The Menopause Wiki

The official menopause wiki for Lemmy's c/menopause community, and its Reddit siblings, r/menopause and r/perimenopause.

The following information is intended for educational purposes only, to provide a basis on which to further explore with your doctors. It is not a substitute for professional medical advice.

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Find a menopause practitioner at the following menopause societies or check our Menopause Provider Directory for more

Introduction

Menopause is not a disease, it is a natural biological process, experienced by half the population. Medical intervention is not always necessary, but it’s important to educate ourselves on what to expect so that we can make informed decisions throughout the transition.

Due to the recent ’re-awakening’ of menopause in social media, there are many conflicting and confusing views on menopause and how to manage symptoms. This Menopause Wiki provides s balanced introduction so that you can arm yourself with knowledge, and feel the empowerment in taking charge of your own journey.

Menopause is different for everyone

Doctors recommend checking with your mother as an indicator of what to expect, but this may not be an accurate gauge; your experience might be more in line with sisters instead. Similarities shared during upbringing and exposure to the same lifestyle/environment are better predictors of how you might experience symptoms, but the age at which your mother reached menopause may be similar to yours. Either way, asking the women in your family could help to plan ahead. Some women breeze through the menopause transition with few or no symptoms, while others experience debilitating symptoms for a decade or longer; most fall somewhere in-between. The transition is often described as “reverse puberty” and this is most apt. Therapies that work for some women may not work at all for you.

No one talks about it

Our mothers/aunts/grandmas never discussed what they went through. Older generations felt it was largely taboo to discuss ‘delicate’ women’s issues. Others simply didn’t associate many of the common symptoms to hormonal changes, or their brain fog made them forget entirely! This knowledge gap has lead to a new generation of women who know little-to-nothing about this major change in our lives. Almost everyone relates menopause to two things: (1) hot flashes and (2) periods ending (freedom from all the mess and pregnancy worry), when in fact one of the most common symptoms of menopause (and rarely heard of) is “atrophic vaginitis”, the thinning, drying and shrinking of your vagina…horrifying right?! For many coming into perimenopause (the time before menopause), we first notice subtle changes in our cycles and in our bodies and moods, but have no idea what is going on. This is why it is so important we talk about menopause, not only for those of us experiencing it, but also for the next generation of women who are worried and confused about what’s happening to their bodies and are too afraid to seek help. Collectively we can move beyond the realizations that we’re not crazy, or worse, dying, and seek help without barriers.

Medical professionals know very little about women’s health in general, and even less about menopause

Most medical professionals are woefully inadequate in recognizing menopause, and even less equipped in offering advice or treatment options. In fact, only a small fraction of doctors receive any formal training in menopause medicine, and even then it’s only a brief chapter in medical school; some gynecologists also struggle to identify menopause. Due to this lack of training and knowledge, less than 15% of women receive effective treatment for their symptoms. Doctors are quick to prescribe antidepressants and pain medication for what sounds like depression/anxiety and ’normal aging’ aches and pains. Doctors can be very dismissive when presented with symptoms so it is important to know what you want and be persistent.

Note: Arm yourself with knowledge – read research, form a network (talk to your friends and relatives), and know that when you enter perimenopause, you are not crazy and you are not alone!

The menopause transition (climacteric, means the change)

1. Perimenopause (the start of the change)

Occurs usually between the ages of 40-50 (can be earlier) and is the time leading up to menopause. The average length of this stage is anywhere between 4 and 8 years. Hormones (estrogen, progesterone and testosterone) wildly fluctuate and physical changes occur, including the length of time between periods.

The menopause transition occurs over a number of years in two phases (1) the early phase and (2) the late phase.

Note: Periods can become quite heavy in perimenopause, these are often called “super-soaker events” and soaking through two pads an hour for two hours requires medical investigation.

Not sure if symptoms are hormone-related? See… is this perimenopause?

2. Menopause

Occurs usually between the ages of 45-60 when one full year (12 months) has passed without a period. According to meta-analyses of global data (2024), the mean age of reaching menopause (aka post-menopause) is 48.8 years (Europe is 51), but typically it can be between the ages of 45 and 55.

Early (non-surgical) menopause, before the age of 45, is often influenced by other factors, such as social class, mother’s smoking, and those who smoked in childhood and early adulthood and early menopause carries other risk factors.

In menopause, ovaries have stopped producing estrogen, or only produce a very small amount. Around this time testosterone slows, resulting in decreased sex drive. You reach menopause on the one day…the day after 12 months without a period. Once menopausal, there is no magic “yay” moment where all other symptoms stop too and life goes back to normal. In fact, many women continue to experience all the same symptoms as before (just without periods), and these symptoms can carry on for years or even decades beyond that last period. Even if symptoms resolve around this time, physically and mentally we may feel different.

Note: If spotting occurs when nearing that 12 month mark, the clock resets back to one month and the count starts all over again - which does happen and is very frustrating. Also if any bleeding occurs after 12 months of not having a period, you must see your doctor to have tests done. Any bleeding beyond the 12 months is not normal and should be investigated.

Induced/surgical menopause

Occurs at any age when a woman’s ovaries are removed or badly damaged due to a medical treatment such as chemotherapy or radiation. When hormone-producing ovaries are removed, women are thrown into immediate menopause, which is a shock to the body and can be very debilitating and may have permanent, significant repercussions on health if not treated.

When a woman has a hysterectomy (removal of the uterus and/or cervix), she sometimes has her ovaries removed as well, and sometimes not. In cases where one or both ovaries are retained, the woman will most likely continue to have ovarian function and not be menopausal, though in some cases, the shock of the surgery might hasten menopausal changes. When both ovaries are removed, immediate menopause occurs which is quite debilitating. In women who have had a hysterectomy, they cannot rely on vaginal bleeding patterns to assess menopausal status, so testing FSH levels may be helpful. There is no definitive blood test to diagnose menopause, but repeated hormonal tests over a period of time may provide some insight.

3. Post-menopause

Occurs usually between the ages of 45-60 when more than one year has passed without a period. This is also the same day as reaching ‘menopause’ (above). Despite no longer having periods, we can continue to experience varying degrees of symptoms beyond that last period. Even in post-menopause, our ovaries still produce very small amounts of estrogen but not enough for pregnancy to occur. While hormonal swings settle down and some symptoms may improve, post-menopausal women are now faced with increased risk for diseases, particularly heart disease, osteoporosis (bone loss) and dementia to name a few. The average age of becoming menopausal (aka post-menopausal) is 48-51 years old, and because of increased life expectancy, women can expect to spend approximately 40-50% of their lives in a post-menopausal state. It is estimated that by 2025 more than one billion women globally will be in perimenopause or post-menopause.

Note: any post-menopausal bleeding/spotting is not normal and should be evaluated by your doctor. Oftentimes it can be just one last spike in hormones or due to vaginal atrophy/tearing. Doctors should suggest a pap, pelvic ultrasound, and perhaps uterine biopsy to rule out other potential issues.

Symptoms

Approximately 85% of women experience menopausal symptoms. Symptoms are directly attributed to fluctuating and declining hormones, particularly estrogen. Symptoms come and go at any time between perimenopause and well into post-menopause, affecting women for years long after periods have stopped. Symptoms may improve and disappear entirely, while new ones crop up and/or become worse. Unfortunately there is no limit of how long symptoms will last, it is different for everyone. For some, symptoms continue for decades, for others they simply stop, and for many others, symptoms can be mild, temporary, and very manageable without any intervention.

Peri/menopause is diagnosed by SYMPTOMS, or rather the process of eliminating those symptoms as being due to something else. (It is not diagnosed through follicle-stimulating hormone blood or saliva test). Menopause symptoms can mimic other ailments/diseases, and this is why it’s very important to track symptoms using an app (like a period tracker) to see trends and cyclical activities over a period of time. This information can then be shared with doctors to help rule out anything else that might be going on.

Due to hormonal swings, existing conditions can also be further aggravated/worsened, such as increased IBS/GERD flare-ups, increased susceptibility to osteoarthritis, Rheumatoid arthritis, (inflammatory diseases) increased skin irritations, and generally the overall weakening of our immune systems, opening the door to other medical issues. The Impact of Estrogens and Their Receptors on Immunity and Inflammation during Infection

A 2024 comprehensive study (comprised of 482,067 middle-aged women) found that joint and muscular pain were the most common symptoms of menopause, experienced by 65%.

The first step with any new or unusual symptom is to visit a doctor. Check The Menopause Society (previously NAMS) to find a menopause practitioner near you and also check our Menopause Provider Directory for more options. There are a wide array of options to both alleviate symptoms and to also provide long-term health benefits as we age.

