ByJoAnn V. Pinkerton, MD, University of Virginia Health System
Reviewed/Revised Jul 2023

Menopause is the permanent end of menstrual periods, ovulation, and fertility.

  • For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular, and symptoms (such as hot flashes) may occur.

  • Menopause is diagnosed when a woman has not had a period for 1 year; blood tests are usually not necessary to confirm it.

  • Certain measures, including hormone therapy or other medications, can lessen symptoms.

  • After menopause, bone density decreases.

During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the ovary (ovulation) in the middle of the cycle (about 2 weeks after the first day of the previous period). For this cycle to occur regularly, the ovaries must produce enough of the hormones estrogen and progesterone.

Menopause occurs because as women age, the ovaries stop producing estrogen and progesterone. During the years before menopause, production of estrogen and progesterone begins to fluctuate, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and ovulation end permanently, and pregnancy can no longer occur naturally. A woman’s final period can be identified only later, after she has had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed since their last menstrual period.)

The aging of the female reproductive system before and after menopause is described in stages:

  • Reproductive stage includes the time from a woman's first menstrual period through the menopausal transition.

  • Menopausal transition is the phase that leads up to the final menstrual period. It is characterized by changes in the pattern of menstrual periods. The menopausal transition lasts from 4 to 8 years. It lasts longer in women who smoke and in women who were younger when it began. Research shows that, on average, Black women experience more years of menopausal transition than White women.

  • Perimenopause is part of the menopausal transition and refers to the several years before and the 1 year after the final menstrual period. The number of years a woman is in perimenopause before her final menstrual period varies greatly. During perimenopause, estrogen and progesterone levels fluctuate widely and eventually decrease significantly, but the changes vary in other hormones (such as testosterone). These hormone fluctuations are thought to cause the menopausal symptoms experienced by many women in their 40s.

  • Postmenopause refers to the time after the final menstrual period.

In the United States, the average age for menopause is about 51. However, menopause may occur normally in women aged 45 (or even 40) to age 55 or older. Menopause may start at a younger age in women who

  • Smoke

  • Live at a high altitude

  • Are malnourished

  • Have an autoimmune disease

Menopause is considered premature when it occurs before age 40. Premature menopause is also called premature ovarian failure or primary ovarian insufficiency.

Did You Know...

  • Symptoms of menopause can start years before menstrual periods end.

  • The average age for menopause is about 51, but anywhere between age 40 and 55 or older is considered normal.

Symptoms of Menopause

Perimenopause symptoms

During perimenopause, symptoms may be mild, moderate, or severe, or there may be no symptoms. Symptoms may last from 6 months to about 10 years, sometimes longer.

Sometimes symptoms that are thought to be due to menopause can be caused by other medical issues. If symptoms occur and the timing does not line up with menopause or if the symptoms do not improve with measures used for menopausal symptoms, a woman should discuss other possible causes with a health care professional.

Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often, but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become regular again. In some women, periods are regular until menopause.

Hot flashes affect 75 to 85% of women. Hot flashes usually begin before periods stop. They last for an average of almost 7 1/2 years but can last more than 10 years. Research shows that, on average, Black women experience hot flashes more frequently and over a longer period of time than Asian, Hispanic, or White women. Usually, hot flashes become milder and occur less frequently as time passes.

What causes hot flashes is unknown. But it may involve a resetting of the brain's thermostat (the hypothalamus), which controls body temperature. As a result, very small increases in temperature can make women feel hot. Hot flashes may be related to fluctuations in hormone levels.

During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing the skin, especially on the head and neck, to become red and warm (flushed). Women feel warm or hot, and perspiration may be profuse. Hot flashes are sometimes called hot flushes because the face can become red.

A hot flash lasts from 30 seconds to 5 minutes and may be followed by chills. Night sweats are hot flashes that occur at night.

Other symptoms may occur around the time of perimenopause or menopause. The changes in hormone levels that occur at this time may contribute to the following:

  • Breast tenderness

  • Moodiness

  • Worsening of migraines that occur just before, during, or just after menstrual periods (menstrual migraines)

Depression, irritability, anxiety, nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue may also occur. Many women experience these symptoms during perimenopause. Although these symptoms may be related to other factors (such as aging itself or a disorder), they are often worsened by the hormonal fluctuations and decreases in estrogen during perimenopause.

Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship of fatigue, irritability, loss of concentration, and mood changes to menopause seems less clear.

Symptoms after menopause

Many of the symptoms that occur during perimenopause, although disturbing, become less frequent and less intense after menopause. However, the decrease in estrogen levels causes changes that can continue to negatively affect health (for example, increasing the risk of osteoporosis). These changes may worsen, unless measures to prevent them are taken. The following may be affected:

  • Reproductive tract: The lining of the vagina becomes thinner, drier, and less elastic (a condition called vaginal atrophy). These changes may make sexual intercourse painful. Other parts of the female anatomy—the labia minora, clitoris, uterus, and ovaries—decrease in size. Sex drive (libido) commonly decreases with age. Most women can still have an orgasm, but some require more time to reach orgasm or feel that their orgasm is less intense.

  • Urinary tract: The lining of the urethra becomes thinner, and the urethra becomes shorter. Because of these changes, microorganisms can enter the body more easily, and some women develop urinary tract infections more frequently. A woman with a urinary tract infection may feel a burning sensation when she urinates. After menopause, women may sometimes experience episodes in which they have a sudden need to urinate (called urinary urgency), sometimes resulting in urge urinary incontinence—leaking small or large amounts of urine. Urinary incontinence becomes more common and severe with age. However, it is unclear how much menopause contributes to incontinence. Many other factors, such as the effects of childbirth, obesity, and the use of hormone therapy, may contribute to incontinence.

  • Skin: The decrease in estrogen, as well as aging itself, causes a decrease in the amount of collagen (a protein that makes skin strong) and elastin (a protein that makes skin elastic). Thus, the skin may become thinner, drier, less elastic, and more vulnerable to injury.

  • Bone: The decrease in estrogen often leads to a decrease in bone density and sometimes to osteoporosis because estrogen helps maintain bone. Bone becomes less dense and weaker, making fractures more likely. During the first 5 years after menopause, bone density decreases rapidly. After that, it decreases at about the same rate as it does in men (by about 1 to 3% each year).

  • Cholesterol (lipid) levels: After menopause, levels of low-density lipoprotein (LDL—the unhealthy) cholesterol, increase in women. Levels of high-density lipoprotein (HDL—the good) cholesterol remain about the same as before menopause. The change in LDL levels may partly explain why atherosclerosis and thus coronary artery disease become more common among women after menopause. However, whether these changes result from aging or from the decrease in estrogen levels after menopause is unclear. Until menopause, the high estrogen levels may protect against coronary artery disease.

Some postmenopausal women experience burning mouth syndrome.

Genitourinary syndrome of menopause is a fairly new, more accurate term used to refer to symptoms that affect the vagina and urinary tract and that are caused by menopause. These symptoms include vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections.

Did You Know...

  • Genitourinary syndrome of menopause is a fairly new term used to refer to menopausal symptoms that affect the vagina, vulva, and urinary tract, such as vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections.

Diagnosis of Menopause

  • Recent pattern of menstrual periods

  • Rarely, blood tests to measure hormone levels

In most women, menopause can be diagnosed after 1 full year without menstrual periods. Thus, laboratory tests are usually not needed.

Timing of cessation of menopause is described based on age, as follows:

  • Premature menopause: 39 years old or younger

  • Early menopause: 40 to 45 years old

  • Menopause (usual age range): 46 years old or older

If menopause occurs before age 45 or if the menstrual pattern is not clear-cut (for example, periods stop for several months but then bleeding occurs), tests may be done to check for disorders that can disrupt menstrual periods. If blood tests are needed to confirm menopause, the tests measure levels of follicle-stimulating hormone (FSH), which stimulates the ovaries to produce estrogen and progesterone.

Sometimes doctors do a pelvic examination to check for typical changes in the vagina, which support the diagnosis of menopause, or as part of the evaluation if a woman has uncomfortable symptoms (such as vaginal dryness or pain during sexual intercourse).

Treatment of Menopause

  • Cognitive-behavioral therapy

  • Clinical hypnosis

  • Nonhormonal medications

  • Hormone therapy

Understanding what happens during perimenopause can help women cope with the symptoms. Talking with other women who have gone through menopause or with a doctor may also help.

Treatment of menopause focuses on relieving symptoms such as hot flashes, sleep issues, mood changes, and vaginal dryness.

