Menopause is a natural change of life that begins when ovarian hormone production slows. This article describes what are the 3 stages of menopause. It is important to recognize the differences between premenopausal, perimenopausal and post-menopausal stage so you can receive optimal support and treatment during each phase.
What are the 3 Stages of Menopause?
Understanding the 3 stages of menopause is an important aspect of women’s health. There are three stages of menopause: perimenopause, menopause and post-menopause.
Pre-menopause is the stage before menopause when a woman’s ovaries are still working normally the menstrual cycle is regular and she is having predictable periods. This is the stage most women are in from puberty when their periods start, to their mid-30s to mid-40s when they begin to notice symptoms of perimenopause.
During the late pre-menopause there may be no symptoms but there is an increase in the hormone levels of follicle stimulating hormone (FSH) as the brain is needing to send higher levels of FSH to the ovaries so they can continue to function normally. Some women experience difficulty becoming pregnant during this phase.
Perimenopause: the first stage of menopause
Perimenopause is the transition period when a woman’s ovaries begin to produce less estrogen and progesterone. It is the period immediately prior to the final menstrual period when hormonal and body changes occur as well as women start noticing symptoms.
The symptoms can be subtle at first and look a lot like other conditions. Many women are treated for multiple conditions at this time, with multiple medications such as for poor sleep, creeping blood pressure, acne, low sexual drive rather than a recognition that these are all symptoms of perimenopause.
Can you get pregnant during perimenopause?
Yes you can. Even though your periods can become very erratic and spaced out during the perimenopause, you can still ovulate during some cycles. If this happens you may still become pregnant and so contraception is still needed during this time.
Perimenopause is divided into early and late phases.
Before women experience changes in the length or flow of their period, they may experience hormone related symptoms. Early perimenopausal symptoms begin as early as the mid 30s although many women experience them in their 40s.
What are the first symptoms of early menopause?
Early perimenopause symptoms are mostly related to higher estrogen levels. In early perimenopause there are early changes in the reproductive hormones especially erratic high swings of estrogen which cause symptoms associated high estrogen levels such as:
- cyclical breast pain
- menstrual migraines or headaches
- worsening pre-menstrual symptoms including mood changes
- mood swings or persisting low mood
- Sleep disturbance
- difficulty concentrating, remembering or brain fog.
- dry skin or dry eyes
- muscle and joint aches
- heavier periods
- weight gain
- reduced sex drive
Will my cycle change during early perimenopause?
As early perimenopause progresses most women also begin to experience changes in their cycle with the length of their cycles varying by more than 7 days.
What is Late Perimenopause?
As perimenopause progresses, the estrogen peaks gradually decline and women enter a lower estrogen state.
Late perimenopause usually happens close to the final 1-3 years before a woman’s last period. At this time, most women will have menstrual cycles that are shorter or longer than normal and may skip periods altogether.
During late perimenopause, FSH levels continue to increase as the ovaries produce less estrogen. As FSH levels rise, they stimulate the ovaries to produce eggs less frequently. As a result, ovulation becomes irregular and may eventually stop altogether.
What are the symptoms of Late Perimenopause?
Late perimenopause is defined by a woman having no periods for 60 days or more.
During the late perimenopause or menopausal transition, women are more likely to experience low estrogen-associated symptoms:
- hot flashes or hot flushes
- night sweats,
- vaginal dryness
- pain with sex
- low sexual desire or libido
- recurrent urinary infections.
During hot flashes women experience extreme heat, sweating and flushing. These symptoms are mostly experienced around the head, neck, chest, and upper back.
Hot flashes and night sweats are experienced by 60 to 80 % of women and can disturb sleep and significantly disrupt quality of life. Hot flashes and night sweats can be successfully treated with body identical hormone replacement therapy (HRT).
It is also during this phase where bone density starts to considerably decline (Berger 2008), which means the bones become more fragile, prone to osteoporosis and fracture. Commencing HRT during late perimenopause is also protective and slows this process.
Do I need hormone blood tests during perimenopause?
Your hormone blood tests are usually normal and variable during the perimenopause.
