FAQ: 10 Most Asked Questions About Menopause

Perimenopause is the transitional phase before menopause, characterized by fluctuating levels of estrogen and progesterone. It often starts in a woman’s 40s and typically lasts 4–8 years, although some women may experience it for as little as a few months or as long as a decade. Menopause, on the other hand, is defined as the point when a woman has gone 12 consecutive months without a menstrual period and is marked by significant reductions of estrogen and progesterone levels and the end of a woman’s reproductive years. Perimenopause includes varied symptoms, among them irregular periods, worsening PMS, hot flashes, insomnia, vaginal dryness, weight gain around the mid-line, and more. Such symptoms often persist or worsen during menopause, a milestone indicating that ovarian reproductive function has ceased. From that point forward, women enter postmenopause, a biologic state of estrogen and progesterone deficiency that persists, without hormone replacement therapy, for the remainder of a woman’s lifespan. Fun Fact: The average age for menopause in the U.S. is 51, but it can occur earlier or later depending on factors like genetics, smoking, or medical conditions.

Common symptoms include: Hot flashes: Experienced by 75–80% of women, these sudden feelings of heat can last 1–5 minutes and occur several times a day. Irregular periods (during perimenopause but not menopause wherein menstrual cycles cease): Shorter or longer cycles, heavier or lighter bleeding, and skipped periods are all common. Night sweats: A nocturnal version of hot flashes, often disrupting sleep. Mood swings: Fluctuating hormones can contribute to irritability, anxiety, and depression. Vaginal dryness: Declining estrogen affects vaginal tissues, leading to discomfort during sex. Diminished libido and ability to orgasm: both vaginal dryness and reductions in hormones of desire like testosterone can negatively impact sexual health. Brain fog: A “pressured” head, difficulty concentrating and memory lapses are frequently reported. Other symptoms may include weight gain, particularly around the mid-line, thinning hair, dry skin, and joint pain. These vary widely among women.

Perimenopause typically begins in a woman’s early-to-mid 40s, but some may notice changes as early as their late 30s. On average, it lasts about 4 years, though for some women it can last less than a year or extend up to 10 years. Factors like smoking, autoimmune conditions, and genetics can influence the onset and duration of perimenopause. Example: A woman who notices irregular periods and mild hot flashes at age 43 may be in perimenopause. If her symptoms persist and she stops menstruating entirely by age 48, her perimenopause would have lasted 5 years.

Hormone Replacement Therapy (HRT) is the most effective treatment, reducing the frequency and intensity of hot flashes by as much as 75% or more. Treatment typically focuses on treating perimenopause as a state of relative progesterone deficiency by supplementing with micronized progesterone and, in some cases, the addition of estradiol. Controlling cyclical hormonal fluctuations with a low dose oral contraceptive or an implanted IUD (intrauterine device) can also help to alleviate symptoms if the aforementioned bioidentical options don’t provide adequate relief. For women who can’t take hormones, alternatives include: Non-hormonal medications: Antidepressants (e.g., venlafaxine or paroxetine), fezolinetant, or gabapentin can reduce symptoms. Lifestyle changes: Dressing in layers, using fans, and avoiding triggers like spicy foods and alcohol. Natural remedies: Black cohosh, red clover, or soy-based supplements, though evidence for their effectiveness is mixed. Pro Tip: Mind-body techniques like mindfulness, yoga, or acupuncture may also provide complementary relief, while given the root source of symptoms are hormonal sea changes, the challenges are often best addressed by managing that hormonal imbalance at the source.

HRT involves using estrogen, typically with progesterone, to alleviate symptoms like hot flashes, night sweats, mood changes, weight gain, and vaginal dryness. For menopausal women living in a state of estrogen and progesterone deficiency, it also helps prevent bone loss and reduces the risk of fractures. Properly delivered and commenced within 10 years of onset of menopause, HRT helps reduce risk of heart attack, stroke, and Alzheimer’s dementia. Importantly, however, the quality of life and preventive health benefits of HRT still needs to be weighed against any potential risk and treatment personalized and using the most beneficial, well tolerated, and low risk options. As examples, some older and now outdated forms of therapy may precipitate a slightly increased risk of breast cancer, blood clots, and stroke, especially in women over 60, while other, more natural ‘bioidentical’ forms will not. Starting HRT within 10 years of onset of menopause is another factor in weighing the benefits versus the risks of starting therapy later. Stat: A 2022 study found that women starting HRT within 10 years of menopause onset benefit the most, with fewer risks than those who start it later.

Yes! During perimenopause, ovulation becomes irregular as hormone levels fluctuate but doesn’t stop completely until menopause. Pregnancy is still possible, albeit less likely, and contraception is recommended if pregnancy isn’t desired. Stat: The chance of conceiving naturally decreases to about 10–20% per cycle in the early 40s and is lower as women approach menopause.

