Menopause: Symptoms, Stages and What to Expect

Menopause is when your periods stop because your hormone levels fall. You've reached it once you haven't had a period for 12 months, as long as you're not using hormonal contraception (NHS). It usually happens between the ages of 45 and 55 (WHO). In the US, the average age is 52 (Office on Women's Health).

Symptoms usually last 7 to 9 years, sometimes longer (NHS), but a range of hormonal and non-hormonal treatments can help (WHO).

Here's what to expect at each stage, the most common symptoms and what helps, including hormone replacement therapy (HRT), and when to see a doctor.

The three stages of menopause

The changes usually happen over several years, in three stages.

Perimenopause: the transition

Perimenopause is the time when your periods become irregular, before they stop altogether (NHS). Your periods may come more or less often, and bleeding may get heavier or lighter. Other symptoms, such as hot flushes, can start at this stage too (NHS).

In the US, perimenopause usually starts in the mid- to late 40s. It can last between 2 and 8 years before your periods stop, and 4 years on average (Office on Women's Health).

You can still get pregnant. Pregnancy is possible during perimenopause, even if you miss your period for a month or a few months (Office on Women's Health). When you can stop using contraception depends on your age and where you live:

• UK and Ireland: keep using contraception for 2 years after your last period if you're under 50, or for 1 year if you're 50 or over (NHS; HSE). Ireland's HSE adds that you can stop at 55.
• US: keep using birth control until one full year after your last period (Office on Women's Health).

These rules don't apply if you use hormonal contraception, because it can affect your periods (HSE). Ask your doctor or a contraception service what's right for you.

Menopause: the 12-month milestone

Menopause is confirmed once you've gone 12 months in a row without a period, with no other obvious cause (WHO).

In the US, it usually happens between the ages of 45 and 58 (Office on Women's Health).

Menopause is caused by a fall in hormone levels. It can also be caused by surgery to remove the ovaries, and sometimes the reason isn't known (NHS).

Postmenopause: the years after

Postmenopause is the time after menopause. Symptoms don't always stop at this point, and they can change over time (NHS). Your bones and heart also need more attention from now on, as explained below (WHO).

Some conditions linked to periods change too. For example, endometriosis symptoms usually stop after the menopause, although some people still have them (NHS). Our guide to managing endometriosis symptoms covers treatment and support.

Early and premature menopause

Early menopause is when your periods stop before the age of 45. Premature menopause is when this happens before 40 (NHS).

It's more likely if it runs in your family, you started your periods early, you smoke or you're underweight. It can also follow treatments such as radiotherapy, chemotherapy, some hormone medicines and surgery to remove the ovaries (NHS).

An early menopause raises your chance of problems with your bones and heart. The main treatments are the combined contraceptive pill or HRT, which replace the hormones that are at low levels. If you think you have menopause symptoms, see a GP. If you're under 45, you may be offered blood tests (NHS).

Common symptoms

Menopause affects everyone differently. Symptoms can have a big impact on your relationships, social life, family life and work, or you may hardly have any at all (NHS).

The most common symptoms include (NHS):

• changes to your periods, which may come more or less often and be heavier or lighter
• hot flushes and night sweats
• problems getting to sleep or staying asleep
• mood swings, low mood or depression
• problems with memory or concentration, often called brain fog
• weight gain
• dryness, burning, irritation or itching in and around the vagina
• urinary tract infections (UTIs) or UTI-like symptoms

Other symptoms can include (NHS):

• a faster, slower or more noticeable heartbeat (palpitations)
• needing to pee more, or not being able to control when you pee (urinary incontinence)
• headaches and migraines that are worse than usual
• muscle aches and joint pains
• hair thinning or hair loss
• dry and itchy skin
• a lower sex drive
• sensitive teeth, painful gums or other mouth problems

Anxiety is common too (WHO). Some changes have no obvious symptoms: loss of bone density, for example, can lead to osteoporosis (NHS).

What helps with common symptoms

Hot flushes and night sweats

Hot flushes are when your face, neck and chest suddenly feel very hot or cold. They can make you sweat a lot, cause palpitations or anxiety, or make you feel dizzy, and can last for several minutes. Hot flushes at night are called night sweats (NHS).

