Introduction

photo of woman (PantherMedia / Markus Nicolini)

The balance of hormones in a woman’s body changes during menopause. Many processes in the body are regulated by hormones, and it can take some time to adapt to the changes. These changes are sometimes associated with menopause symptoms such as hot flashes (also called “hot flushes”), sleep problems or mood swings. There are a number of different options for relieving these symptoms. Women's experiences of menopause vary greatly, and only a few have severe symptoms that last a long time.

Around their mid-forties, women’s bodies gradually start making less of the female sex hormone estrogen (also spelt “oestrogen”). Their monthly periods become less regular and eventually stop completely. A woman has reached menopause when she has had her last period. The word “menopause” might be misleading because it is not a “pause,” but an ending. Women can no longer get pregnant after menopause. The average age of menopause is 51, although some women might go through it much earlier, or a little later. Many women are happy that the hassle of contraception and periods are now a thing of the past. But the idea of no longer being "fertile" can also feel like closing a chapter in your life.

Menopause is often accompanied by other significant life changes: Children are becoming more independent or have already moved out, and some couples have to re-connect with each other. Some women make major career changes, and others may take a step back because their parents need their support. It becomes more apparent that your own body is gradually aging. So the hormonal changes are not the only reason why menopause is a time of physical and emotional change.

Symptoms

Up to two-thirds of women will have hot flashes and sweats during menopause. These are the most common symptoms. They can make it difficult to sleep if they occur at night. Some women have hot flashes that they barely notice, while others might have such severe and frequent hot flashes that they really affect their daily life. Hot flashes last about three minutes on average. Their frequency, severity and duration can vary from day to day.

Hot flashes and sweats usually keep occurring for more than one year. Without treatment, they stop on their own after about four to five years. A few women have them for longer.

The lining of the vagina changes around menopause too. It usually becomes thinner and drier.

Other symptoms include trouble falling asleep or sleeping through the night, mood swings and depressive moods. Some women may also have less sexual desire during menopause. Many women gain a bit of weight around this time.

Causes

Throughout their reproductive years, women’s ovaries produce the female sex hormones estrogen and progesterone. These hormones not only prepare the womb (uterus) for a possible pregnancy, but they also affect things like the skin and mucous membranes.

Every month a new egg matures inside a follicle in an ovary. The follicle produces hormones itself. If the mature egg is not fertilized after it is released from the ovary (ovulation), the woman has a menstrual period. During the time leading up to menopause the ovaries gradually make less and less hormones. A woman has reached menopause when her ovaries stop releasing eggs.

It is thought that all of the egg cells a woman will ever have are already inside her ovaries when she is born. There is probably a link between the time when a woman reaches menopause and the time when her supply of egg cells is used up. Before the age of about 40, the number of follicles that mature decreases gradually. After that, the number decreases quite quickly, until no more follicles mature.

Women might go through menopause at a younger age as a side effect of a treatment, such as the removal or radiation of both ovaries in the treatment of cancer. This is known as induced or artificial menopause. The symptoms of induced menopause are usually very similar to those of natural menopause.

Outlook

The start of the menopausal transition can be so subtle that some women do not notice any changes at all. But others have very noticeable physical symptoms. Their periods might sometimes be lighter or heavier, or the gaps between periods might become irregular.

On average, women have their last menstrual period at the age of 51. Until then they can still get pregnant. You can only really know that it was your last period in hindsight. As a rule of thumb, if you have not had a period for twelve months in a row, you very likely reached menopause when you had your last period. Menopause before the age of 40 is called premature menopause.

The one or two years leading up to a woman’s last menstrual period is called perimenopause or pre-menopause, and the time afterwards is referred to as post-menopause. Her body gets used to the new balance of hormones during this time. The length of this process varies from woman to woman, but it usually takes a few years. Another word that is sometimes used to describe this phase of life is “climacteric.” This comes from the Latin word for the step of a ladder, which is an ancient symbol for “a critical point in life.”

There is some evidence that the age of menopause might be genetically determined. This means that mothers and daughters experience menopause at about the same age. Other factors probably influence when menopause starts as well, such as how many times a woman has given birth. This would also explain why women in developing countries where the birth rate is higher reach menopause at an earlier age.

