Menopause transforms the body, and science is finally beginning to understand it.

Menopause transforms the body, and science is finally beginning to understand it .

what occurs in the body before, during,and after menopause and how to navigate this transition smoothly?

Women typically experience menopause in their fifties, marking a significant hormonal shift. Despite its prevalence, affecting over half of the global population, menopause has long been a taboo subject. Nanette Santoro, chair of the Department of Obstetrics and Gynecology at the University of Colorado School of Medicine and a seasoned menopause researcher, notes that only recently has there been more open discussion about menopause, both among those going through it and in the media.

Our current knowledge of menopause largely stems from the SWAN (Study of Women's Health Across the Nation), an epidemiological study that has tracked nearly 3,000 women in the United States since 1994. While this study has provided valuable insights, Santoro emphasizes the need for larger studies to answer the many remaining questions. For example, SWAN found that women who frequently experience hot flashes are at a higher risk for cardiovascular disease. The study also confirmed that during menopause, lean body mass tends to decrease while fat mass increases, even if overall weight doesn’t change significantly.

Further research has shed light on the causes and biological processes behind hot flashes, a common symptom of menopause. Scientists from the University of Arizona, the University of North Carolina, and other institutions discovered that the drop in estrogen levels in the hypothalamus—a part of the brain—leads to the enlargement of specific neurons. This enlargement causes disturbances in the areas of the brain responsible for regulating body temperature. This discovery is promising for developing new, non-hormonal therapies targeting these symptoms.

The Origins of Menopause

From birth, every woman has all the eggs (oocytes) she will need throughout her life stored in her ovaries. These eggs are surrounded by granulosa cells, which are responsible for producing hormones like estrogen. As women reach their forties, both the number and quality of their eggs begin to decline, and the production of estrogen decreases.

This decline, along with less frequent egg release, leads to irregular menstrual cycles. When several menstrual cycles are delayed by a week or more for several months, this stage is referred to as perimenopause (or premenopause).

This phase typically begins between the ages of 45 and 50, but it can start as early as 40 or as late as 55. The duration of perimenopause can range from two to eight years. According to Nanette Santoro, it's the fluctuations in hormone levels rather than their absolute decrease that trigger the symptoms associated with menopause.

During this phase, fertility decreases, but ovulation (and therefore the possibility of pregnancy) can still occur. The North American Menopause Society (NAMS) recommends continuing contraception during this period for this reason 

What Does the Term "Menopause" Mean?

While many women refer to the entire process as "menopause," the term actually describes the point when estrogen levels drop so low that ovulation and menstruation stop permanently. To determine if a woman has reached menopause, some doctors check the levels of follicle-stimulating hormone (FSH), which increase as ovulation decreases. However, this marker isn't entirely reliable since the levels can fluctuate, as explained by Jackie Thielen, director of the Women’s Health Specialty Clinic at the Mayo Clinic. After reaching menopause, women enter the postmenopausal phase, which lasts for the rest of their lives.

Early Menopause

A small percentage of women naturally enter menopause before the age of 40, a condition known as "early" menopause. Additionally, some women may experience immediate menopause after undergoing medical treatments that remove or significantly damage both ovaries, such as cancer surgery, chemotherapy, or radiation therapy. According to the North American Menopause Society (NAMS), the symptoms of menopause induced by these treatments are typically more intense due to the abrupt hormonal changes.

COMMON MENOPAUSE SYMPTOMS

Hot Flashes: Up to 80% of women experience hot flashes, a type of vasomotor symptom (VMS) characterized by a sudden, intense feeling of heat in the upper body, which causes the skin to flush due to blood vessel expansion. These hot flashes typically last between 1 and 5 minutes and can occur several times a day. Night sweats, a related symptom, occur during sleep and involve heavy sweating. While hot flashes may cease when a woman reaches menopause, they can persist for up to ten years or more. Some women are only mildly affected, but others find them debilitating. "These symptoms are significant. They affect many aspects of women’s lives, including their relationships and work performance," says Stephanie Faubion, director of the Mayo Clinic Center for Women’s Health and medical director of NAMS.