Things you can try (NHS):

• wear lightweight clothing
• keep your bedroom cool at night
• take a cool shower, use a fan or have a cold drink
• find ways to reduce stress
• avoid or cut down on possible triggers, such as spicy food, caffeine, hot drinks, smoking and alcohol
• exercise regularly and keep to a healthy weight

If self-help isn't enough, HRT is effective at relieving hot flushes and night sweats (NHS). There are other options too. The NHS says you may be offered cognitive behavioural therapy (CBT), a type of talking therapy. If that doesn't help, a doctor may suggest a medicine called clonidine or an antidepressant (NHS).

In the US, fezolinetant, a non-hormonal medicine that works on the body's temperature control system, is also FDA-approved for hot flushes (Office on Women's Health). Every medicine can have side effects, so talk through the options with your doctor.

Sleep problems

Not being able to get to sleep or stay asleep can make you feel irritable, stressed and anxious. It may be worse if you also have night sweats (NHS).

What can help:

• Keep to a regular sleep routine (NHS).
• Set yourself up for sleep. NHS tips include waking up at the same time every day, keeping your bedroom dark and quiet, avoiding alcohol, tea and coffee for at least 6 hours before bed, and avoiding screens right before bed (NHS guidance on insomnia).
• Ask about CBT. The NHS says CBT can help with sleep problems, as well as low mood and anxiety (NHS).

Mood changes, anxiety and brain fog

You may have mood swings, low mood or depression, and notice problems with your memory or concentration. These symptoms may feel worse if you're sleeping badly and feel very tired (NHS).

What can help:

• Look after the basics. Get as much rest as you can, exercise regularly and make time for relaxing activities (NHS).
• Try CBT, which can help with low mood and feelings of anxiety (NHS).
• Ask about medicines. HRT can relieve low mood and anxiety linked to menopause (NHS). If you have low mood, depression or anxiety caused by menopause, you may also be offered antidepressants (NHS).
• Use memory aids. Lists, calendars and phone reminders can help.

If your mood is affecting your daily life, talk to your doctor. If you ever feel you might harm yourself, get help straight away (see When to see a doctor, below).

Vaginal dryness and urinary symptoms

You may get dryness, a burning feeling, irritation or itching in and around the vagina, and these symptoms can make sex painful (NHS).

What can help:

• Moisturisers and lubricants. You can buy vaginal moisturisers and lubricants, including water-based lubricants, from a pharmacy without a prescription (NHS).
• Vaginal oestrogen. A doctor can prescribe hormonal treatments you put in your vagina, such as creams, pessaries, gels or rings (NHS). The dose is low and little of the medicine gets into the rest of your body, so vaginal oestrogen doesn't have the same risks as other types of HRT. It treats vaginal dryness and irritation, but it won't help other symptoms such as hot flushes (NHS).
• Treatment for urinary symptoms. Oestrogen cream or pessaries can also be used to treat urinary symptoms after the menopause (NHS).

Low sex drive

There are many reasons your sex drive may drop around menopause, including relationship difficulties, how you feel about yourself and physical discomfort (NHS). Treating vaginal dryness can make sex more comfortable. In the UK, testosterone gel or cream can help some people with low libido, and you may be able to get it on prescription from a menopause specialist (NHS).

Hormone replacement therapy (HRT): benefits and risks

HRT replaces the hormones oestrogen and progesterone, which fall to low levels as you approach the menopause (NHS). You can take it if you have menopause symptoms, including during perimenopause and after your periods stop (NHS).

How HRT is taken

Oestrogen is the main type of HRT. It comes as tablets, patches, a spray or a gel. If you haven't had a hysterectomy, you'll also need a progestogen to protect your womb. This comes as tablets, as part of a combined patch, or as a hormonal coil (NHS).

Benefits

HRT is effective at relieving most perimenopause and menopause symptoms. It also helps prevent osteoporosis, which is particularly important if you had an early menopause (NHS).

Risks

The NHS says the benefits of HRT usually outweigh the risks, and that recent evidence shows the risk of serious side effects is very low. The main risks it describes are (NHS):

• Breast cancer. Combined HRT (oestrogen plus progestogen) leads to around 5 extra cases of breast cancer in every 1,000 women who take it for 5 years. Oestrogen-only HRT causes little or no increase. The risk goes up the longer you take HRT, and goes down after you stop.
• Blood clots and stroke. HRT tablets slightly increase the risk, but patches, gels and sprays don't.
• Heart disease. HRT has little or no effect on the risk of coronary heart disease.