Symptoms include, but are not limited to:

It is important to point out that symptoms could also be associated to normal aging, and/or previous/existing medical conditions, and/or other medications/herbals remedies, and/or nutrient deficiencies.

Note: While hormone therapy can help with many symptoms listed above (particularly hot flashes/night sweats, vaginal atrophy, irritability, low sex drive, etc), it is not meant to eliminate all things-all the time. Menopause hormone therapy (MHT) can help to improve quality of life overall, but we also need to take charge of our health by incorporating several methods, such as making lifestyle changes (be the healthiest you can be) and using other medications.

Atrophic vaginitis (vaginal atrophy), or the genitourinary syndrome of menopause (GSM)

Atrophic vaginitis (vaginal atrophy) is the drying and thinning of the vaginal tissues, and is one of the most common symptoms of perimenopause/menopause, experienced by approximately 60-70% of post-menopausal women (along with hot flashes), but yet we only ever expect hot flashes, not the burning, shrinking, drying of our vaginal tissues. The genitourinary syndrome of menopause is one of the most alarming and discouraging events to experience during peri/menopause, mostly because no one talks about it (it’s not expected), and because menopause is supposed to be a time for spontaneous sex without worry of pregnancy or period interference. It is a cruel joke.

A separate, but similar issue is clitoral atrophy (urogenital atrophy) is when the clitoris loses sensitivity and shrinks/disappears.

Specifically, our vaginal area (including urethra tissue) is coated in androgen receptors and when these receptors stop receiving sex hormones (from estrogen), they begin to collapse on themselves, preventing normal emptying of the urethra, therefore increasing risk for more infections (UTIs). Without ongoing and consistent treatment, GSM/atrophy will not resolve on its own.

Both GSM and clitoral atrophy are commonly due to the reduction in estrogen, progesterone, and testosterone. While both issues may be difficult to diagnose at first, and research is seriously lacking (big surprise!), the good news is that both are highly treatable and reversible. The sooner treatment is started, the better the long-term outcome.

Symptoms of vaginal atrophy:

Symptoms of clitoral atrophy:

It is important to note that interstitial cystitis (IC) shares some symptoms of vaginal atrophy (along with other conditions) which makes it extremely difficult to diagnose. IC is a chronic bladder condition involving pelvic pain and urinary changes. Estrogen loss affects bladder, urethra, and vulva tissues, making them more fragile and susceptible to irritation and infection which may contribute to interstitial cystitis. Starting treatment earlier for vaginal atrophy (GSM), may help prevent risk of IC.

Hormonal treatment of vaginal atrophy

Vaginal low-dose localized estrogen is the “gold standard” treatment for GSM/vaginal atrophy, it is well-tolerated by most and quite safe for many, no matter what age.

Studies show that localized estrogen therapy eliminates the symptoms of vaginal atrophy in 80%–90% of cases, while systemic MHT does so in 75% of cases. Some use both localized and systemic estrogen at the same time for an added boost.

A note about vaginal estrogen package warnings

The inserts/medication guides found within vaginal estrogen packaging contain long,detailed and scary warnings about all the dangers associated to estrogen. This is because of the Women’s Health Initiative (WHI) 2002 study, when estrogen was identified as increasing risks, this warning had to be applied to ALL estrogens in any form. These insert warnings may eventually change based on updated information, however do not let them scare you off using vaginal estrogen.

The estrogen warnings, according to Dr. Jen Gunter:

This (estrogen warning) does not apply in ANY way to vaginal estrogen. There are no studies that have actually linked any health concerns with vaginal estrogen. Everybody can use it and there’s really just one exception…is if you’ve got a cancer, or have had a cancer that is estrogen receptor dependent, or estrogen dependent, and in that situation, talk to your doctor first.

Non-hormonal treatment for vaginal atrophy

Further reading for vaginal atrophy:

Hair loss

What happened to my luscious locks?

Half of menopausal women notice changes to hair texture and hair loss. According to a study of 178 post-menopausal women, 52% experienced female pattern hair loss (FPHL). More recent statistics indicate that by age 60, an estimated 80% of women experience hair loss. Hair loss occurs due to hormone fluctuations, particularly from the loss of estrogen and progesterone. In menopause (and also due to aging) hair becomes thinner resulting is the hair follicle shrinking, causing it to fall out. However, there are also many other factors associated to hair loss, such as genetics, low iron levels, thyroid issues, other nutrient deficiencies, stress, medications, autoimmune issues, and even some birth control. There is not a lot of research on how estrogen affects hair, but one study found that estrogen receptors are present in hair follicles, indicating that perhaps declining estrogen affects hair loss.

Hair loss is not associated to colouring your hair or shampooing it too much, but certain hair styles that pull on the roots (ponytails, braids, etc) can damage hair follicles resulting in hair loss.

Symptoms of hair loss:

Treatment for hair loss

Biotin is a popular recommended treatment for hair loss, however there is limited evidence that supplementing biotin is beneficial for hair or nail growth. A serious concern is that biotin can interfere with lab testing for thyroid, troponin (a biomarker to diagnose heart attacks), and other medical lab tests, resulting in false high or low results depending on the test. According to the US Food & Drug Administration:

…biotin in patient samples can cause falsely high or falsely low results, depending on the type of test, the FDA is particularly concerned about biotin interference causing a falsely low result for troponin, a clinically important biomarker to aid in the diagnosis of heart attacks, which may lead to a missed diagnosis and potentially serious clinical implications

Further reading for hair loss:

Hot flashes and/or night sweats (VMS-vasomotor symptoms)

Vasomotor Symptoms (VSM) or hot flashes/flushes affect approximately 80% of women during the menopause transition with the median duration of 8-10 years (meaning half will experience VSM longer than 8-10 years). However, some lucky few never experience them. Hot flashes are essentially the same as night sweats, except night sweats occur at night (go figure). Night sweats are a common first symptom, because estrogen levels are lowest at night. However, those who experience hot flashes during the day may not have any night sweats. Hot flashes are uniquely experienced, so much so that many of us have no idea how to accurately describe or define them.

Following is a sampling of how our users describe their hot flashes ….

“sort of like a whoosh”, “uncontrolled sweating from every pore”, “anxious”, sense of dread in the pit of my stomach", “sweating only on arms”, sweating only on feet", “drenched in sweat”, “last only a few minutes”, “last for hours”, “cold sweats”, “shivering”, “hot, then cold, then hot”, “swamp crotch”, “internal fire”, “prickly hot” “accompanied with nausea”, “like having a bad sunburn”, “radiating heat”, “sweating in places never before”, “like an electrical jolt”, “like a panic attack”, “suddenly start/stop”, “occur the same time every night” “everytime I drink alcohol I get a hot flash”, “hot all the time”, “hot only at certain times of the day”, “dripping sweat, but then cold chills”, “sweaty mess!”, “swampy, steamy and sour” …. and an overall desire to step into a freezer, carry portable fans, and strip down at a moment’s notice!

As an added bonus, our reaction to the hot flash contributes to even more heart palpitations/racing and stress!

Research indicates that hot flashes are related to decreased estrogen levels which causes our body’s thermostat (hypothalamus) to become more sensitive to small changes in body temperature. When our brain thinks we are too warm, a hot flash occurs to cool us down.

As outlined by Dr. Jen Gunter (author of The Menopause Manifesto) in her Vajenda article:

With a hot flash, you aren’t feeling hot because your body temperature is rising, what is happening is that you are receiving an incorrect chemical signal that it is! Basically, the call is coming from inside the house. Meaning, your brain has assembled a message of excess heat because it received a signal from the KNDy neurons, and now as far as your brain is concerned (which is all that matters), you are hot and so you feel hot. … …Skin is hot with hot flash because the brain, mistakenly thinking you are hot, starts to deploy the mechanisms to cool down. This involves dilating blood vessels and shunting blood to the skin so you can dump body heat from blood. This is also why many people sweat during a hot flush. Because core temperature was never elevated, body temperature can actually drop after a hot flash because the body has deployed mechanisms to cool off. This is why some people feel cold and shiver after a hot flash.

Hot flashes/night sweats can continue for many years (7-9 years according to Dr. Jen Gunter) but some continue to experience hot flashes long into post-meno and into their 70’s or 80s. According to Harvard Health, studies indicate that 30% of women still had hot flashes 10 to 19 years after menopause, and 20% had hot flashes more than 20 years after menopause. The Study of Women’s Health Across the Nation (SWAN), which included 1449 women, found that frequent hot flashes lasted more than 7 years for more than half of the women. Hot flashes/night sweats also contribute to chronic sleep deprivation which affects our long-term health so it’s important to seek treatment to improve sleep quality.