Effective measures that do not involve hormones include

  • Hypnosis by a qualified health care professional to help relieve hot flashes

  • Cognitive-behavioral therapy

Cognitive-behavioral therapy has been adapted to be used during the menopause transition and postmenopause. It can help women manage hot flashes and night sweats.

If such measures are not successful, hormone therapynorepinephrine

In addition to treatment of menopausal symptoms, postmenopausal women should be screened for osteoporosis if they meet the following criteria:

General measures

General measures such as cooling methods (for example, using fans, wearing light clothing), avoiding triggers (such as alcohol or spicy food), and dietary changes may help some women. Mindfulness, exercise, or yoga may help with sleep or a general sense of well-being. However, research has had mixed results about all these general measures and they have not been proven to be effective, so many menopause experts do not recommend them.

To manage sleep disturbances, women can follow a routine to calm themselves before they go to bed and when night sweats wake them up. Developing good sleep habits and exercise can also help improve sleep.

Bladder control may be improved by Kegel exercises. For these exercises, a woman tightens the pelvic muscles as if stopping urine flow. Women may be taught how to use biofeedback to help them learn to control their pelvic muscles. Biofeedback is a method of bringing unconscious biologic processes under conscious control. It involves using electronic devices to measure information about these processes and to report it back to the conscious mind. Other measures that may help include

  • Limiting fluid intake at certain times—for example, before going out or 3 to 4 hours before bedtime

  • Avoiding foods that irritate the bladder (such as caffeine-containing fluids and spicy or salty foods) 

If vaginal dryness is uncomfortable or makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. For some women, applying a vaginal moisturizer daily or a few times a week helps. Staying sexually active or masturbating also helps by stimulating blood flow to the vagina and the surrounding tissues and by keeping tissues flexible.

Nonhormonal medications

Several types of medications can help relieve some of the symptoms associated with menopause.


A sleep aid is sometimes recommended to relieve insomnia.


Herbal or dietary supplements

Overview of Dietary Supplements/Safety and Effectiveness).

Some supplements (for example, kava) can be harmful. Furthermore, some supplements can interact with other medications and can worsen some disorders.

Concerns about using standard hormone therapy have led to an interest in using hormones derived from plants such as yams and soy. These hormones have nearly the same molecular structure as hormones made by the body and thus are called bioidentical hormones. Many of the hormones used in standard hormone therapy are also so-called bioidentical hormones derived from plants. Menopause experts recommend use of the hormones in standard hormone therapy because have been tested and approved, and their use is closely monitored.

Sometimes a pharmacist custom makes (compounds) bioidentical hormones for a person according to a health care professional's prescription. These are called compounded bioidentical hormones. Their production is not well-regulated. Thus, many doses, combinations, and forms are possible, and purity, consistency, and potency of the products vary. Compounded bioidentical hormones are often marketed as substitutes for standard hormone therapy, sometimes along with claims they are a better, safer treatment than standard hormone therapy. But there is no evidence that compounded products are safer, more effective, or even as effective as standard hormone therapy. Sometimes women are not told that compounded bioidentical hormone products have the same risks as standard hormones.

Women who are considering taking these compounded hormone therapies are advised to discuss them with a doctor.

Hormone Therapy for Menopause

Hormone therapy can relieve moderate to severe symptoms of menopause such as hot flashes, night sweats, and vaginal dryness, and, for some women, to prevent or treat osteoporosis. However, hormone therapy may increase the risk of developing certain serious disorders.

Hormone therapy for menopause improves quality of life for many women by relieving their symptoms. However, if a woman does not have menopausal symptoms, hormone therapy is not recommended because it does not improve overall quality of life. Whether to take hormone therapy is a decision that must be made by a woman and her doctor based on the woman’s individual situation. Women should ask their doctor about the risks and benefits of hormone therapy before they start taking the medications.

For many women, risks outweigh potential benefits, so this therapy is not recommended. However, for some women, depending on their medical conditions and risk factors, potential benefits may outweigh risks.

For healthy women with bothersome menopausal symptoms who are under age 60 or were diagnosed with menopause fewer than 10 years previously, potential benefits of hormone therapy are most likely to exceed potential harms.

Usually, doctors do not recommend that women start taking hormone therapy if

  • Women are older than 60.

  • Menopause was diagnosed more than 10 to 20 years previously.

In these women, the risk of coronary artery disease, stroke, blood clots in the legs, blood clots in the lungs, and dementia is higher.