Women who smoke a lot may go through menopause earlier too. Being underweight or overweight and the length of a woman’s menstrual cycle are also believed to influence when her menopause starts. But there is no clear evidence here.

Effects

As estrogen levels fall, the risk of osteoporosis increases, because the female sex hormone helps to protect bone tissue. But bone strength depends on more than just hormone levels:

As the vaginal lining become thinner and drier, it is less protected from bacteria and other germs, making it more susceptible to infection.

Sex can be uncomfortable if the vagina is not lubricated well enough through arousal. But sexual changes around this time of life are not only due to menopause. Relationships play a big role too.

Many of the physical and emotional symptoms of menopause are not related to changes in hormone levels. There is no scientific proof to support the assumption that menopause could increase women's risk of cardiovascular disease. Many menopausal women have a higher risk of cardiovascular disease than they used to, but that’s more likely to be because they are getting older. There is also no real proof that concentration or memory problems are due to the menopause.

Menopause can also have positive effects, although they often go unmentioned: It makes contraception and menstrual problems a thing of the past. The latter can really improve quality of life in women who previously had very heavy and painful periods or endometriosis. Migraines sometimes go away after menopause too.

Diagnosis

If a woman would like to know for sure whether she has entered menopause, a doctor can measure the levels of various hormones in her blood. The overall level of estrogen gradually decreases during menopause. This changes the balance between estrogens and other hormones. The body also reacts to the reduction in estrogen by producing more of another type of hormone called follicle-stimulating hormone (FSH). These changes are typical during menopause.

But checking hormone levels has little practical value: They can't be used to tell whether a woman can still get pregnant and how long she has to keep using contraception for - or whether she should have treatment if she has menopause symptoms.

Treatment

Menopause symptoms can be relieved in various ways. In most women, though, things like hot flashes, sweats and mood swings lessen over time and then go away completely without any treatment. Menopause is not an illness. It is normal for hormone levels to fall in middle age.

There are a lot of herbal medicine products for the relief of menopause symptoms. These are often available in the form of dietary supplements. They have not been proven to work. The best-researched herbal products are those containing plant-based estrogens, known as phytoestrogens. These include soy-based products. But it is not clear whether they actually help relieve menopause symptoms. This is true of products containing red clover and black cohosh (Cimicifuga racemosa) too. There is also no proof that certain foods can make menopause symptoms better or worse.

The currently most effective treatment for menopause symptoms is hormone therapy with a combination of estrogen and progestin, or with estrogen alone (for women who have had a hysterectomy).

But the symptoms often come back when women stop using the hormones. Women might have spotting, breast tenderness and/or nausea in the first few months of hormone therapy. Having hormone therapy over several years may also increase the risk of various serious diseases such as cardiovascular disease and breast cancer.

Hormones are available in the form of tablets, patches, nasal sprays and injections. These enter the blood stream and can therefore travel around the whole body. Problems affecting the lining of the vagina can be treated locally with hormones in the form of creams, suppositories or vaginal rings. Hormone-free alternatives include plant oils, lubricants and creams to relieve vaginal dryness.

Antidepressants and the hormones testosterone and DHEA are sometimes used to relieve menopause symptoms too. It is not clear how effective they are. But they can have considerable side effects. Most of them have not been licensed for the treatment of menopause symptoms in Germany.

The hormones that are used to relieve menopause symptoms do not prevent women from getting pregnant.

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Everyday life

Many women try out things like relaxation techniques, breathing exercises, meditation, yoga and tai chi to help them get through this sometimes difficult time of life. Although these activities will probably not relieve symptoms such as hot flashes, they might improve women’s overall wellbeing and help them sleep better. The same is true for sports and exercise: Physical activity has a positive effect on your cardiovascular system and bones, improves overall fitness, muscle strength and mobility. Exercise can also help you maintain a healthy body weight, or lose weight if you are overweight.

Even though the often negative perception is gradually changing, menopause is still mainly associated with growing older and the related problems. But many women see menopause as the start of a new phase of life. Not all women have menopause symptoms or other problems during menopause. And some women even discover a new sense of freedom and new opportunities during this phase of their lives.

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Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and counseling services?”

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