Perimenopause and menopause

What is the menopause?

The menopause is the natural end of a woman's reproductive life. The ovaries gradually stop responding to the hormones of the pituitary gland, the production of estrogen falls and the periods stop. The menopause can only be confirmed looking back: when there has been no period for 12 months in a row. The average age is 51, and in most women it happens between the ages of 45 and 55. The menopause itself is a specific point in time. It marks the start of a whole new phase of life.

Because there are estrogen receptors almost everywhere in the body, the fall in estrogen does not only affect the period. It affects the brain, the heart, the blood vessels, the bones, the skin, the urinary tract and metabolism.

The stages

The perimenopause is the transition before the last period and lasts until 12 months after it. It can start as early as the age of 38 to 40 and has two phases, which differ in how often the periods come. In the early phase of the perimenopause, estrogen production is disturbed. Estrogen levels go up and down from day to day, and these swings often cause strong symptoms, such as breast tenderness, heavier periods, symptoms like premenstrual syndrome, and changes in mood and sleep. Despite these symptoms, the period stays fairly regular. In the late phase of the perimenopause, ovulation is missed more and more often and the period becomes irregular. In this phase, hot flashes and night sweats become more common. They are strongest at the end of this phase and in the first years after the menopause. This phase gradually leads into the menopause and lasts about 1 to 3 years.

The perimenopause marks the move from the reproductive to the non-reproductive phase of a woman's life, and it is a window of opportunity. The right approach in this phase can lead to a longer life in better health. It also appears that starting hormone replacement therapy at a specific point within this period can lead to different results (timing hypothesis). This applies especially to heart and blood vessel health and to brain function in the future.

When the menopause happens between the ages of 40 and 45, it is called early menopause. Before 40 it is called premature ovarian insufficiency, and according to ESHRE (2024) it affects about 3-4% of women. It can happen on its own or be caused by surgery, chemotherapy or radiotherapy. In this case hormone replacement therapy is recommended at least until the age of natural menopause, around 51, to protect the bones, the heart and the brain. More in the article Premature ovarian insufficiency.

The symptoms

About 80% of women have symptoms. On average they last about four years after the last period, but in 10% of women they can last up to twelve years. A significant number of women still have symptoms at the age of 60 to 65.

The best known are hot flashes and night sweats, which can seriously disturb sleep and daily life. There are often also sleep problems, tiredness, pain in the joints and muscles, headaches and palpitations. Emotionally, there are mood swings, irritability, anxiety, low mood, difficulty concentrating, memory problems and the so-called “brain fog”. The fall in estrogen also affects the vagina and the bladder, with dryness, pain during sex, frequent urination, incontinence and repeated urinary infections. Sexual desire often decreases.

These symptoms do not simply have to be endured. They affect family, work, relationships and sexual life, and there are effective solutions.

The long-term effects

The menopause is not only about symptoms. It is also about health in the decades that follow.

According to what women themselves report, the health issues that concern them most in the menopause are, in order of importance: body weight, cancer, heart and bone health, the condition of the skin, incontinence, mental health (including memory and thinking) and sexual function.

The bones lose mass faster, with a higher risk of osteoporosis and fractures. The heart and the blood vessels lose the protection of estrogen, and heart disease becomes the most common cause of death in women, much more common than breast cancer. Metabolism changes: fat collects more around the belly, and the risk of metabolic syndrome, type 2 diabetes and high blood pressure rises. Low estrogen is also linked to a higher risk of depression, and its role in how the brain works is being actively studied.

That is why good care in the menopause has two goals: relief from the symptoms and prevention for the future.

How is the diagnosis made?

In women over 45, the diagnosis is based on the symptoms and the changes in the period. Hormone tests are usually not needed for the diagnosis, because in the perimenopause the values change from day to day and a single result can be misleading. Tests are useful in women under 45, after a hysterectomy, or when the symptoms are not clear. Blood tests are, however, helpful for assessing the metabolic and cardiovascular risk before a treatment is chosen.