Recent research indicates that frequent and persistent hot flashes/night sweats can increase risks for cardiovascular disease and dementia:

Non-hormonal treatment of hot flashes

For those that cannot do MHT or choose not to, the following are non-hormonal pharmaceutical treatments:

The following non-pharmaceutical options may also be effective with varying results:

Hormonal treatment of hot flashes

Menopause Hormone Therapy (aka Hormone Replacement Therapy) - systemic (travels throughout the body) estrogen and progesterone (if you have a uterus). MHT is the gold standard for treating hot flashes and, if on the correct dosage, can improve or eliminate hot flashes/night sweats entirely. For some, that change can be almost immediate or it may take a few weeks to notice results.

Further reading for hot flash/night sweats:

Further studies/articles on herbals, soy/phytoestrogens, and menopause supplements:

Irregular periods

Here comes reverse puberty!

Any unusual change in menstruation should be discussed with your doctor, but if you are in the perimenopausal age range of (40-50), irregular bleeding should not be immediate cause for concern. However, if bleeding is persistent, over a longer period of time, unusually heavy, and/or causing pain then it’s important to see a doctor. (fibroids, cysts, polyps are common contributors)

Irregular periods are another common early symptom of perimenopause, and for those who have been extremely regular most of their reproductive life, the disruption can be very alarming. We often associate regularity with optimum health, and when we skip a period or have two in one month, it comes as quite a shock. We assume our periods will get further apart, not closer together! If only we were informed and expected irregular bleeding as part of the normal menopausal transition, it wouldn’t fill us with unnecessary grief, worry or fear.

Irregular periods are defined as missed periods, longer/shorter,closer together/further apart, heavier/lighter, flooding, spotting, clotting, and/or dark/different coloured blood. Tracking periods becomes an important tool as it helps to identify patterns and anomalies which is helpful to doctors as well. Everything we know about period predictability goes out in the window in perimenopause, but it should not be cause for alarm.

A study analyzed the bleeding patterns of 1,320 women during the menopause transition found that 77.7% had periods lasting 10+ days and 35% had heavy bleeding for 3+ days.

The early phase of perimenopause often involves changes in cycles, where they are lengthened by seven or more days. Progesterone is usually the first hormone to drop, causing these irregular periods (heavier, lighter) and skipped periods.

The late phase of perimenopause is characterized by more skipped periods (>60 days between periods). According to Dr. Jen Gunter, “when a women starts skipping two menstrual periods in a row, there is a 95% chance her final menstrual period will be within the next four years”, but this is only a rough guideline.

Note: Periods can become quite heavy in perimenopause, these are often called “super-soaker events” and soaking through two pads an hour for two hours requires medical investigation.

So, what can be done about irregular bleeding?

Further reading about irregular periods:

Osteoporosis

A silent symptom of menopause

Menopause significantly accelerates bone loss due to declining estrogen; we can lose as much as 20% of bone within the first five years of becoming menopausal. According to the 2022 Endocrine Society, “one in two postmenopausal women will have osteoporosis, and most will suffer a fracture during their lifetime”. Osteopenia is commonly a precurser to osteoporosis; it is a loss of bone mineral density (BMD) which weakens bones. Whereas, osteoporosis is more severe as bones become brittle and easily break. However, not everyone who has osteopenia will develop osteoporosis.

Risk factors include:

Symptoms are subtle, we may not feel or notice anything:

Diagnosing osteoporosis

Diagnosis involves measuring bone density through a duel-energy x-ray absorptiometry (DEXA) scan. The scan is quick and painless and uses a low dose radiation. Doctors do not recommend this test until the age of 65, which may be too late. Since bone loss rapidly occurs once we become menopausal, testing should be performed shortly after becoming post-menopausal - no matter what age. The Bone Health and Osteoporosis Foundation recommends that scans be performed as early as age 50.

The test reveals a “T Score” as follows:

Calculate your Fracture Risk for probability of fracture over the next ten years.

Prevention & treatment of osteoporosis

The first step in prevention is making healthy lifestyle changes, including:

Hormone therapy is the most effective for prevention and treatment of osteoporosis, reducing risk of hip fractures by 30-50%. A study of 80,955 post menopausal women found that after they discontinued their MHT (due to the WHI 2002 study), there was a 55% increase in the risk of hip fracture. Hip fracture in postmenopausal women after cessation of hormone therapy

Even low dosage transdermal estradiol can improve bone mineral density in post-menopause. This randomized, placebo-controlled, double-blind trial of 417 post-menopausal women found that even an ultra-low dosage of transdermal estrogen (0.014 mg) can increase lumbar spine mineral density.

Testosterone may be another possible treatment to improve bone mineral density. The science is contradictory, but one study of 2,198 female participants (ages 40-60) found a positive correlation between testosterone and lumbar bone mineral density.

For those who cannot do MHT (or choose not to), there are other non-hormonal options available; speak to your doctor. Pharmaceutical treatment options include bisphosphonates and denosumab and SERMS.

We can also reduce risk and prevent further loss by doing weight bearing and resistance exercises, which forces us to work against gravity. These include walking, hiking, jogging, climbing stairs, playing tennis, dancing, jumping, using hand-weights, resistance bands, machines, and our own body weight.

Researchers from Australia were the first to demonstrate that post-menopausal women can not only stop bone density loss, but a can actually reverse it by lifting heavy weight. Prior to this, studies showed that lifting weights did not work to stop or reverse osteoporosis. These researchers later discovered it was because the women test subjects weren’t lifting heavy enough. Researchers worried that if post-menopausal women with severe osteoporosis lifted weights that are too heavy, they would fracture their bones. However, since that time, their Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation (LIFTMOR) trial determined that twice-weekly, 30-minute high-intensity resistance and impact training (HiRIT) is effective at enhancing bone (particularly in the spine, pelvis and thigh bones), while improving stature and fall prevention.

Another consideration is that between the ages of 50 and 70, we lose about 30% of our muscle strength, putting us at risk for falls. We can help minimize this risk by building more muscle mass, but also practising balance every day which helps strengthen our core and prevent falls. Balancing can be done anytime throughout the day; it’s a simple as standing one leg.

Further reading for osteoporosis:

Sleep disruption/insomnia

What happened to our ability to fall asleep, and STAY asleep?

Data from the National Institutes of Health indicates that sleep disturbances varies from 16% to 42% before menopause, from 39% to 47% during menopause, and a whopping 35% to 60% after menopause.

According to the Centers for Disease Control & Prevention, insufficient sleep is linked to the development of a number of chronic diseases and conditions including, type 2 diabetes, cardiovascular disease, obesity, and depression. Sleep deprivation also affects our reflexes, reduces our coping capacity, critical thinking, and significantly affects moods and memory.

Sleep deficiency impacts every aspect of our health and well-being so it is important to address this issue sooner than later. There are a variety of tools and sleep aids available, whether it be prescription medication, OTC supplements and/or incorporating sleep hygiene, relaxation techniques found online, podcasts, etc…the following are some common recommendations.

Things you can do right now

Non-prescription treatment options for insomnia

Scientific research for OTC (over-the-counter, non-prescription) options is limited and contradictory. Labels may not accurately reflect the ingredients, and most are only recommended for short-term use.

Please consult your doctor/pharmacist before starting any new supplement as they can interfere with existing medications, affect blood labs, or have other negative short-or-long term affects.

Prescription options for insomnia

Further reading:

Weight gain

Why… oh why?!

Decreasing hormones does not cause weight gain, but hormonal changes can alter weight distribution, where weight settles around the middle and becomes annoying belly fat. Even those that never had excess weight around the middle before are alarmed at the sudden change. Menopause does not slow down our metabolism but aging does. A Science journal found that metabolism doesn’t fall during menopause, but remains roughly stable between the ages of 20 and 60, but then declines approximately 1% per year after that. Between the ages of 30-40 we start to lose muscle mass/tone (sarcopenia), which accelerates as we enter menopause, losing as much a 8% of muscle each decade. Muscle helps to burn more calories (even at rest) and the less muscle we have, the more fat we gain. According to the Mayo Clinic, by engaging in regular strength exercise we can gain muscle back at any age.

