What is menopause?
I am a doctor, but the reality of experiencing perimenopause and menopause still caught me by surprise.
It’s one thing to have educational knowledge about menopause, but completely different to be experiencing it.
Looking back, I started to notice changes in my body and menstrual cycle in my mid 30’s. Even with my medical training, I did not recognize what was causing it at the time.
I wish I had identified it then, as I would have made some helpful changes much earlier.
In this article, I’ll be covering the nuts and bolts of menopause. My hope is to give you information I wish I’d had in my 30’s and 40’s, that you can use right now to improve your wellbeing.
What is Menopause?
The simple answer is that it’s when your periods have finished forever!
It gets a bad rap, but lets just celebrate for a minute that you no longer need to manage monthly bleeds :)
Menopause is defined as the date of your last menstrual period. Of course you won’t realize it was your last one until 12 months later.
Once 12 months have gone since your last period, you are officially post menopausal and can stop using contraception.
Any vaginal bleeding that occurs after this time is considered to be abnormal and needing a further check-up with your doctor.
Why menopause happens:
It’s kind of amazing to realize that when we’re born, female babies already have all the eggs we will ever need present in our ovaries. In fact, by 9 weeks gestation (9 weeks of pregnancy), a female fetus already has all her eggs formed.
After puberty, each month we release an egg from one of our ovaries. If this is not fertilized (falling pregnant), we have our period.
Commonly somewhere between the ages of 45 and 55 years old, ovulation (an egg being released) stops and the amount of hormones being produced by our ovaries drops.
Did you know that you actually still have around 1000 follicles containing eggs in your ovaries when your periods stop in menopause? Women often think they have “run out of eggs” but in fact their ovaries are just getting older and unable to respond to hormones like they did when younger. This means they can’t release the remaining eggs.
The average age that women experience menopause is 51 years old but any age from 45 onwards is considered normal.
What is the earliest age for menopause?
Some women can go through menopause early (between 40 and 45 years old).
If menopause happens before the age of 40 it is considered significant early menopause - also called Primary Ovarian Insufficiency, or POI (this term basically means the ovaries are stopping working prematurely). This is different from normal menopause but can have similar symptoms.
What are the chances of a women having POI? Around 1 in 1000 women will go through menopause before the age of 30 and 1 in 100 women under the age of 40.
It carries some increased health risks so needs to be carefully assessed and managed. I’ll cover this in more detail in a later blog article.
The most important thing you need to know about this now is that if your period stops for more than 3 months, you are under the age of 40, and you are not pregnant, you need to see a doctor to get this checked out.
What is “surgical menopause”?
Some women can enter menopause early because they need surgical removal of their uterus/womb and/or ovaries, or have had chemotherapy or radiation for cancer. There is evidence that women who enter menopause in this way may have more severe symptoms.
I can say from personal experience and also from having talked to lots of women in my clinic, that women are often discharged from hospital after a hysterectomy (surgery to remove the womb) with the advice to “Just see how you go!” from their specialist.
My answer to that piece of advice is it usually does not go well. I’m not suggesting that every woman will need hormone replacement after this treatment, but that the odds are more likely that you will need it.
Within three months of having my surgery, I noticed a marked increase in symptoms. Before, I had suffered from occasional night sweats and frequent heavy bleeding. After the surgery, I started to get frequent hot flushes with nausea, had palpitations which made me feel as though I was going to pass out (scary!) and was struggling at work because I kept forgetting what we were talking about, and the names of important things like medications I needed to do a prescription for.
I was also waking frequently overnight feeling as though I was choking (little did I know I was developing sleep apnoea - a condition which becomes more common in women after menopause).
Like many women, I initially saw menopause as “a normal change of life” and wanted to try and manage as naturally as I could. In hindsight, given how many symptoms I had, I would have sought help from a doctor experienced in menopause a lot earlier.
How menopause starts and the 3 stages of menopause:
This is the bit I wish I’d known more about in my 30’s!
(Diagram from Lara Briden’s Hormone Repair Manual)
The menopause transition can be divided into three stages:
Perimenopause : the ovaries are working less, or only intermittently, with reduced hormone production. Periods can be irregular for some people, and symptoms of menopause may begin. This can happen as early as your late 30’s.
Subtle changes in your cycle can start even before perimenopause becomes obvious. This is something that is often missed by women. The cycle may get longer or shorter, or the bleeding during your period may be heavier or lighter.
It also starts to become more difficult to conceive.
It’s important to recognize this stage because it gives us the opportunity to take proactive steps to protect our long term wellbeing.
In particular we can put strategies in place to protect our bone health, our mental health, and our metabolic and heart health.
The other important thing to consider in this stage is that the transition is going to happen over a period of years.
I have often met women in clinic who are struggling through severe symptoms in their 40’s but who are hoping that “things will settle soon because I’m nearly 50”. I can totally sympathize because I did the same thing!
(PS: remember realistically that some women won’t have their last period until the age of 55, and maybe even later!)
What I wish I’d been able to tell my younger self and I now often tell women is that it’s likely to be a marathon rather than a sprint, so not to put off seeking help. The other reason I wish I’d known earlier is because I would have done more to protect against muscle and bone loss and entered post menopause in better shape both physically and mentally.
The good news is that even if you missed the opportunity that perimenopause presents, it’s not too late to start improving your health and it is possible to do this.
Menopause : the date of your final period.
Also the date when many women expect they’ll be done and dusted, and they are distressed if they find their symptoms seem to be ongoing. I often get asked “Why am I still having symptoms? I haven’t had a period for months!”
