs of cancer. This test may be done when a woman is having irregular, frequent or heavy bleeding, but it is not routinely recommended as a test for menopause.

Expected Duration

The changes that occur during menopause last for the rest of your life. A woman is considered to be postmenopausal a full year after she has had her last menstrual period.


Menopause is a natural event and cannot be prevented. Medications, diet and exercise can prevent or eliminate some symptoms of menopause and enhance your quality of life as you grow older.


Lifestyle Changes
Diet, exercise and lifestyle changes can reduce the symptoms and complications of menopause. You can:

  • Refrain from smoking. Smoking is associated with an increased risk of osteoporosis and hip fractures. Smoking also increases the risks of heart attack and stroke.

  • Limit caffeine. High caffeine intake, more than three cups per day, can aggravate hot flashes and may contribute to osteoporosis.

  • Wear layers of clothing. Since hot flashes can occur any time, wearing layers can help you to cool off quickly during a hot flash and warm up if you get chilled after a flush. Keep bed blankets light and use layers at night for the same reason.

  • Exercise. Exercise can provide a wide range of benefits, including:
    • Reducing blood pressure and the risk of heart attack and stroke
    • Relieving hot flashes in some women
    • Reducing osteoporosis and fractures
    Exercise to prevent weak or thin bones must be weight-bearing exercise such as walking, low-impact aerobics, dancing, lifting weights or playing a racquet sport such as tennis or paddleball. Exercise does not need to be vigorous to help. Walking a few miles per day helps to maintain bone mass.

  • Get sunlight and vitamin D. Vitamin D helps your body absorb adequate calcium from food. You can get enough vitamin D with only a few minutes of sun exposure each day.

  • Consume calcium. Women should get between 800 to 1,500 milligrams of calcium every day. Good sources of calcium include:
    • Dark green vegetables (except spinach, which contains another ingredient that reduces the amount of calcium that can be absorbed from the food) — One cup of turnip greens supplies 197 milligrams of calcium and broccoli provides 94 milligrams.
    • Dairy products — One cup of milk provides approximately 300 milligrams of calcium, and one cup of yogurt supplies 372 milligrams. Cheese is another good source. One ounce of Swiss cheese has 272 milligrams of calcium.
    • Sardines and salmon — Four ounces of sardines provide 429 milligrams of calcium, and four ounces of salmon have 239 milligrams of calcium.
    • Legumes — One cup of navy beans supplies 127 milligrams of calcium.

Medication Therapy
A number of medications are used to treat the symptoms of menopause. The most common treatment is hormone replacement therapy (HRT), also called estrogen replacement therapy (ERT). This therapy involves taking estrogen with or without progesterone hormones to replace the loss of natural hormones after menopause.

HRT involves taking small quantities of estrogen or a combination of estrogen and progesterone on a regular basis to control or alleviate problems related to menopause. Estrogen can be prescribed alone when a woman no longer has her uterus. The combination of hormones is used when a woman still has her uterus. Progesterone is necessary to balance estrogen’s effect on the uterus and prevent changes that can lead to uterine cancer.

Reasons for using estrogen include:

  • Hot flashes, irritability and sleep disturbances — Estrogen therapy dramatically relieves hot flashes, and reduces sleep disturbances caused by hot flashes. Improved sleep and fewer hot flashes lead to improved mood and decreased irritability.

  • Vaginal dryness, vaginal irritation and inflammation — Estrogen therapy quickly improves and restores vaginal secretions and reduces irritation and inflammation.

  • Osteoporosis — Bones will start to thin and weaken over time as the ovaries stop making estrogen. Estrogen can be prescribed during menopause to supplement diet and exercise in helping bones remain strong and decrease the risk of fracture. The risk of fracture remains lower as long as a woman continues to use estrogen. However, bones will become thin and weaken over time once a woman stops using estrogen.

Until recently, estrogen had been thought to reduce the incidence of heart attack and stroke in postmenopausal women, but recent clinical trials, known as the Women’s Health Initiative, have thrown doubt on that theory. This research shows that women actually may be more at risk of heart attack and stroke while using combined estrogen-progesterone therapy. Based on this study, the combined use of estrogen and progesterone is no longer recommended for the prevention of heart disease. Research on the effects of estrogen-only therapy is still in progress.

Women who still have a uterus and use estrogens should be aware that they can experience bleeding, which can be similar to a regular menstrual cycle. You should talk with your doctor about any bleeding you experience.

Women who have the following problems should not take estrogen:

In addition, women with migraine headaches, gallbladder disease, high blood pressure or endometriosis may not be candidates for estrogen therapy. If you have these problems, you should discuss the issue with your doctor.

Another type of medication used to treat menopause symptoms is selective estrogen receptor modulators, or SERMs. SERMs can stimulate some but not all the estrogen receptors located throughout a woman’s body. SERMs vary according to the type of estrogen receptor, tissue or organ that they affect. SERMs include medications such as raloxifene (Evista) and tamoxifen (Nolvadex). Raloxifene is used to protect against osteoporosis because it stimulates estrogen receptors in the bones. However, it does not stimulate estrogen receptors in the uterus. Raloxifene, therefore, can be used without progesterone because it does not increase the risk of developing uterine cancer. Raloxifene also appears to protect against breast cancer. Tamoxifen prevents osteoporosis and provides protection against breast cancer returning in women who have had the disease. However, it also stimulates uterine tissue, so there is a greater chance of developing uterine cancer while on tamoxifen.

Issues surrounding the risks of estrogen therapy remain controversial. Researchers are studying the effect of estrogen on:

Other medications prescribed to prevent and treat menopause-related osteoporosis include:

  • Calcitonin (Calcimar and others) — This hormone is produced by the thyroid gland and conserves calcium. A nasal spray form of this drug is used to help prevent bone loss in women at risk. This medication will not reduce hot flashes or vaginal dryness.

  • Etidronate (Didronel) and alendronate (Fosamax) — These synthetic compounds are used to help prevent bone loss when vitamins and calcium supplements have not been successful. These medications only affect bone density, not other symptoms of menopause.

  • Calcitriol — This dietary supplement is a metabolically active form of vitamin D that increases the body’s ability to absorb of calcium. It can help to maintain bone density, but will not affect other symptoms of menopause.

Several alternative treatments have been proposed to treat the symptoms of menopause. Scientific studies have found no benefit to the use of vitamin E or primrose oil. No evidence has been found to support the use of acupuncture, herbs or homeopathy, but few studies of these therapies have been done.

One alternative treatment demonstrated to have a possible benefit is the use of soy products. Soy has small amounts of phytoestrogens that may help relieve hot flashes. Researchers speculate that the soy-based diet of Japanese women plays a role in preventing hot flashes. However, it’s not clear whether Japanese women have fewer hot flashes or whether they report this problem less often.

When To Call A Professional

You should see your doctor if you have any of the following:

  • Periods that come closer together than every 21 days
  • Periods that last longer than seven days
  • Periods that are very heavy
  • Bleeding between periods


Although menopause can cause some uncomfortable symptoms, both lifestyle practices and medication can help to alleviate these symptoms and complications.

Johns Hopkins patient information

Last revised:

Diseases and Conditions Center

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