Your own risk depends on your age, your health and the type of HRT, so ask your doctor to talk you through it.

Who may not be able to take HRT

HRT may not be suitable if you (NHS):

• have a history of breast, ovarian or womb cancer
• have a history of blood clots (you may need patches or gels rather than tablets)
• have untreated high blood pressure (it will need to be controlled first)
• have liver disease
• are pregnant

In the US, the Office on Women's Health also advises talking through the risks if you've had heart disease or a stroke, have high triglycerides (a type of blood fat), or have a family history of breast cancer or gallbladder disease (Office on Women's Health).

Side effects

Side effects such as headaches, breast tenderness, feeling sick and mood changes are common at first, but usually improve. The NHS suggests carrying on with treatment for at least 3 months if you can. Irregular bleeding or spotting is common in the first few months and usually settles within 6 months (NHS).

How long can you take HRT?

Advice differs between countries:

• UK: there's no fixed limit, but it's best to take HRT only for as long as the benefits outweigh the risks. After the age of 60 in particular, the risks may start to outweigh the benefits. If you decide to stop, reducing your dose gradually over 3 to 6 months is usually recommended (NHS).
• US: the FDA advises using the lowest dose that works for the shortest time needed (Office on Women's Health).

Herbal remedies and 'bioidentical' hormones

Herbal remedies such as red clover and black cohosh are sometimes sold for menopause symptoms, but there's very little evidence about how well they work or how safe they are (NHS). Talk to a doctor before taking herbal supplements or complementary medicines (NHS).

You may also see 'bioidentical' hormones that are compounded, or custom-made, by a pharmacy. In the US, the FDA says it has no evidence that compounded bioidentical hormones are safe and effective, or safer or more effective than FDA-approved hormone therapy (Office on Women's Health).

Protecting your bones, heart and pelvic health

Bone health

Loss of bone density at menopause is a significant contributor to higher rates of osteoporosis and fractures (WHO). Women lose bone rapidly in the first few years after menopause. The risk of osteoporosis is higher if your menopause started before 45 or you've had your ovaries removed (NHS).

Other risk factors include a family history of osteoporosis (especially a parent who broke a hip), smoking, heavy drinking, a low body mass index and taking high-dose steroids for more than 3 months (NHS).

To help protect your bones, the NHS suggests (NHS):

• regular exercise, especially weight-bearing exercise such as walking, running or dancing, and resistance exercise such as using weights
• a healthy diet with plenty of fruit, vegetables and sources of calcium, such as milk, yoghurt and kale
• getting some sunlight on your skin, which helps your body make vitamin D, and taking vitamin D supplements
• not smoking, and not drinking more than the recommended alcohol limit

Bone density scans. A bone density (DEXA) scan is a short, painless test that measures how strong your bones are, and your doctor may refer you for one (NHS). In the US, the US Preventive Services Task Force recommends osteoporosis screening for all women aged 65 and over, and for younger postmenopausal women at increased risk, as estimated by a clinical risk assessment (USPSTF). Ask your doctor whether you need one.

Heart health

Before menopause, women have an advantage over men when it comes to cardiovascular disease, but this gradually disappears after menopause (WHO). An early menopause also raises your chance of heart problems (NHS).

Staying active, eating a balanced diet, not smoking and keeping alcohol within recommended limits are good for your heart as well as your bones. Know the signs of a heart attack too (see When to see a doctor).

Pelvic health

Menopause can also weaken the structures that support your pelvic organs. This raises the risk of pelvic organ prolapse, where an organ such as the womb or bladder drops down from its usual position (WHO).

Myths and facts

Myth: Once your periods are irregular, you can't get pregnant.

Fact: You can still get pregnant during perimenopause, even if you miss your period for a month or a few months (Office on Women's Health). Keep using contraception until it's safe to stop (see the perimenopause section above).

Myth: HRT is too risky for most people.

Fact: The NHS says the benefits of HRT usually outweigh the risks, and the risk of serious side effects is very low (NHS).

Myth: Herbal remedies are a safe, natural alternative.

Fact: There's very little evidence about how well they work or how safe they are (NHS). 'Natural' doesn't always mean safe.

Myth: You just have to put up with it.

Fact: A variety of hormonal and non-hormonal treatments can help ease menopause symptoms (WHO). If your symptoms are affecting your life, ask for help.