Post menopause: actually starts straight after your final period, but you won’t be able to confirm this until 12 months have passed (since your last period). It lasts for the rest of your life.
Some symptoms such as hot flushes and sweats eventually settle, but often joint and urinary/vaginal symptoms may continue and worsen with age unless treated.
What are the signs and symptoms of menopause?
We think of our hormones as only affecting our reproductive organs, but they also have many other functions in our body and brain.
This is why menopausal symptoms can affect so many parts of our bodies, as well as mood and thinking.
Common signs and symptoms can include hot flushes, night sweats, changes in your menstrual cycle leading up to periods stopping (bleeding may be irregular, heavier or lighter than usual), vaginal dryness, bladder irritation and urinating more frequently, dry skin, weight changes with increasing abdominal weight.
What surprises most patients is that other less common symptoms can also be due to menopause: like thinning hair, mood changes, insomnia (trouble sleeping), dry/itchy skin, tinnitus (ringing in ears), headaches and aching joints or muscles.
Not everyone will get these symptoms. Some women may get all of them!
Everyone’s experience is different, depending on their genetics, lifestyle, other health conditions, life stresses and mental health.
What I do know from experience treating many women: the more knowledge and support women have in transitioning through menopause, the more relaxed and empowered they feel, because when their troublesome symptoms occur they have a plan.
Can you get pregnant after menopause?
For understandable reasons, this is a question I am often asked!
If you are over 50 years old and 12 months have passed since your final menstrual period, it is considered safe to stop using contraception. It is rare to fall pregnant naturally after this. In many years of clinical practice seeing patients I have not personally cared for anyone who has fallen pregnant post menopause.
There have been very rare cases reported worldwide of women falling pregnant after menopause (interestingly the total number of such cases over the whole global population was 745 pregnancies between 1997 and 2018 - around 35 cases per year for 1.2 billion women)
Some of these cases were thought to be due to hormone replacement therapy (HRT, MHT) triggering ovulation.
This is another reason why women are advised to see their doctor for a check-up if they develop bleeding after menopause, especially if they are on hormone replacement.
There is a higher risk of an unplanned pregnancy during perimenopause, when the menstrual cycle is less regular. Many women think if their periods are less frequent and lighter that it is less likely they can fall pregnant, but this is not the case.
Careful contraception is advised until at least 12 consecutive months without a period.
It is possible to fall pregnant after menopause with assisted reproduction (IVF) but this does require hormonal supplements and careful medical care as these pregnancies carry a higher risk of complications for both the mother and baby. Often donor eggs are required for a pregnancy because an older women’s own eggs may no longer be viable.
If the uterus is healthy it can carry a pregnancy with appropriate hormonal support regardless of a woman’s age.
How can you test for menopause?
The honest answer is that lab testing for menopause can be unreliable because women’s hormone levels fluctuate daily. One day your hormone levels may be normal and the next not. This makes relying on blood tests for diagnosis difficult.
If you are over the age of 45 years old, have the typical symptoms of menopause, and other possible causes of your symptoms have been excluded, you can be diagnosed without hormone levels needing to be checked.
Blood tests can still be useful to rule out other causes of your symptoms (for instance, thyroid problems can cause weight changes, tiredness, and hot flushes also).
There are a couple of situations where I find checking hormone levels is important:
If you have primary ovarian insufficiency or POI (your periods stop before the age of 40) it is important to have testing done to exclude other causes of absent periods, and confirm the diagnosis of POI.
It can also be useful when women aged over 40 have significant mood changes and we need to figure out together whether they have a primary mood disorder like depression/anxiety, or whether a lack of estrogen is underlying the change in mood. Unfortunately some women are told they have depression without exploring the possibility that it might be a menopausal symptom that could potentially be treated with MHT/HRT.
What can you do to prevent menopause?
This is another hot topic often asked in clinic!
Basically this is a life stage that you can’t prevent, but there are lifestyle factors you can change if you want to reduce the risk of going into early menopause.
We know that genetics is the main factor which influences when you are likely to enter menopause.
One of the best predictors is the age your mother went through menopause.
Smoking increases your risk of having early menopause.
Breastfeeding your baby for 7-12 months can reduce your risk of early menopause.
A healthy diet which is high in omega three fats and antioxidants may contribute to delaying the age of menopause.
One sad thing I hear often in clinic:
Women often come in apologizing to me and saying they “don’t want to waste a doctor’s time”.
What I’d like to reply to this is that no woman is wasting my time.
I have a couple of questions for you:
Would you want your daughter or friend’s daughter to go through puberty without information, explanation, reassurance and support? Would you expect them to cope with mood swings, heavy bleeding and pain if they had these problems, without addressing them?
I think all of us would answer “no”!
We need to treat ourselves the same way as we would a daughter or another loved one.
Remember we are often the glue holding our families and communities together. It’s OK for us to ask for the support we need to feel healthy and enjoy life.
What to do next:
This week
Download my free Menopause symptom tracker (click the button at the bottom of this page) and log your symptoms for 2 weeks.
Write down your top 3 questions for a consultation
Before your appointment
Review your symptom tracker and identify your biggest quality of life symptom
Note what you’ve already tried and whether it helped
Think about your goals (better sleep?, reduced anxiety? less hot flushes?)
During your consultation
Share your symptom patterns (I love data!)
Discuss your concerns about different treatment options
Ask about expected timelines for improvement
Clarify a follow-up plan and when to check in
Ready to talk? Book your consultation by clicking the button below this blog.
I’ll review your symptom history and we’ll create a personalized treatment plan together.