According to the January 2024 review on the Importance of Nutrition in Menopause and Perimenopause:

The prevalence of obesity increases with age. The incidence of abdominal obesity in women increases with age, and a rapid increase is observed in middle-aged women. Weight gain is a symptom of menopause, experienced by 60–70% of middle-aged women. On average, women gain about 6.8 kg per year during their midlife period (ages 50–60), regardless of their initial body size, race, or ethnicity

According to 2022 WHO data, 55% of women are overweight or obese. Health consequences include:

There are many other variables as to why we gain weight, such as we may become less physically active as we age, but continue to consume the same amounts as before; our exercise recovery takes longer; we experience increases in overall inflammation; lack of sleep affects cortisol levels, blood sugar regulation (among other things), stress, fear, and anxiety also triggers a cortisol response, which directly affects belly fat.

Risks of belly fat (visceral fat and metabolic syndrome)

Belly fat has serious consequences for health, especially because visceral fat (deeper fat surrounding our organs) increases our risks for heart disease, diabetes, stroke, high cholesterol and high blood pressure. Visceral fat is considered abdominal obesity when waist circumference is greater than 88cm (35").

According to the American Heart Association waist size predicts heart attacks better than BMI, especially in women. Knowing your waist circumference is helpful to assess risk for heart disease, diabetes and stroke. The best way to do this is to measure your waist. According to the Mayo Clinic, to correctly measure your waist circumference: (you can find visual charts online)

The National Heart, Lung and Blood Institute indicates that for those in the ‘overweight’ or ‘obesity’ BMI range, a waist circumference of >88 cm (35") have a higher disease risk. Each 1cm (0.4") over 88cm (35") increases cardiac disease by 2%. The National Institutes of Health states that “women who carry excess fat around their waists were at greater risk of dying early from cancer or heart disease than were women with smaller waistlines, even if they were of normal weight”.

Knowing weight circumstance also helps to determine a condition called Metabolic Syndrome, and is diagnosed when at least 3 of 5 conditions below are present:

It is important to know these levels, so talk to your doctor about specific testing

The good news, is that we have the ability to significantly lower these risks. A reduction of 5cm (2") is enough to lower the risk of heart disease by 15%! We can take steps to lose weight, exercise, and take medications to treat any abnormal conditions. Regular exercise may not specifically target visceral fat but studies indicate that high-intensity exercise training (HIET) can reduce total abdominal fat and regular exercise can help keep visceral fat from returning. We cannot specifically target weight loss in one area, but to effectively lower waist circumference, we must consume fewer calories overall and our bodies will decide how and where to lose.

Losing weight in menopause is possible, but requires planning and tracking. Focus on healthy, sustainable eating habits over time. Some find success adopting intermittent fasting, where you only eat between a certain period of time (ie: between 11:00 am and 7:00 pm) and the rest of the time only consume water. Others find success following a keto plan or variations of that. The Mediterranean diet for heart health is more plant-based, and incorporates heart-healthy fats and whole foods.

There is no special trick to losing weight in menopause. It is simply finding a healthy eating plan and routine that works for you. Avoid anything too restrictive, monitor calories, incorporate heart-healthy foods, drink enough water, get regular sleep –consistency and long-term sustainability are key. The good news is that weight loss is NOT contingent on exercise; while exercise is important for overall health (keeps our bones and muscles strong) it does not effectively contribute to weight loss. So if losing weight and incorporating exercise into your daily routine are things you’d like to change, consider focusing on a healthy-eating routine first; changing lifestyle habits all at once is a lot to take on, which ultimately leads to failure. Once your are comfortable in your dietary routine, then consider incorporating an exercise plan.

Ultimately, numbers on the scale don’t matter, extra weight here and there isn’t necessarily a bad thing. A large study from the Ohio State University found that “people who are at normal weight at age 31 and gradually move to overweight status in middle or later adulthood have the lowest mortality risk, even compared to those who maintain normal weight throughout adulthood.”

Focus on OVERALL health, not just what numbers say on a scale.

Take control of your health; be the healthiest you can be

The menopause transition is a time to take stock, reassess, and determine how we want to spend the remainder of our lives. Taking charge of our health is empowering and the following are things we can incorporate right now!

Tips to minimize symptoms and maximize health

Quitting smoking, eating healthier, maintaining a healthy weight, de-stressing, sleeping better, etc… are all things we all know and hear so often as the answer to everything, but it is especially important for us during menopause. Symptoms may persist no matter what we try but by making some simple changes, we can help minimize the effects of many symptoms and be healthier overall.

Menopause, and living without estrogen, is for the rest of our lives, but by incorporating some of the recommendations below, we can improve our health and quality of life.

Expect your doctor to know very little (or nothing at all) about menopause and even less about treatment options

Doctors are likely less informed than you are and simply do not recognize the signs of peri/menopause. They do a poor job of listening, and are quick to dismiss symptoms as being anything other than stress or anxiety. (What Doctors Don’t Know About Menopause) If under the age of 45, doctors refuse to even acknowledge that it could be perimenopause, they only know that the average age of “reaching” menopause is 51 (which is true), but anything before that (e.g., perimenopause) must all be in your head.

Common, lazy and dismissive responses from doctors are:

“You are too young to be in menopause”
“You are anxious/stressed, here’s a prescription for anti-depressants”
“Lose weight, exercise more, do yoga and you will feel better”
“It’s normal aging, you’re fine”
“Dry vagina? you need to have more sex”
“You can’t have hormone therapy until you are menopausal/post-menopausal”
“Hormonal blood tests will confirm if you are in peri/menopause”

There is no blood test that is perfectly reliable to diagnose menopause

Many doctors rely heavily on the FSH test (hormonal blood/saliva) as their main diagnosing tool. This test does not provide a definitive diagnosis of perimenopause. Because hormones wildly fluctuate during peri/menopause, the test cannot capture anything more than what hormones were doing on that day, which has no bearing on anything. Therefore, a hormonal test taken at one point in time only indicates what your hormones were doing on the one day the test was taken, and are not indicative of what hormones are doing the other 29 days of the month.

Unfortunately, many doctors demand this test, claiming that it’s necessary to know levels before they can provide treatment, or to “prove” that everything is “normal”. Doctors just don’t know any better. But for many menopausal clinics and functional medicine practitioners, hormonal testing is insisted upon, because it’s a money-making scam, meant to keep you coming back for more testing while they ‘attempt’ to ‘balance’ hormones. No reputable doctor or menopause society recommends hormonal testing as a diagnosing tool for peri/menopause.

Two common outcomes of hormonal testing are:

  1. Results return ’normal’ levels, which gives doctors a reason to dismiss anything else you have to say about your symptoms, claiming ‘you cannot be in peri because your FSH is normal’
  2. Results return ‘post-menopausal’ levels, which often comes as a complete shock to suddenly realize you are no longer in child-bearing years, and have already made the transition without even knowing, causing unnecessary stress and anguish (it is not possible to be post-menopausal if you still have periods, which is why this test is useless)

Normal or Post-menopausal hormonal levels are not a true indication of anything. Menopause clinics almost always insist on hormonal testing. They then offer products to ‘balance’ those hormones, tweaking dosages/supplements in an attempt to get hormone levels to fall within certain ranges. Balanced hormones do not equate to optimum health, or have any correlation to peri/menopausal symptoms.

The only time FSH testing is beneficial, are for those who believe they are post-menopausal but no longer have periods as a guide (those who had induced/surgical menopause). Then a series of regular/consistent FSH testing may be effective at confirming menopause. Also for younger women (in their 20s or under the age of 44) who haven’t had a period in months/years, then FSH tests at ‘menopausal’ levels, could indicate premature ovarian failure/primary ovarian insufficiency (POF/POI).

The British Menopause Society’s stance on hormonal testing:

Blood tests are rarely required to diagnose perimenopause or menopause in women aged over 45 and should not be taken. While measurement of FSH has often been used in the past to diagnose perimenopause or menopause, the level fluctuates significantly and bears no correlation with severity or duration of symptoms or to requirement for treatment. Reducing inappropriate use of testing FSH levels will produce savings in terms of cost of test, time for further consultation to discuss the results and will reduce delay in commencing agreed management.

Dr. Jen Gunter, author of The Menopause Manifesto states:

A screening test can’t apply to menopause because menopause is a normal biological process. A diagnostic test isn’t needed because, medically, we determine menopause has occurred based on one year of no menstruation for someone age 45 or older. (Hormone Testing and Menopause).
…
Just as you didn’t need blood tests to check on your journey through puberty, you don’t need blood work to track your progress towards menopause. In fact, there is no test that can accurately predict where you are in the menopause transition. And one isn’t needed, because we don’t offer therapy based on hormone levels, we offer therapy based on symptoms and risks for conditions, such as osteoporosis.