Your action plan for this week

1. Start a symptom diary. Note your periods, hot flushes, sleep, mood and anything else that bothers you. A few weeks of notes make it easier to explain what's happening.
2. Book an appointment if you think you have symptoms of perimenopause or menopause and want to know your options (NHS).
3. Write down your questions. For example:
   • Could my symptoms be caused by perimenopause or menopause?
   • Is HRT suitable for me, and which type would you suggest?
   • What can I try if I can't or don't want to take HRT?
   • Do I still need contraception, and for how long?
   • Should I have a bone density scan?
4. Try one or two self-help changes, such as keeping your bedroom cool, cutting down on triggers like caffeine and alcohol, or adding weight-bearing exercise to your week (NHS).
5. Talk to someone. The NHS suggests talking to other people going through the same thing, such as family, friends or colleagues (NHS).

When to see a doctor

Call emergency services if

• you have chest pain that feels tight or like squeezing on your chest
• you have chest pain that spreads to your arms, neck or jaw
• you're having severe difficulty breathing
• your lips or skin are pale, blue or grey

These can be signs of a heart attack (NHS guidance on heart attack).

Get emergency help too if you've seriously harmed yourself, or you feel you may be about to harm yourself (NHS guidance on suicidal thoughts). If you're struggling with thoughts like these, let family or friends know what's going on, and contact your doctor or a local crisis line.

See a doctor as soon as possible if

• you have any vaginal bleeding after menopause, even if it's only a small amount, only spotting or has only happened once

Bleeding after menopause isn't usually serious, but it's important to get it checked because it can be a sign of cancer (NHS guidance on postmenopausal bleeding). US advice is to see a healthcare provider as soon as possible (Office on Women's Health).

See a GP or your usual doctor if

• you think you have symptoms of perimenopause or menopause and want to know your options
• you have symptoms like a fast heartbeat (palpitations)
• you still have periods, but your bleeding pattern has changed and you're bleeding more, not less, than before

These reasons come from the NHS guidance on menopause symptoms (NHS). Getting advice is especially important if you're under 45, because early menopause can affect your bones and heart (NHS).

If you're taking HRT, also see a GP if irregular bleeding lasts more than 6 months, your bleeding gets heavier, or you bleed after a long time without periods (NHS).

Frequently asked questions

Does menopause cause weight gain?

Weight gain is one of the common menopause symptoms (NHS). The NHS recommends a healthy, balanced diet and regular exercise during menopause (NHS).

Can menopause affect my teeth and gums?

Yes. Sensitive teeth, painful gums and other mouth problems are among the symptoms the NHS lists (NHS). Mention any changes to your dentist.

Is HRT a form of contraception?

No. It's still possible to get pregnant while taking HRT, so you'll need to keep using contraception until it's safe to stop (NHS).

Where can I find support?

Menopause organisations can offer information and support. In the UK, the NHS lists The Menopause Charity, Women's Health Concern (from the British Menopause Society) and Rock My Menopause (NHS). Look for similar organisations where you live.

Next steps

You don't have to put up with symptoms that affect your health, work or relationships. Start a symptom diary, try a few self-help changes, and book an appointment to talk through your options, including HRT and non-hormonal treatments.

Think about the long term too. Ask about your bone health, keep up the habits that protect your heart, and know the signs that need urgent help.

This article is for general information only. It doesn't replace advice from your doctor or another healthcare professional about your own symptoms and treatment.

Sources

• WHO: Menopause
• NHS: What are menopause and perimenopause?
• NHS: Symptoms of menopause and perimenopause
• NHS: Treatment for menopause and perimenopause
• NHS: Things you can do for menopause and perimenopause symptoms
• NHS: Help and support for menopause and perimenopause
• NHS: Early or premature menopause
• NHS: About hormone replacement therapy (HRT)
• NHS: Benefits and risks of HRT
• NHS: Side effects of HRT
• NHS: When to take HRT
• NHS: About vaginal oestrogen
• NHS: Postmenopausal bleeding
• NHS: Osteoporosis
• NHS: Heart attack symptoms
• NHS: Help for suicidal thoughts
• NHS: Insomnia
• NHS: Endometriosis
• Office on Women's Health (US): Menopause basics
• Office on Women's Health (US): Menopause treatment
• HSE (Ireland): Contraception and menopause
• US Preventive Services Task Force: Osteoporosis to prevent fractures: screening