Some women do have high follicle stimulating hormone (FSH) during later perimenopause (>25IU/L).
As there are changes in sleep and metabolism during perimenopause it is useful to have your cholesterol and blood sugars checked during perimenopause as part of your annual well woman check.
The middle stage: when does Menopause occur?
Menopause occurs when a woman has not had a period for 12 consecutive months. It is diagnosed retrospectively, meaning that a woman is only considered to have experienced menopause once she has gone 12 months after her last menstrual period.
The average age of menopause is 51 years old, with most women experiencing menopause between the ages of 40 and 60.
What are menopause symptoms?
During the 12 months with no periods leading up to menopause it is likely that women will continue to experience low-estrogen symptoms of hot flashes, night sweats and vaginal dryness.
Until a woman is post-menopause they may still become pregnant, so it is important to continue to use birth control if pregnancy is not desired.
The final stage: what is Post-menopause?
Post-menopause is the period of a woman’s life after she has experienced menopause. The stage of life from 12 months after the final period.
Once a woman has reached menopause, her ovaries no longer ovulate or release eggs and she can no longer become pregnant.
Post-menopause is a low estrogen and progesterone state.
What are postmenopausal symptoms?
Once you reach post-menopause, you have not had a period for 12 months. You will likely continue to experience some menopausal symptoms, such as hot flashes and vaginal dryness. The hot flashes and night sweats settle on average 4.5 years after the final period.
The most common ongoing symptoms for postmenopausal women are symptoms relating to GSM – Genitourinary Syndrome of Menopause.
GSM symptoms include:
- vaginal dryness,
- recurrent urinary tract infections
- pain with sex
- Pain on passing urine
- vaginal itchiness or pain
- needing to urinate frequently
- needing to urinate urgently
Can Genitourinary Syndrome of Menopause be treated?
Many women feel these are symptoms of aging and just need to be put up with, but they can dramatically reduce a woman’s quality of life, her sense of wellbeing and sexual health.
These symptoms can be reduced by commencing HRT in the first 10 years after menopause and may continue through the post-menopause stage if HRT is not used. There are alternate treatments to HRT for those women for which HRT is not recommended.
If you experience menopausal symptoms that are interfering with your quality of life, talk to your healthcare provider about treatment options.
How long does postmenopause last?
The postmenopause stage lasts from 12 months after the last menstrual period till the rest of your life. Your hormone levels (estrogen and progesterone) will remain low and you’ll no longer have a monthly period.
What is Early Menopause?
Early menopause occurs when a woman experiences menopause, i.e. has no periods for over 12 months, between ages 40 to 45.
What is Premature Menopause or premature ovarian insufficiency?
Approximately 1% of women will experience premature or early menopause which is when menopause occurs before the age of 40.
If you have not had a period for more than 12 months and you are aged less than 40 years of age you should see your healthcare provider to investigate if this is premature menopause or another medical condition such as PCOS or thyroid disease.
What is medically induced menopause?
Some women experience a medically induced menopause which can occur earlier or more suddenly than a natural menopause. It can be caused by:
- removal of your ovaries
- removal of your uterus (hysterectomy) – even if your ovaries are still present because this surgery can reduce the blood supply to your ovaries.
- radiation to the pelvis.
What are the treatments for menopause?
There is no one-size-fits-all approach to treating menopause. The best treatment varies from woman to woman depending on her individual symptoms and health risks. This is why individualized advice from your doctor is important.
There are a number of treatment options available that can help alleviate the symptoms of menopause and reduce the associated health risks. These include hormone replacement therapy (HRT), lifestyle changes such as exercise and diet, and complementary therapies such as acupuncture or herbal supplements.
Hormone Replacement Therapy for Menopause
Hormone therapy is the most effective treatment for menopause. It can be taken in the form of pills, patches, or creams. Read more about HRT here.
There are two main hormones used for hormone replacement therapy: estrogen and progesterone. Estrogen can be taken alone or in combination with progesterone. The safest form of estrogen therapy is estradiol that is in a form that is absorbed via the skin or the vaginal. Oral estrogen increases the risk of blood clot but estrogen via the skin or vaginal does not.