When hormone therapy is used, doctors prescribe the lowest hormone dose that controls symptoms and for the shortest time needed.

Hormone therapy can include

  • Estrogen

  • Both

Progestogens resemble progesterone, a female hormone made by the body.

For women with general menopausal symptoms, such as hot flashes, mood changes, or sleep issues, a full dose of estrogen and progestogen are given, which treats the whole body. If symptoms are only affecting the vagina or urinary tract, vaginal medications are usually given that treat symptoms just in that area of the body.

Most women are given a combination of both estrogen and a progestogen (combination hormone therapy). Estrogen alone is given only to women who have had a hysterectomy (surgical removal of the uterus), because taking estrogen without a progestogen increases the risk of cancer of the uterine lining (endometrial cancer). The progestogen helps protect against this cancer. The exception to this is very low dose vaginal estrogen therapy (used for genitourinary syndrome of menopause), which can be given without a progestogen. Another option for women with a uterus is the .

For women at risk of bone loss or fracture, hormone therapy may be recommended if

  • They are under age 60.

  • Menopause was diagnosed fewer than 10 years previously.

  • They cannot take other medications (such as bisphosphonates) to prevent bone loss and fractures.

Hormone therapy reduces bone loss and risk of fracture in these women.

Estrogens with or without a progestogen: Potential benefits and risks

Estrogen is helpful in relieving several types of symptoms:

  • Hot flashes: Estrogen is the most effective treatment for hot flashes.

  • Drying and thinning of vaginal tissues: Estrogen can prevent or treat vaginal dryness, and this can be very helpful if a woman has developed pain with sexual intercourse. When the only problem a woman has is drying and thinning of these tissues, doctors may recommend a form of estrogen that is inserted into the vagina. These forms include low-dose estrogen tablets, a low-dose estrogen ring, a low-dose estrogen cream, and a DHEA (dehydroepiandrosterone) suppository. When a low dose of estrogen is used, women who still have a uterus do not have to take a progestogen. With high doses of estrogen, women with a uterus need to take a progestogen.

  • Frequent urinary tract infections or an urgent need to urinate: Forms of estrogen that are inserted into the vagina (creams, tablets, or rings) help relieve these problems.

  • Osteoporosis: Estrogen, with or without a progestogen, helps prevent or slow the progression of osteoporosis. However, taking hormone therapy for the sole purpose of preventing osteoporosis is usually not recommended. Most women can take a bisphosphonate or another medication to help prevent osteoporosis instead (although these medications have their own risks). Bisphosphonates increase bone mass by reducing the amount of bone the body breaks down as it re-forms bones. The body continuously breaks bone down and re-forms it to help bones adjust to the changing demands placed on them. As people age, more bone is broken down than is re-formed.

Estrogen is usually taken with a progestogen. Estrogen taken without a progestogen increases the risk of endometrial cancer in women who have a uterus (have not had a hysterectomy). The risk increases with higher doses and longer use of estrogen. Taking a progestogen with estrogen almost eliminates the risk of endometrial cancer, reducing the risk below that for women who do not take hormone therapy. Nonetheless, doctors evaluate any vaginal bleeding in women taking any type of hormonal therapy to rule out endometrial cancer.

Estrogen increases the risk of the following:

  • Breast cancer: The risk of breast cancer begins to increase by a very small amount after taking estrogen plus a progestogen for about 3 to 5 years. But if estrogen is taken alone at the beginning of menopause, risk may not begin to increase until after 10 years or even 15 years.

  • Stroke

  • Blood clots in the legs (deep vein thrombosis) and blood clots in the lungs (pulmonary embolism)

  • Gallbladder disorders (such as gallstones)

  • Urinary incontinence: Taking estrogen at full dose increases the risk of developing incontinence and worsens preexisting incontinence. However, low-dose vaginal estrogen therapy improves urinary incontinence.

Although taking hormone therapy increases the risk of the above disorders, the risk is still low in healthy women who take hormone therapy for a short time during or shortly after perimenopause. Risk of most of these disorders increases with age, particularly 10 years or more past menopause, whether hormone therapy is taken or not. In women who start hormone therapy after age 65, taking estrogen plus a progestogen also increases the risk of coronary artery disease.

Risks of hormone therapy are thought to be lower when low doses of estrogen are used. Most forms of estrogen that are inserted into the vagina (such as estrogen creams or tablets or rings that contain estrogen) are much lower doses than full-body doses in pills or skin patches. One exception is a vaginal ring that has a full-body dose and is used to treat general menopausal symptoms.