Sleep Problems: According to the Office on Women’s Health at the U.S. Department of Health and Human Services, fluctuations in progesterone levels can make it difficult to fall asleep and stay asleep. Night sweats can also disrupt sleep.

Mood Changes: Studies indicate that depression rates can double in women going through perimenopause or menopause compared to those not yet at this stage. It’s unclear whether these mood changes are directly linked to hormonal shifts, related to the emotional impact of losing fertility, or due to other factors. Experts have observed that women who experience hot flashes and night sweats may also be more prone to depressive symptoms. Even women who are not usually prone to depression might experience irritability or unexplained crying spells. Those who have had mood swings during their menstrual cycle or after childbirth are especially vulnerable.

Vaginal Changes: Pain during sex may occur due to thinning vaginal tissues from reduced estrogen levels. This, along with similar dryness in the bladder and urethra, is known as genitourinary syndrome of menopause (GSM). While most menopause symptoms eventually fade, GSM causes lasting physiological changes, according to Santoro.

WHEN DO THE SYMPTOMS START?

The SWAN study indicates that most symptoms emerge or become more pronounced during the late stage of perimenopause. However, a 2021 online survey reveals that symptoms can appear earlier, sometimes even before noticeable changes in menstruation. "This research has shown many women that their feelings are valid even if they still have regular periods," notes Faubion, who was not part of the study.

WHAT ARE THE POSSIBLE TREATMENTS?

Simple lifestyle changes can help many women manage this transitional phase. To alleviate hot flashes, try wearing layered clothing, practicing slow and deep breathing, and drinking cold water at the onset of a hot flash. High body fat has been linked to more severe hot flashes, so weight loss might benefit those who are obese or overweight. Smoking has also been associated with more intense hot flashes.

For better sleep quality, maintain a consistent bedtime, avoid late afternoon naps, and limit caffeine and alcohol in the evening.

Several mind-body techniques have proven effective, such as hypnotherapy, which can significantly reduce severe hot flashes, and cognitive-behavioral therapy (CBT), which can decrease their frequency.

Research indicates that herbal remedies and other traditional menopause treatments are "unlikely to relieve hot flashes," according to the North American Menopause Society (NAMS).

When symptoms have a significant impact on a woman's life, medical treatment may be necessary. Women in perimenopause may be prescribed contraceptives to provide higher levels of the same hormones needed to prevent pregnancy (estrogens). Postmenopausal women might receive menopausal hormone therapy (MHT), usually in the form of patches or pills, as explained by Faubion.

Many doctors hesitate to prescribe MHT due to the well-known findings of the Women's Health Initiative study from 2002, which reported increased risks of heart disease, breast cancer, and stroke in women taking estrogens and progesterone, particularly after menopause. However, the medical director of NAMS notes that this study was not designed to assess whether younger women with these symptoms could benefit from MHT. Subsequent evaluations have challenged the Women's Health Initiative's conclusions about the risks of MHT.

"If a woman is under 60 and within ten years of menopause, the benefits of hormone therapy generally outweigh the risks," says Faubion. This may not apply to those with a history of breast cancer, uterine cancer, liver disease, heart disease, stroke, blood clots, or smoking, who should discuss their personal situation with their doctor.

Other medications for menopause, such as clonidine (used for high blood pressure) and gabapentin, have shown some benefits. A targeted, non-hormonal treatment called fezolinetant, developed to address hot flashes originating in brain neurons, is currently under review by the U.S. Food and Drug Administration (FDA). Early research suggests it might reduce weekly hot flashes by 45%.

Genitourinary syndrome of menopause (GSM) symptoms can be treated with vaginal moisturizers or vaginal estrogens, a method that seems safer than systemic hormones, according to Thielen. Pelvic floor therapy and laser vaginal treatments (to stimulate blood flow) are also promising options, according to MyMenoPlan, a website created by a network of menopause researchers and funded by the U.S. National Institutes of Health.

As menopause symptoms can persist for years, it’s important to accept this new reality to adapt effectively, says Thielen. "The experience of menopause is about managing the loss of estrogen and learning to live with levels that are initially unstable and then low."