Vaginal estrogen is an effective low-dose HRT treatment for menopause. It comes in the form of a cream, tablet, or ring that is inserted into the vagina. Vaginal estrogen can help with vaginal dryness, itching, and burning. It can also help with urinary incontinence and sexual dysfunction.
Estrogen can be given via the skin as a patch which is worn for half the week or a gel which is used daily.
Oral estrogens are the less preferred form of estrogen for anyone at risk of a blood clot as they can increase this risk.
Micronized progesterone is body identical progesterone. It is taken orally and is usually taken at night as it is metabolized to allopregnanolone which is a neuro-steroid that supports sleep.
Alternatives to micronized progesterone include oral synthetic progestins.
Low-dose antidepressants are often prescribed for menopausal symptoms such as hot flashes and night sweats. They can also help with mood swings and anxiety. Gabapentin: Gabapentin is a medication that is sometimes used to treat hot flashes and night sweats.
How can menopause be supported?
A healthy diet is important for supporting menopause. Eating plenty fiber from fruits, vegetables, whole grains, beans and legumes supports a healthy gut, and hormone metabolism. Eating lean protein can help reduce the risk of heart disease and diabetes.
Regular exercise is also important during menopause. Getting at least 30 minutes of moderate exercise each day can help strengthen bones and maintain muscle mass which prevents frailty and fractures. It also keeps the heart and brain healthy.
Certain supplements may support you through the menopause. Taking a multivitamin every day can help ensure that you’re getting all the nutrients you need. Additionally, taking vitamin D supplements if you cannot get good UV exposure from the sun can help reduce the risk of developing osteoporosis.
Some women also find that avoiding triggers such as hot weather, hot showers, reducing caffeine and alcohol intake and spicy foods can reduce hot flashes. Relaxation techniques can also help with the increased anxiety and mood changes associated with menopause.
What are the health risks of menopause?
When women go through menopause their lose the protective effects that estrogen and progesterone have on their health. This lack of hormones creates low grade inflammation in the body and set up the body for the development of disease in later life. Women who have experienced the menopause are at increased risk of:
- heart disease & stroke
- MS, autoimmune thyroid disease
- cognitive decline such as Alzheimer’s disease
Can the health risks of menopause be reduced?
The health risks of menopause can be reduced by maintaining a healthy lifestyle and by using HRT. Maintaining a healthy lifestyle means eating a diet with diverse plant foods and lean protein, exercising regularly and getting enough sleep.
Hormone replacement therapy can also help reduce the risk of some diseases such as heart disease, stroke and osteoporosis. HRT should be individualized and the risks and benefits discussed with your doctor.
If you are going through menopause or are postmenopausal, it is important to have regular checkups with your doctor so that any health concerns can be identified early and managed accordingly.
Frequently asked questions about menopause
Is HRT a form of contraception?
The only form of HRT that acts as birth control is the Mirena©️ intrauterine device (IUD) or other similar hormone containing IUDs. The Mirena©️ IUD contains a progestin called levonorgestrel. It is licensed to be used in the US for contraception that lasts 8 years.
All other forms of HRT are low dose hormones designed to replace your hormones at levels similar to during your reproductive phase.
How long does menopause last?
The hot flashes and night sweats of menopausal transition lasts 7.4 years on average, and over 10 years for some women (Avis 2015). However the symptoms of high estrogen can occur years before the vasomotor symptoms begin.
The postmenopause state lasts from 12 months after the final period for the rest of your life. Some women continue to experience symptoms of low estrogen through the postmenopausal stage of a woman’s life without use of HRT.
Wherever stage of menopause you are in, we wish you well with your health and wellbeing.
Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.
Berger C, Langsetmo L, Joseph L, et al. Canadian Multicentre Osteoporosis Study Research Group. Change in bone mineral density as a function of age in women and men and association with the use of antiresorptive agents. CMAJ. 2008 Jun 17;178(13):1660-8.
“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.