Be prepared to provide details of personal and family history

It is essential for your doctor to review family and personal medical history, including other blood work to determine overall health and risk factors. Provide your doctor with a synopsis of your basic lifestyle, such as smoking/drinking habits, personal history of weight issues, cancers, depression, etc. A review of family history should include: Alzheimer’s disease, osteoporosis, diabetes, cancers, liver disease, thyroid disease, heart disease, blood clot disorder, to name a few.

Bring a detailed list of all your symptoms (as much detail as possible, including all tracked data)

Symptoms are what determines a peri/menopause diagnosis, or rather the elimination of those symptoms as being due to something else. Provide detailed information about your symptoms, how they affect your quality of life (are they debilitating, annoying, causing family disruption, relationship issues, causing pain?). Do not let your doctor dismiss your concerns with claims of “normal aging” and/or “a normal” FSH result alone!

Some symptoms should result in further investigation

Many of the symptoms listed above, are found in other illness/diseases, therefore it is important to follow-up with testing to rule out any other potential causes and to get a baseline of your current health. Examination could include a physical exam, weight/height measurements, etc. Blood tests could include liver/kidney function, anemia, fasting blood sugar, triglycerides, lipid (cholesterol), thyroid. Other testing includes mammogram, bone mineral density test, pap screening, pelvic ultrasound, etc. If doctors do not offer further testing for specific symptoms, then request them.

Other potential tests to request from your medical professional:

Common blood work:

Ask your doctor to provide treatment options

What do they recommend to treat x, y, z symptoms? What can you expect from the drug/medication? What are the risks vs. benefits of each? What does it treat specifically? How long until it begins working? Are there concerns about long-term use?

What are their thoughts on hormone therapy? If you know you want to try MHT, then it’s important to be direct and ask for it. Doctors will not willingly offer MHT, or they will make every effort to discourage you from pursuing it with claims of “it causes cancer”, “you’re too young”, “you must be post-menopausal first”, etc. (You don’t have to be post-meno before starting MHT, in fact research indicates it’s more beneficial if started during perimenopause.) Be prepared to stand your ground, provide your reasons and directly ask for it.

Example: “My symptoms are ruining my quality of life, I’ve read the scientific research, am aware of my personal/familial risks, and believe I am a good candidate for MHT. I would like to trial it for 6 months, after which time we can review.”

Bring this to your doctor: The Menopause Society’s 2022 hormone therapy position statement (PDF)

Be wary of doctors that are quick to prescribe other medications

Doctors hear, anxiousness, not sleeping, pain, mood swings/depression, and immediately jump to prescribing antidepressants and other sleep/pain medications. While these medications may be very effective at treating the specific symptom they are not addressing the underlying issue, which is declining estrogen. While some medications have off-label benefits, such as helping with hot flashes, they also have other side effects and risks which may exacerbate existing menopausal symptoms, cause issues that are also symptoms of menopause, or become addictive/difficult to wean off. Again it’s important to understand what you are taking, why you are taking it, and for how long.

Many doctors are fearful of prescribing menopause hormone therapies as viable treatment options, citing outdated sources of increased risks for various cancers, however some OB/GYNs may be better informed regarding the current research on risks/benefits of menopause hormone therapy.

If your doctor is dismissive, does not investigate symptoms, and/or refuses to offer treatment options

If you are generally unhappy with a doctor’s assessment and suggested treatment, it is best to find a new doctor who will listen and act. Alternatively, arm yourself with knowledge and go back to your doctor with research, and be prepared to argue your case.

The Menopause Society provides a list of menopause practitioners near you. Oftentimes it feels like it’s impossible to find someone who will listen, who understands menopause and can offer effective treatment options, so it may mean visiting a few doctors before finding the right fit for you.

Also it’s important for those who see gynecologists (instead of General Practitioners GPs), to ensure other health factors are considered. While gynos tend to focus on reproductive issues, it is absolutely necessary to have a full body work-up that focuses on other areas as well, especially heart and bone health.

Treatment options for menopause and perimenopause symptoms

The most important thing to realize is that you do not have to suffer. Women have a built-in mechanism of putting ourselves last, or believe we can get through difficult situations on our own, while we quietly put up with aches, pains, sleep deprivation, hot flashes, dryness, mood swings, etc. We need to recognize that we aren’t meant to ‘suffer through’ menopause. Getting three hours of sleep a night is nothing to be proud of, and lack of sleep alone is enough to seriously impact many symptoms as well as our ability to simply function day-to-day.

Symptoms can be mild, annoying, debilitating and everything in between, dependent on monthly cycles and/or declining estrogen. There are many options that work, but the trick is to find something that works for you.

There are generally two camps on traversing menopause:

  1. Non-hormonal (“no” to pharmaceutical intervention)
  2. Menopause hormone therapy (aka MHT/HRT, medical intervention)

Non-hormonal therapy of peri-to-post menopause symptoms

For most of us starting the menopause transition, we first look to holistic options and supplements to help minimize symptoms. Why involve drugs and invite potential complications from side effects and increased risks?

Without prescribed hormones, “going natural” often refers to the use of herbs, vitamins, supplements, over-the-counter hormonal treatments, traditional medicine (acupuncture, etc) diet, exercise, and incorporating comfort items (cooling clothing/sheets, fans, etc). Some women employ a combination of vitamins/supplements, along with prescribed medications such as anti-depressants, sleep aids, etc.

While many women find the right balance to deal with some symptoms, there is not enough evidence to prove that any over-the-counter product works. Supplements are not regulated, and there is no requirement to offer scientific evidence of efficacy. They often make claims of higher success rates due to their own in-house low quality studies and/or rely heavily on anecdotal user reviews. Holistic treatments may contribute to an overall sense of well-being and ‘healthiness’, but they won’t specifically address the underlying issue…which is declining hormones.

See the sections above for more tips on incorporating methods to help with some symptoms:

Vitamins

Disclaimer: The following are common recommendations. Some vitamin deficiencies can be identified with medical lab tests, but dosage amounts should be discussed with your health care professionals (dietitian, etc) for any potential conflicts with diet and/or existing medications. It is important to learn about the side effects and risks of any over-the-counter herbal/supplement/vitamin. Recommended dosages may be at unsafe levels or not meant for long-term use. This list is just a starting point to consider, please do your own research, discuss with your doctor/pharmacist and decide what is right for you.

Generally it is best to get vitamins through food consumption as much as possible for effective absorption, but sometimes it is difficult to get enough through foods.

CBD (Cannabidiol) and/or THC (Tetrahydocannabinol)

Seek out a reputable (and legal) source to discuss your needs

Common herbals/supplements/OTC products

The National Center for Complementary and Integrative Health provides more information of some herbs listed above.

The Menopause Society indicates that by 2025, more than 1 billion women worldwide will be post-menopausal. Marketing agencies recognize this abundance of buying power and we are seeing more over-the-counter options (Amberen, Estroven, Remifemin, Menosmart) and online support clinics targeted at treating menopause. These OTC ’treatments’ are marketed at inflated prices and contain a variety of ingredients listed above. Each claim to help with menopause symptoms, however there is limited research to establish their efficacy. It may be better (and cheaper) to buy singular vitamins/supplements, rather than buy a product with a bunch of ingredients/fillers specifically marketed for menopause.

Menopause and women’s “wellness” is big business. Celebrities are talking about it, and menopause is rapidly fuelling women-focused startups, ‘femtech’ companies, tele-medicine, and a myriad of products for anti-aging, hormones, weight loss, cooling devices, etc. More and more online services are jumping into the menopause industry, providing customized hormonal testing and individualized attention for a price. Services are advertised by “trained medical professionals” and “knowledgeable staff”, but this may not always be the case, therefore it is important to thoroughly research these ‘clinics’ before giving them your details and your money.

Online services can offer both supplements and menopausal hormone therapy, but we need to pay attention to what type of ‘bioidentical’ hormones are on offer. Many clinics make their own compounded products (hormones and supplements) and insist on hormonal testing before they offer services, as a way in which to keep you coming back for more testing and for more supplement or hormonal adjustments. (No medical or menopause society recommends compounded hormones or hormone testing.)

SERMS (Selective Estrogen Receptor Modulator) a less discussed non-hormonal medical option

SERMS produce some of the benefits of estrogen, and should be considered for those cannot do MHT (or choose not to). SERMS provide relief for some symptoms but also prevent osteoporosis. Discuss these options with your doctor if you are not a candidate for MHT.

Hormonal therapy of peri-to-post menopause symptoms

Research indicates that hormone therapy is the most effective treatment for symptoms of menopause. When hormone therapy is started before the age of 60 and within 10 years of entering menopause, there is also an important secondary consideration, and this is the overall long-term benefits to our health. New studies show that MHT is beneficial for the maintenance of bone, heart and brain health (among other things) and that MHT can lower risks for a number of diseases, and help keep our bodies healthy and active well into old age.