Contraception

In the perimenopause a pregnancy is still possible. Under the age of 50, contraception continues until two years have passed without a period. Over 50, it continues until one year has passed. Hormone replacement therapy for the menopause is not contraception, but it can be combined with a contraceptive method.

What a woman can do herself

Lifestyle is the basis of every treatment. Regular exercise, about 150 minutes of moderate activity a week, with strength training twice a week, helps with the symptoms, the bones, the weight and the mood. A Mediterranean diet with enough calcium and vitamin D protects the heart and the bones. Smoking makes hot flashes worse and raises the risk of cancer. Alcohol makes the symptoms worse and raises the risk of breast cancer, so it is best to limit it, with several alcohol-free days a week. Keeping a normal weight is especially important, because obesity is now one of the most important risk factors for cancer.

The treatment options

Menopausal hormone replacement therapy is the most effective treatment for the symptoms and, for most women, a low-risk option. It can be a powerful tool. Used correctly, it can improve quality of life and lower overall mortality. It is not suitable for every woman, and for each woman the choice of treatment must be individual. Detailed information is available on a separate page:

Menopausal hormone replacement therapy →

For women who cannot or do not want to take hormones, there are non-hormonal options. Newer medicines act directly on the temperature control center in the brain (neurokinin receptor antagonists): fezolinetant, approved in Europe since 2023, and elinzanetant, approved since 2025. They clearly reduce hot flashes and night sweats. Fezolinetant requires checks of liver function. Some antidepressants, gabapentin and clonidine can also help, but they more often have side effects. Cognitive behavioural therapy has good evidence for mood, anxiety, sleep and hot flashes.

Herbal products and supplements (soy isoflavones, red clover, black cohosh, evening primrose oil) have limited or conflicting evidence. Because they can interact with other medicines and their content is not always controlled, their use should be discussed with the doctor.

For vaginal dryness there are local estrogens, which are safe and can be used for a long time, as well as non-hormonal moisturisers and lubricants.

What about menopause caused by cancer treatment?

In many women, menopause does not come naturally but as a result of cancer treatment. It often comes suddenly and at a young age, and the symptoms are usually stronger. After chemotherapy, however, not every woman enters the menopause. Detailed information is available on a separate page:

Iatrogenic menopause →

Menopause and work

Women in the perimenopause and the menopause are a very active part of society. They have a great deal of experience, and the demands on them are especially high. They need to be strong in body and mind, both to cope with a difficult and competitive environment and to enjoy their lives. Many women struggle at work because of tiredness, poor concentration, memory problems or low self-confidence, and they often do not talk about it out of embarrassment.

In recent years, there has been growing discussion about how to support these women at work and how to break the taboos around the menopause, which make many women afraid to speak openly. An open conversation with the employer about small changes, such as flexible working hours or a well-ventilated workplace, can make a big difference.

The doctor should be a source of support for the woman at work as well, and the woman should ask for this support whenever she needs it.

Every woman is different

Every woman experiences the menopause in her own way. There is no single treatment for everyone. Each decision is individual and takes into account the woman's symptoms, history, risks and wishes. Every woman can get help, and no woman has to simply live with her symptoms.

The practice's approach

Sources: NICE – Menopause: identification and management, NG23 (2015, updated 2024). The Menopause Society – Hormone Therapy Position Statement (2022). EMA – Veoza (fezolinetant) and Lynkuet (elinzanetant), product information. ESHRE – Premature Ovarian Insufficiency guideline (2024). STRAW+10 – Stages of Reproductive Aging Workshop (Harlow et al., 2012). Cochrane – Boardman et al. (2015), hormone therapy and cardiovascular disease. WHI – Cauley et al., JAMA 2003 (fractures). WHIMS – Shumaker et al., JAMA 2003 (dementia). KEEPS – Gleason et al., PLOS Medicine 2024 (brain function). Heinemann LAJ et al., The Menopause Rating Scale (MRS): reliability of scores of menopausal complaints, Health and Quality of Life Outcomes 2003. Heinemann K et al., The Menopause Rating Scale (MRS) scale: a methodological review, Health and Quality of Life Outcomes 2004. ESHRE – Guideline Premature Ovarian Insufficiency (2024).