What are menopause and perimenopause?

Menopause is the end of a woman's menstrual cycles, confirmed by the absence of menstruation for 12 consecutive months, in the absence of other known causes, or when the ovaries are removed or severely damaged. It is a natural event that every woman experiences and marks the end of the reproductive or fertile phase. It is associated with reduced ovarian function and, consequently, lower production of ovarian hormones, especially estrogen.

Perimenopause is the phase that represents the transition from the reproductive period to the non-reproductive period, and therefore includes menopause. Its duration varies among women and begins with changes in ovarian hormones and those that regulate them. During the transition from the fertile age to postmenopause, women experience physical changes. Most of these changes are normal, but some may be related to health conditions.

Types

Menopause is referred to as natural menopause when the cessation of menstruation occurs spontaneously, without any medical intervention, typically between the ages of 40 and 55 for most women. Induced menopause is caused by the surgical removal of the ovaries or by chemotherapy or radiotherapy treatments, provided they cause serious and irreversible damage to the ovaries. Premature menopause occurs before the age of 40, either naturally or as a result of medical intervention.

Diagnosis

The diagnosis is clinical, confirmed through the analysis of the patient’s medical history and reported symptoms, with hot flashes and menstrual changes being the most common symptoms during perimenopause.

Menopause is diagnosed one year after the last menstrual period. Although hormone level testing is not necessary in most cases, it may be performed when there is uncertainty or suspicion of another cause for the symptoms.

Symptoms

The most common findings during perimenopause include:3

irregular menstrual cycles, with shortened or lengthened intervals, changes in duration and flow volume, and occasional intermenstrual bleeding. These changes begin four to eight years before menopause in 90% of women, although some may reach their final period without any prior alterations
hot flashes, characterized by episodes of flushing and a sensation of heat affecting the face, neck, and torso. These may be accompanied by rapid heartbeat, increased sweating, followed by chills, and, in some cases, anxiety. When they occur at night, they can disrupt sleep and lead to night sweats. Poor sleep, in turn, may cause fatigue and irritability. Some hot flashes are mild and tolerable, while others are quite disruptive. Most women experience these symptoms for three to five years, though it is not possible to predict when they will end
psychological symptoms, such as mood swings, depression, anxiety, and memory decline. These are common complaints among mature women, although there is no scientific proof of a direct link to menopause. Women between 40 and 50 often experience shifts in self-perception, self-esteem, and body image. In a society that values youth, menopause may coincide with other stressors. While psychological issues are not caused by menopause, they may emerge or intensify during this phase
decreased sexual desire, which is common in both sexes with aging. Hormonal decline during menopause can affect sexual function, but the degree of impact varies. Many women remain sexually active after menopause, especially those who accept physical changes and maintain a positive body image, which supports sexual well-being
genital changes, including thinning of the vaginal and vulvar mucosa, reduced lubrication, and loss of elasticity—known as atrophy. These changes tend to become more pronounced and bothersome a few years after menopause
urinary symptoms, such as incontinence, increased frequency, and urinary tract infections. These are common in older age and may be partially influenced by menopause. Estrogen deficiency leads to thinning of the urethral lining, and aging weakens pelvic muscles
headaches, more common in women previously sensitive to hormonal fluctuations, such as those with a history of menstrual migraines or oral contraceptive use
skin and hair changes, including thinning and dryness of the skin due to reduced estrogen and collagen levels. There may also be a relative increase in male hormones, leading to increased facial hair on the cheeks, chin, and upper lip
cardiovascular disease, with a two- to threefold increase in the risk of heart attack, stroke, and thrombosis compared to premenopausal women, with risks continuing to rise over time
osteoporosis, with increased risk of fractures in the spine, hips, ribs, and limbs, which can have serious consequences. Although bone loss begins gradually at age 30, it accelerates in women during the first years after menopause

Treatment

The need for treatment is based on the intensity of short-term symptoms and the risk of long-term diseases (such as osteoporosis and cardiovascular disease). Significant differences are observed between women with natural menopause and those with early or induced menopause, who often require specific care. However, regardless of symptoms, all women in the perimenopause phase should be followed by a medical professional.

General measures are always recommended, including: Maintaining a healthy weight, eating a diet rich in calcium and vitamin D and low in saturated (animal) fats, avoiding smoking and excessive consumption of alcohol or caffeine, exercising regularly (aerobic, weight-bearing, and flexibility exercises), controlling blood pressure, preventing or managing diabetes, reducing stress and managing cholesterol and triglyceride levels.

Pharmacological treatment is individualized, and the need or indication for hormone therapy should be discussed with a physician based on symptoms, existing conditions, contraindications, and potential side effects.

Hormone therapy may involve estrogen alone or estrogen combined with progestogen, administered through various routes: pills, injections, patches, gels, nasal sprays, or vaginal creams. These can have local (vaginal) or systemic effects. Hormone therapy can improve hot flashes, genital atrophy, and bone loss. However, prolonged use may increase the risk of heart disease, stroke, vascular thrombosis, and breast cancer.

Contraindications for hormone use include: History of breast câncer, unexplained uterine bleeding, active severe liver disease, history of venous thrombosis and presence of cardiovascular disease.

Side effects of hormone therapy may include: Uterine bleeding, breast pain, náusea, abdominal bloating, headache, dizziness, fluid retention and mood changes.

The use of phytoestrogens (“natural hormones”), such as isoflavones, may seem to relieve hot flashes in some cases, but there is insufficient scientific evidence to confirm their effectiveness and safety.

It is true that all women go through menopause, each in a unique way, and will spend about one-third of their lives in postmenopause. Therefore, it is beneficial to work with a physician to tailor treatment plans to each case, with regular reassessments based on scientific advances and lifestyle changes.

References

Menopause - NHS
Menopause - StatPearls - NCBI Bookshelf
What Is Menopause? | National Institute on Aging
Menopause - Cleveland Clinic