Most people are good candidates for hormone therapy. Dosages and method of delivery varies, but the ‘right’ dose is where symptoms are managed and you feel an overall sense of well-being. Balancing hormonal levels is not the goal of hormone therapy, the goal is finding “balance” in how you feel.

Menopause hormone therapy (MHT), or hormone replacement therapy (HRT) is prescribed by medical practitioners and commonly consists of two hormones: estrogen and progesterone. It is necessary to include progesterone if you have a uterus and take estrogen. If you do not have a uterus, then progesterone is not required however, even without a uterus, progesterone may be a good option to include as it can help with sleep. (Synthetic progesterone does not provide sleep benefits.) Both hormones come in a variety of dosages and applications. Some have both estrogen and progesterone combined into one application, while others are separate in two different methods of delivery.

Birth Control Pills (BCP) are suitable during early stages of perimenopause to help with some symptoms and when pregnancy is a concern. The hormones in birth control are different than those found in MHT. BCP are generally higher dose, synthetic hormones, meant to ‘override’ your own hormones, and have less customization in terms of dosages and/or method of delivery. Some symptoms of menopause may not improve while taking birth control pills. Users of BCP can generally continue on this regime until roughly the age 50-55 (speak to to your doctor) and then switch to MHT to assist in the transition.

Testosterone (androgens) therapy (pills, patches, implant, gels, injections) is an entirely optional treatment for specific menopause symptoms. Younger women in surgical menopause may need more testosterone than those within ’normal’ menopause age ranges. Many women use testosterone to help with low libido, hair loss, and building muscle, but excess testosterone can contribute to some negative side-effects such as, voice deepening, facial whiskers, and acne. Testosterone is not FDA-approved for use in women, therefore it’s difficult to determine suitable dosages. (more about testosterone, symptoms, treatment, etc below)

Window of opportunity for starting hormone therapy

MHT professionals agree (also confirmed by research), there is a universal ‘window of opportunity’ of when to start hormone therapy in order to receive the most benefits without many risks. More recent research supports starting MHT during perimenopause (rather than waiting until post-menopause) as early intervention provides better outcomes.

This window is: Being under the age of 60 - OR - less than 10 years of becoming menopausal. Studies indicate that women over the age of 60, that have gone more than 10 years without estrogen (ten years since their last period) are actually at a higher risk of stroke, heart attack, and dementia if starting estrogen for the first time. However this does not necessarily mean that anyone over 60 cannot use MHT, but much depends on overall health, medical history, and personal risk factors. This means that women who fall outside the window of opportunity must discuss MHT options with their family doctor and weigh their own risks vs. benefits.

Who are NOT good candidates for hormone therapy

(there may be other reasons, but these are the most prominent)

For anyone considering MHT and has had ANY cancer, it is imperative you consult with your medical professional team (GP, gynecologist, endocrinologist, oncologist, etc) to determine if MHT is safe for you.

Hormone therapy methods and dosages (systemic)

For most people, hormone therapy (MHT/HRT) consists of systemic estrogen and progesterone (or progestin).

If you have a uterus, it’s imperative to take progesterone (or progestin) along with any estrogen, as it protects the uterus. The concern is that unopposed estrogen causes the uterine lining to thicken, and this thickening significantly increases risk of endometrial cancer. Endometrial cancer risk increases when the progesterone dosage is not adequate (not the right dosage in relation to the estrogen) or when progesterone is not taken at all while using systemic estrogen.

If you do not have a uterus, then progesterone is not required, however some studies indicate that progesterone is beneficial for those in perimenopause to help with symptoms, and may provide other benefits even without a uterus. However, for post-menopausal women without a uterus, taking progesterone is shown to have little benefit/value, although it might help with sleep.

  1. Estrogens (commonly estradiol): tablets/pills, patches, gels, lotions, creams, sprays, injections, vaginal rings (hormones estrone and estriol are not used)
  2. Progesterone/Progestin: tablets/pills, suppository, IUD, combined progestin/estrogen in one patch (Note: the progesterone brand name of Prometrium is considered ‘bioidentical’ and the safest form of progesterone; while progestin is the synthetic form of progesterone and considered to have slightly increased risks.)

Estrogen and progesterone/progestin dosages are dependent on the method of delivery and each has their own benefit vs. risk ratio. Below are some common types of hormones and dosages.

The most common, well-tolerated, and ‘safer’ estrogen is transdermal estradiol, found in patches, gels and sprays, which are derived from soy/yams. They are considered “bioidentical” hormones designed to be very similar to the hormones our bodies naturally produce. These hormones are not widely promoted as ‘bioidentical’ because it is a marketing term and not a medical one. Even though transdermal estrogen is pharmaceutically manipulated, it is almost identical to our own hormones. Transdermal methods provide a more steady, consistent dosage of hormones throughout the day.

In terms of safety, transdermal estrogen does have the first pass through the liver, therefore DVT (blood clot risk) is lower, they may decrease blood pressure, triglycerides, and LDL (bad cholesterol) but might not change HDL.

MHT Patches

Patch brand names include: Alora, Climara, Estradot, Menostar, Vivelle-Dot, etc.

Dosages vary from the lowest at 0.025mg up to 0.1mg, so it’s often best to start at the lowest dosage and work up to higher dosages as symptoms dictate. Depending on the brand, patches are changed weekly, or twice a week (every 3.5 days). Each brand may contain slightly different chemical properties, so switching from one brand to another may cause some symptoms to temporarily return. (actual patch size and adhesive quality varies depending on the brand)

Follow the package inserts of where to place the patch, oftentimes the “fattier” the area the better it is for absorption

MHT Gels/Sprays - Estrogen-only gel/spray dosages

Gels and sprays are applied daily, directly to the skin. Drying time is commonly a few minutes, and it’s recommended to leave as much time as possible (at least 2 hours) before showering/swimming.

Gels are colourless but may have a slight alcohol odor when first applying, but once spread onto skin it dries quickly. Each brand of gel may have different application areas, for instance Estrogel is commonly recommended to use on arms (wrist to shoulder), while Divigel is applied to upper thighs.

Note: Follow the package inserts of where to use the gels

Spray (Evamist) is applied to the skin (commonly inside of forearm, below elbow) through a cone applicator. It should not be rubbed into skin, but air-dries within a few minutes.

MHT Combined Patches

Combined transdermal patches contain both an estrogen/estradiol and a progestin (synthetic progesterone) Because the synthetic progesterone (progestin) is combined in one patch with estradiol, there may be different effects than an estradiol-only patch.

MHT Vaginal Systemic

There is only one systemic vaginal estrogen-only ring which stays in the vagina for up to three months, releasing estradiol acetate.

MHT Oral/Tablets

Oral estrogens are entirely synthetic hormones, containing conjugated estrogens, esterified estrogens, etc. Oral estrogen carries slightly risks and side effects. Tablets seem to have a short half-life, so tend to ‘dump’ hormones at once shortly after taking it, and then quickly winds down, so it may not provide a steady/consistent dosage of estrogen throughout the day.

In terms of safety, oral estrogens have the first pass through the GI tract and liver, therefore they may require highers dosages than those found in transdermal methods, and carry slightly higher risks for DVT (blood clots). Oral may increase inflammatory markers, triglycerides, and blood pressure, and can also increase HDL (‘good’ cholesterol) but might decrease LDL cholesterol.

(Note: Premarin/Prempro oral tablets contain conjugated equine estrogens. Premarin was first introduced in the early 1940s and gained popularity throughout the 1980s. In 1992 it was the number one prescribed drug, and because Premarin has been around a long time, it one of the most well-studied and effective menopause therapies. However, Premarin is made from PREgnant MARe urINe, which involves keeping horses in a perpetual state of pregnancy while confining them in small stalls for long periods of time. Given the inhumane treatment of mares, Premarin has since significantly fallen out of favour.)

MHT Combined Oral Estrogens & Progesterone/Progestin
MHT Progesterone/Progestin

Progesterone (brand name Prometrium) non-synthetic (‘bioidentical) derived from soy/yams, designed to be very similar to the hormones our bodies naturally produce. Progesterone carries less risk than synthetic progesterone (progestins). There is no known risk of breast cancer with progesterone. (Relationship between menopausal hormone therapy and breast cancer)

Progestins (synthetic progesterone) carries a small, but increased risk for breast cancer. However progestins provide excellent uterine protection from the effects of estrogen (keeping the uterine lining thin).

