Menopause

Stages of menopause

See perimenopause for more on the transition.

Early and premature menopause

• Premature menopause (primary ovarian insufficiency): before age 40, affecting about 1%
• Early menopause: between 40 and 45
• Surgical menopause: immediate menopause after removal of both ovaries, often with more intense symptoms
• Medical causes: chemotherapy, pelvic radiation, some hormone treatments

Early menopause raises the long-term risk of osteoporosis and heart disease, so hormone therapy until at least the average age of menopause is generally recommended unless there is a reason to avoid it.

Symptoms

Vasomotor symptoms

Hot flashes and night sweats affect up to 80% of women. A hot flash is a sudden wave of heat over the face, neck and chest, with sweating, flushing and sometimes palpitations, lasting 1 to 5 minutes. They last about 7 years on average, and longer for some, particularly Black women.

Other common symptoms

• irregular periods, heavier or lighter bleeding
• sleep disturbances and insomnia
• mood changes, irritability, anxiety and depression, especially in perimenopause
• brain fog, forgetfulness and poor concentration
• vaginal dryness, itching and painful sex, and urinary urgency or infections (genitourinary syndrome of menopause)
• reduced sex drive
• joint and muscle aches
• weight gain around the abdomen
• dry skin, thinning hair, and breast tenderness
• palpitations and headaches

Diagnosis

For women over 45 with typical symptoms, menopause is diagnosed from symptoms and menstrual history alone. Blood tests are not needed, because hormone levels fluctuate. Tests are useful when:

• periods stop before 40 to 45, to check FSH and look for other causes
• symptoms are atypical, or to rule out thyroid disease or pregnancy

Long-term health after menopause

• Osteoporosis: bone loss speeds up for about 5 to 7 years after menopause. A bone density (DXA) scan is recommended from age 65, or earlier with risk factors.
• Heart disease: risk rises after menopause, with changes in cholesterol, blood pressure and fat distribution.
• Genitourinary changes: progressive without treatment.
• Pelvic floor weakness: urinary incontinence and prolapse.

Treatment

Hormone therapy (HT or MHT)

The most effective treatment for hot flashes and night sweats, and it prevents bone loss.

• Estrogen as pills, patches, gels or sprays. Women with a uterus also need progestogen (or a combined product) to protect the uterine lining.
• Benefits are greatest and risks lowest for women under 60 or within 10 years of menopause who have no contraindications, according to The Menopause Society.
• Risks depend on age, type, route and duration: blood clots and stroke (lower with transdermal estrogen), and a small increase in breast cancer risk with combined therapy over several years.
• Not suitable for most people with a history of breast cancer, blood clots, stroke, heart attack, or unexplained vaginal bleeding.
• Decisions are individualized and reviewed regularly. There is no fixed time limit.
• In late 2025 the FDA announced it would remove boxed warnings from menopausal hormone therapy labels, reflecting updated evidence on risks for younger women.

Vaginal estrogen

Low-dose vaginal estrogen treats dryness, painful sex and urinary symptoms with minimal absorption and is safe for most women, including many who cannot take systemic HT.

Non-hormonal medicines

• Fezolinetant and elinzanetant, which block neurokinin signaling in the brain's temperature center
• SSRIs or SNRIs, such as paroxetine, venlafaxine and escitalopram
• gabapentin, especially for night sweats
• oxybutynin
• cognitive behavioral therapy and clinical hypnosis also reduce the impact of hot flashes

Lifestyle

• dress in layers, keep the bedroom cool, and use fans
• limit alcohol, caffeine and spicy food if they trigger flashes
• stop smoking
• regular exercise, including strength training for bones and muscle
• a healthy diet with adequate calcium and vitamin D
• maintain a healthy weight
• pelvic floor exercises

Many supplements, such as black cohosh and soy isoflavones, have limited or inconsistent evidence. Compounded "bioidentical" hormones are not FDA-regulated and are not recommended over approved products.

Frequently asked questions

What are the first signs of menopause?

The first signs are usually changes in periods, such as cycles becoming shorter, longer or irregular, along with hot flashes, night sweats, sleep problems and mood changes. These typically start in the mid-40s during perimenopause.

At what age does menopause start?

The average age of menopause in the US is 51, and most women reach it between 45 and 55. Menopause before 40 is called premature and before 45 early, and both should be discussed with a doctor.

How long do menopause symptoms last?

Hot flashes and night sweats last an average of about 7 years, and for some women more than 10 years. Vaginal dryness and urinary symptoms tend to persist or worsen without treatment. Mood symptoms often improve after the transition.

Is hormone replacement therapy safe?

For most healthy women under 60 or within 10 years of menopause, the benefits of hormone therapy for symptoms and bone protection outweigh the risks. Risks vary with age, health history and type of therapy, so it should be discussed individually with a clinician.

Can you get pregnant during perimenopause?

Yes. Ovulation can still happen during perimenopause even with irregular periods. Contraception is recommended until 12 months without a period if you are over 50, or 2 years if under 50.