Estrogen given through a skin patch (transdermal form) or vaginal ring appears to have a lower risk of blood clots, stroke, and gallbladder disorders (such as gallstones) than with forms taken by mouth.

Generally, women who have breast cancer, coronary artery disease, or blood clots in the legs, who have had a stroke, or who have risk factors for these disorders should not take estrogen therapy.

Combination hormone therapy reduces the risk of the following:

  • Osteoporosis

  • Colorectal cancer

Progestogens: Benefits and risks

Progestogens have some benefits:

  • Endometrial cancer: Progestogens prevent endometrial cancer in women who have a uterus and are taking estrogen.

  • Hot flashes: High-dose progestogens can relieve hot flashes. But they are not as effective as estrogen.

  • Lower risk of blood clots than estrogen: Progestogens are an option for some women who are at high risk of forming blood clots and cannot use estrogen therapy.

Progestogens may increase the risk of the following:

  • Increase in LDL (the unhealthy) cholesterol levels: Progestogens may have this effect. However, micronized progesterone (a natural rather than synthetic progesterone) appears to have a less negative effect on LDL levels than synthetic progestins.

  • Blood clots in the legs and lungs.

The effect of a progestogen alone on the risk of other disorders is not clear.

Side effects

Side effects of estrogen and progestogens, especially at high doses, may include nausea, breast tenderness, headache, fluid retention, and mood changes.

Forms of hormonal therapy

Estrogen and/or a progestogen can be taken in several ways:

  • Estrogen, progestogen, or combined tablets taken by mouth (oral form)

  • Estrogen lotions, sprays, or gels applied externally to the skin (topical form)

  • Estrogen or combination estrogen-progestogen skin patches (transdermal form)

  • Progestogen-releasing intrauterine device

  • Estrogen creams, tablets, rings, or suppositories inserted into the vagina (vaginal form)

As tablets taken by mouth, estrogen and a progestogen may be taken as two tablets or as a combination tablet. Commonly, estrogen and a progestogen are taken every day. This schedule may result in irregular vaginal bleeding during the first year or more of therapy. (However, if bleeding starts or continues, women should contact their doctor to see if further evaluation is needed.) Alternatively, estrogen may be taken daily, with a progestogen taken for 12 to 14 days each month. With this schedule, most women have monthly vaginal bleeding on the days after they take progestogen.

Vaginal forms of estrogen are inserted into the vagina. These forms include

  • A cream that is inserted with a plastic applicator

  • A tablet that is inserted with or without a plastic applicator

  • A ring that contains estrogen

There are many different products, which come in different doses and which contain different types of estrogen. Creams and rings may contain a high or low dose of estrogen. If a high dose of estrogen is used in vaginal forms, women are also given a progestogen to reduce the risk of endometrial cancer. Usually, a low dose is sufficient for vaginal symptoms.

Using a vaginal form of estrogen may be more effective than taking estrogen by mouth for symptoms that affect the vagina (such as drying or thinning). Such treatment helps prevent intercourse from being painful, lessens urinary urgency, and reduces the risk of bladder infections.

As a lotion, spray, or gel,estrogen can be applied to the skin.

As a patch,estrogen or estrogen plus a progestogen can also be applied to the skin.

Selective estrogen receptor modulators (SERMs)

SERMs function like estrogen in some ways but reverse the effects of estrogen

When women take a SERM, hot flashes may temporarily worsen.

Bazedoxifene is a SERM that is given with estrogen in a combination tablet; progestogen is not needed with this estrogen and bazedoxifene combination. Bazedoxifene can relieve hot flashes and symptoms of vaginal atrophy, reduce breast tenderness, improve sleep, and prevent bone loss. Like estrogen, this medication increases the risk of blood clots in the legs and lungs, but it may reduce the risk of endometrial cancer and affect the breast less.

Dehydroepiandrosterone (DHEA)

Dehydroepiandrosterone (DHEA) is a steroid hormone that is produced in the adrenal glands and that is converted into sex hormones (estrogens and androgens). It is available as a suppository to be placed in the vagina. DHEA appears to relieve vaginal dryness and other symptoms of vaginal atrophy. It is also used to reduce pain during sexual intercourse due to vaginal atrophy.

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