Dosage Equivalent Guide from the Australasian Menopause Society may be helpful when switching between products and determining approximate dosages of various hormones.

It is important to find the right dosage between estrogen and progesterone, not only to manage symptoms, but also to ensure adequate uterine protection. (Inadequate dosages of progesterone may increase risk of endometrial cancer.) The dosages outlined above are standardized and proven to provide adequate uterine protection, dependent on the estrogen dosage and whether or not the progesterone is administered daily or cycled on/off. It may take some trial and error before finding the right dose and method of delivery that works for you, but when it is “right”, it can make a world of difference in how we feel.

When should menopause hormone therapy (MHT) start and stop?

According to the International Menopause Society’s (IMS) Paper on Menopause and MHT in 2024:

Timing of MHT commencement is also a controversial issue in menopause care. MHT has been primarily researched in women who are either post-menopausal (i.e. usually 12 months after the final menstrual period) or, in some studies, in late perimenopause.

For those who are menopausal (aka post-menopausal), hormone therapy should be started before the age of 60 and less than 10 years from the last period. (see the window of opportunity for starting hormone therapy).

Prescribing MHT in perimenopause can be difficult because the fluctuations in hormone levels can result in episodes of estrogen deficiency rapidly followed by espisdoes of estrogen excess.
…
MHT remains an option for these women if they are symptomatic, recognizing that MHT is off-label in this phase of life. Considerably more research is needed to determine optimimum MHT regimens for perimenopausal women. Sequential therapies are preferred but even these may cause irregular bleeding.

Therefore, for many perimenopausal women, combined oral contraception or levonorgesterel intrauterine devices (IUD) are most often prescribed.

Doctors who are willing to prescribe Menopause Hormone Therapy (MHT) likely follow the adage, “prescribe MHT at the lowest possible dose for the shortest period of time”. Starting MHT at a low dose is generally recommended for those in the average peri/menopausal age range however, if symptoms persist after a trial period, then doctors should be open to dosage increases as necessary. For those in surgical or early menopause at a younger age, it is recommended to start with a higher dose estrogen than for those going through menopause at an ‘average’ age.

The shortest period of time recommendation is a bit trickier to identify, in that symptoms can continue much longer than originally anticipated and it becomes difficult to know when to stop MHT, especially if symptoms are managed on the current dosage. Why would we risk stopping our hormones to potentially have symptoms return? Studies indicate that MHT can continue for as long as needed to obtain the best benefits. Essentially as long as we are healthy, monitored by doctors, and re-assessing our risks and benefits at regular intervals, there may be no need to stop hormone therapy at a certain age.

According to the International Menopause Society’s 2024 Menopause and MHT paper:

There is now universal agreement amongst national and international menopause societies that arbitrary limits should not be placed on the duration of use of MHT. The IMS governing principles state, ‘Whether or not to continue hormone therapy should be decided at the discretion of the well-informed woman and her HCP, dependent upon the specific goals and an objective estimation of ongoing individual benefits and risks’.

The Menopause Society’s 2022 position statement on hormone therapy (PDF) indicates that:

There is no general rule for stopping systemic hormone therapy in a woman aged 65 years. The Beers criteria from the American Geriatrics Society has warnings against the use of hormone therapy in women aged older than 65 years. However, the recommendation to routinely discontinue systemic hormone therapy in women aged 65 years and older is neither cited or supported by evidence nor is it recommended by the American College of Obstetricians and Gynecologists or The North American Menopause Society. Of note, the continued use of hormone therapy in healthy women aged older than 65 years at low risk for breast cancer and CVD is limited by insufficient evidence regarding safety, risks, and benefits.

The Menopause Society recently published (April 9, 2024) the study: Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses which suggests the… “possbility of important health benefits with use of menopausal HT beyond age 65 years”.

A note about MHT package warnings

The inserts/medication guides found within MHT packaging contain detailed and scary warnings about all the dangers of MHT. This is because of the Women’s Health Initiative (WHI) 2002 study. These insert warnings may eventually change based on updated information, however do not let them scare you off MHT.

What to expect when starting hormone therapy

Starting hormone therapy for the first time can feel scary, it is afterall a medication, and something that has the potential make everything worse or increase risks for other things, especially based on those package warnings.

Some may have experienced negative side effects with hormonal birth control and come to the conclusion that they cannot tolerate hormones in any form. For the majority, hormone therapy is actually very well-tolerated, with minimal side effects and has the potential to greatly increase our quality of life.

Some things to expect when starting hormone therapy:

  1. Expect hormone therapy to be different than the hormones found in oral birth control. Many hormones in BCP contain high synthetic dosages and suppress ovarian function. Whereas, MHT comes in a variety of forms (both non-synthetic and synthetic forms - patches, gels, tablets, etc), are much lower dosages than those in BCP, and simply supplement or ’top-up’ our own hormones.
  2. Expect to feel better. For some that may mean an immediate improvement (especially for hot flashes) and yet for others (or other symptoms) it can take weeks or even months to feel any benefit.
  3. Expect to give it at least 8-12 weeks to see how you feel overall before assuming it’s not working, there is something wrong with you (because others have seemingly noticed improvements right away), or you’re not absorbing it well.
  4. Expect to feel temporarily ‘off’ during those first 6 weeks, where some symptoms might worsen for a few days/weeks, where there’s some unusual aches and pains, where bleeding kicks up, where sleep is difficult, where you feel more anxious, etc. These issues are likely very temporary as your body adjusts to the hormonal changes; this is also true if there is any dosage change later. (For those who are post-menopausal and experience bleeding after starting hormone therapy, it is important to see your doctor.)
  5. Expect to be hyperviligant (anxious) about each and every hourly twinge, mood, pain sensation. As with starting any new regime, we tend to fixate on issues which contributes to thinking that something is wrong with you or with the hormone therapy. The placebo/nocebo effects are very real. Instead, it is important to shift focus and look at the bigger picture, of how you feel overall after a month or more.
  6. Expect that not everyone hits that right dose the first time around, that it may take more trial and error before finding that sweet spot. This may mean changing dosages and/or changing the method of delivery a few times.
  7. Expect your own fluctuating hormones to contribute to good days and ‘bad’ days while on hormone therapy. This is especially true for those in perimenopause where our own hormones are all over the map. Tracking these events can help recognize associated patterns.
  8. Expect that hormone therapy is not a cure-all for everything that ails us, it is not a fountain of youth, it’s not going to even everything out, or eliminate all symptoms all the time. There are many other factors at play so it is important to have realistic expectations about what hormone therapy is capable of, and what it’s not.

Hormone therapy benefits

As well as helping with many symptoms, research indicates that MHT has a secondary benefit to our overall health as we age. Also, more recent theories suggest that estrogen might play a much bigger role in how we age (more than just losing ovarian function in menopause). Scientists are finding that estrogen affects just about every organ and system in our bodies, and are now just examining the effects of estrogen and the aging process.

Below is a sampling of the more common benefits found in multiple studies,but is it important to do your own research as well.

Further reading about hormone therapy benefits:

Hormone therapy risks

As with any medication or treatment, there are side effects and risks.

Testosterone therapy (optional)

Testosterone is an entirely optional hormone treatment. It is not FDA-approved for women, therefore long-term safety data, benefits and risks are lacking. However, a 1% testosterone cream was recently licensed for women’s use in Australia and perhaps this will prompt others to follow suit.

There is a steady decline of testosterone after our reproductive years, but a small increase during menopause. For those in surgical menopause, the drop may be more extreme (50% lower than women who experience menopause ’naturally’). Unfortunately health care providers have not identified a standard “normal” testosterone test level for women. Even if labs results indicate low levels, this may not mean women automatically experience any of the symptoms below. If symptoms are not evident, then low T levels alone is not reason enough to seek treatment.

Testosterone therapy is gaining popularity for the treatment of Female Sexual Arousal Disorder (FASD) or Hypoactive Sexual Desire Disorder (HSDD). Indications are that testosterone treatment is very effective for post-menopausal people with FASD/HSDD, but data is lacking for those still in perimenopause.

The first line of defence for low libido/decreased sex drive is MHT (estrogen and progesterone). According to the Australasian Menopause Society, “a trial of testosterone therapy may be appropriate for some women whose symptoms do not improve on MHT alone”. Therefore, if there is no improvement after a certain time on MHT, adding a low dose testosterone is recommended. It is important to get regular total testosterone levels checked before and during treatment to help minimize risks noted below.

Testosterone may be another possible treatment to improve bone mineral density. The science is contradictory, but one study of 2,198 female participants (ages 40-60) found a positive correlation between testosterone and lumbar bone mineral density.