Emotional symptoms like irritability, anxiety, and sadness stem from fluctuating hormones and life changes (e.g., aging, caregiving stress). To manage mood swings: Exercise: Regular activity boosts serotonin, the “feel-good” brain chemical. Sleep hygiene: Establishing a healthy sleep routine is essential to optimizing mood and emotions. During perimenopause or menopause, properly delivered HRT can also compliment these efforts by reducing symptoms like hot flashes while nightly micronized progesterone has a sedating quality that facilitates rejuvenating sleep. Therapy or counseling: Various forms of talk therapy with the right counselor for you can be helpful. Meditation or mindfulness practice: Mindfulness based meditation practices can complement all of these efforts to regulate emotions, reduce anxiety and depression, improve sleep, and shift mindset, among other benefits. Supplements: A number of supplements, among them Vitamin D, Omega-3 fatty acids, B Vitamins, Magnesium, Ashwagandha, Rhodiola Rosea, L-Theanine, and Pre and Probiotics may support mood. Medical options: Hormone replacement therapy with native (bioidentical) options can also be very helpful, and, if and when needed, the addition of SSRI types of antidepressants. Example: A 45-year-old woman experiencing irritability and insomnia might find relief by complimenting an effective, personalized HRT regimen with yoga and magnesium or other supplements.

Natural remedies include: Phytoestrogens: Found in soy, flaxseeds, and chickpeas, these mimic estrogen in the body. Black cohosh: An herb shown to reduce hot flashes in some studies. Lifestyle changes: Regular exercise, avoiding caffeine and alcohol, and practicing mindfulness. DIM, cordyceps, and fenugreek: Complementary supplements to support hormone balance without treatment or to enhance the effectiveness of women undergoing HRT. Scientific Note: While some natural remedies work well for certain women, the evidence around their efficacy is mixed. As always, treatment should be personalized, best discussed with a qualified healthcare provider, and adjusted over time to find what works.

Estrogen plays a critical role in maintaining bone density. After menopause, women lose bone mass at a rate of 1–2% per year, increasing the risk of osteoporosis and fractures. Prevention strategies include: Replace estrogen and progesterone: Estrogen treatment reduces bone resorption triggered by menopausal estrogen deficiency. Progesterone amplifies that benefit by helping to promote new bone formation. Together, those two critical women’s hormones work to reduce osteoclastic bone resorption and promote osteoblastic bone formation to improve bone density and reduce osteoporotic fracture risk. Calcium and Vitamin D: For menopausal bone health, aim for 1,200 mg calcium a day from all sources (food and supplement). Similarly, test Vitamin D levels (noting that most people will find they are insufficient or deficient without adequate supplementation) and then supplement with as much as 5,000 IU Vitamin D per day to achieve optimal levels based on lab tests. Eating real, unprocessed, nutrient dense foods and adding 100 mcg of Vitamin K2 as well as other minerals such as magnesium and boron can also contribute positively to bone health. Exercise: Weight-bearing activities like walking, dancing, or strength training help strengthen bones. Bone density tests: Women should get a DEXA bone mineral density scan to establish their baseline as they enter menopause so they can monitor and stay ahead of any decline in menopausal bone mineral density through serial scans. DEXA can also be useful to measure a woman’s skeletal muscle mass and visceral (intra‐abdominal) fat and percent body fat levels to then set targets that will help optimize a woman’s long‐term bone, metabolic health, and functional performance outcomes. Stat: About 50% of postmenopausal women will experience an osteoporosis‐related fracture, sometimes with life‐threatening consequences. As an example, the 1 year mortality after a hip fracture in women over age 65 is approximately 20%. In short,, osteoporosis can pose a serious risk to one’s quality of life and longevity and early detection, prevention (through HRT, lifestyle measures, supplements, and more), and aggressive treatment are key to a woman’s health.

Reduced estrogen levels lead to thinning vaginal walls, dryness, and discomfort during sex, which can lower libido. To boot, testosterone levels, which began declining from their peak in women as early as their 20’s, decline as ovarian function declines in menopause. This can lead to significant reductions in libido and ability to orgasm, along with decreased muscle mass, increased fattiness, fatigue, and (see above) reduced bone density. Local treatments include: Vaginal moisturizers and lubricants: Provide immediate relief for dryness. Low‐dose vaginal estrogen inserts: Improves tissue health, vaginal wall thickness and moisture with minimal systemic absorption. Non‐hormonal options: DHEA vaginal suppositories or laser therapies like MonaLisa Touch. In some cases, women may also benefit from application of topical “arousal creams” before intimacy in a manner somewhat akin to a male taking medication such as tadalafil (Cialis®) or sildenafil (Viagra®) prior to intercourse to assist with sexual performance. Treating the root cause of hormone deficiency related symptoms with systemic HRT can, however, often be quite beneficial and restorative to a woman’s sexual health and relationship, most often negating the need for any of the above therapies. This treatment could include: Estrogen replacement (typically in the form of estradiol), whether through a transdermal patch or oral pill or, in some cases, a subcutaneous estradiol ‘pellet’ implant; Testosterone replacement, whether through a compounded oral micronized testosterone pill, pellet implant, or cream with or without the oral supplement and androgen precursor, DHEA (dehydroepiandrosterone). Example: A woman with painful intercourse might use a silicone‐based lubricant and consider localized estrogen therapy. On the other hand, individualized, more comprehensive, and systemic hormonal treatment to address the root cause of deficiency states by rebalancing hormone levels will provide broader, more holistic, and likely more effective benefits.