There may be other reasons for low testosterone (other than menopause), so it is important to talk to your doctor about other potential causes. Also, oral estrogen therapy can lower testosterone levels.

Symptoms of low testosterone
Methods of testosterone delivery
Risks of testosterone therapy, particularly if dosage is too high

Due to the lack of scientific research and no dosage guidelines for women, it is difficult to get doctors to prescribe testosterone. Compounded pharmacies offer testosterone creams and pellets (implants) but dosages could be at unsafe levels, and/or different levels each time a dose is administered.

Further reading about testosterone therapy:

What is the difference between synthetic, bioidentical pharmaceutical and compounded hormone therapy?

Synthetic hormones: are different to what your body produces, and only mimic our own hormones. These are often found in birth control pills and in oral menopause hormone therapy (tablets that contain conjugated estrogens and progestins). Synthetic forms of hormones tend to have more risks/side effects, but may be more effective and beneficial in some circumstances. Synthetic versions have been widely used for many years and therefore have been exposed to more rigorous scrutiny in research studies. (Synthetic estrogens and progestin were used in the 2002 WHI study.)

Bioidentical: is a marketing term, not a medical one. These are hormones claiming to be “identical” to the hormones our bodies naturally produce. They are heavily advertised compounded hormone ‘products’ with bold claims of being completely natural, healthier, safer, and better for us. The advertising is slick and convincing, offering us the illusion of personalized and customizable care. Bioidentical compounded hormones are widely promoted by menopause clinics, naturopaths, holistic medicine, celebrities and even endorsed by doctors, which can be misleading and confusing.

The confusion is because there are no clear definitions of what constitutes “bioidentical”, or how safety standards are applied to each formation. The term bioidentical is used a lot when describing hormone therapy, but can mean different things to different people, and largely dependent on the source of the hormones, the manufacturing process, and the method of delivery. Therefore, it is important to make the distinction between heavily marketed/widely advertised compounded hormones, and “bioidentical” pharmaceutical,(FDA-approved) hormones, firmly established in medical science.

Below is a breakdown of the main differences between science-based ‘bioidentical’ hormone therapy and marketed (compounded) hormones.

While both bioidentical options listed above begin with the same hormones (extraction of the steroid from soy and wild yams), the final product from compounded pharmacies is not bound by any inspection process or testing. Overall, there is no truth to claims that compounded bioidentical hormones are safer, healthier, better metabolized or tolerated. There is no research to support they lower risks for breast cancer or are safer than FDA-approved biodentical hormones. Whereas, FDA-approved biodentical hormones are held to high standards, undergo extensive safety protocols, and are scientifically researched, so we know exactly what we are getting, and in safe dosages appropriate for our needs. Bioidentical “pharmacuetical” hormones are safer than both compounded hormones and synthetic oral estrogens, because we have a lot of scientific data to support this.

The Endocrine Society’s statement on compounded bioidentical hormone therapy:

“Bioidentical” hormones, particularly estrogen and progesterone, have been promoted as safer and more effective alternatives to more traditional hormone therapies, often by people outside of the medical community. In fact, little or no scientific and medical evidence exists to support such claims about “bioidentical hormones.” Additionally, many “bioidentical hormone” formulations are not subject to FDA oversight and can be inconsistent in dose and purity. As a result of unfounded but highly publicized claims, patients have received incomplete or incorrect information regarding the relative safety and efficacy of compounded bioidentical hormone therapy.
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Hormone customization is very difficult to achieve, because blood hormone levels are difficult to regulate accurately due to normal physiologic and pharmacokinetic variations and limitations of readily available assay methods. Nonetheless, proponents of cBHT assert that simple tests of saliva can provide the information necessary to customize hormone doses. These claims are not supported by scientific data confirming assay quality control, standardization, or clinical correlations.

The revised global consensus statement on MHT states that:

the use of custom-compounded hormone therapy is not recommended because of lack of regulation, rigorous safety and efficacy testing, batch standardization, and purity measures.

Dr. Jen Gunter on compounded hormones:

It isn’t uncommon to see compounded hormones that are concoctions, a mix of estradiol and estrone and estriol (sold as Bi-est or Tri-est) or with DHEA or testosterone and this is offered as some kind of “bespoke” mix tailored for your needs. This is a sales tactic. There is zero data that these special mixes do anything, but they are more expensive and give the illusion of customization.
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Compounded products are typically paired with lab work that further enhances the illusion of safety. This might be salivary hormone testing (which is useless for menopause in every way as it’s not even accurate, so your provider is literally charging you for a medically worthless test), urine testing, or blood work. I can see how the specialized blood work and the review of the lab work with a provider makes the patient feel heard, and can enhance the placebo effect, but that is all it is. That and wasted money.

The Menopause Society on compounded hormones:

Custom-compounded hormones are not safer or more effective than approved bioidentical hormones. They are not tested for safety and effectiveness or to prove that the active ingredients are absorbed appropriately or provide predictable levels in blood and tissue. In fact, they may not even contain the prescribed amounts of hormones, and that can be dangerous. For example, when the progesterone level is too low, you are not protected against endometrial (uterine) cancer. When estrogen levels are too high, there can be overstimulation of the endometrium and breast tissue, putting you at risk of endometrial cancer and possibly breast cancer.

Further reading on bioidentical compounded hormones:

Hormone therapy controversy, or why people are scared of HRT/MHT

HRT is not without controversy. It is a topic that is debated so often, that we have dedicated an entire section below about its controversy and many commonly held beliefs.

A brief history of hormone therapy

The 2004 National Use of Postmenopausal Hormone Therapy report indicates that:

“In 1975, hormone therapy prescriptions peaked at 30 million. Prescriptions subsequently declined to approximately 15 million in the early 1980s as evidence emerged showing an increased risk of endometrial cancer with unopposed estrogen use. Prescription growth resumed as progestins were prescribed in combination with estrogen, and prescriptions for hormone therapy reached 36 million in 1992, representing approximately 6 million women.”

In the late 1990s, menopause hormone therapy was the most commonly prescribed treatment in the U.S…but in 2002 that all changed when the Women’s Health Initiative (WHI) released a study indicating that hormone therapy significantly increased risk for breast cancer, heart disease, stroke and dementia for women of all ages. Panic ensued, and overnight women all over the world immediately stopped their hormone therapy and doctors flat-out refused to prescribe it.

A hormone therapy history timeline from the Management of perimenopausel and menopausal symptoms

The results of the study were immediately released to the media without any customary review or due diligence, resulting in the shocking headline: “HRT Causes Breast Cancer!”. At the time, the NIH director of the study was quoted as saying that the NIH was going for “high impact” with the goal “to shake up the medical establishment and change the thinking about hormones” and in that respect they were successful, as their message doomed hormone therapy for millions of women from 2002 to today. Unfortunately, what was widely reported was exaggerated, misleading or just wrong, but the damage had already been done. Where Are We 10 Years After the Women’s Health Initiative?

The WHI study’s condemnation of hormone therapy has been long and far-reaching. Most anyone today immediately associates MHT with increased risk for breast cancer, and many doctors still refuse to prescribe it, simply based on findings from a flawed study, 20+ years ago. Hormone therapy does have risks, but more recent research indicates that the risks are not statistically significant as originally reported, and that MHT should be offered as a viable treatment option for symptoms of menopause for women under the age of 60.

Simplifying the 2002 WHI study results

Estrogen does not cause breast cancer, it may be cancer ‘promoting’, but this is different than cancer ‘initiating’. Breast cancer risk simply increases as we age - with or without hormones.

The average age of the participants in the Women’s Health Initiative Study was 63 years old. Only 10% of the women were between the ages of 50-54. Many women who participated in the study were overweight (70%), smokers (50%) and had high blood pressure (35%), and many assigned hormone therapy for the first time (not the placebo) were already in their 70s.

The study found that for the older women there was a 26% increase in the risk of breast cancer compared with those women who were assigned the placebo. This translated to 39 women per 10,000 on MHT, compared with 30 women per 10,000 taking the placebo (9 cases per 10,000 equals less than 1% absolute risk increase). To put this in perspective … the risk of breast cancer for those older women taking MHT, was similar to the risk reported due to obesity and low physical activity. Further, the risk of breast cancer from using MHT was only slightly higher than the risk (found by the same study) of drinking one glass of red wine a night, but less than the risk of drinking two glasses of wine a night. A different 2020 large, observational study found that 3 glasses of milk/day increased breast cancer risk by 80% (even one glass raises risk to 50%) Comparatively, breast cancer risk from hormone therapy is lower than drinking two glasses of red wine a day, or one glass of milk. But yet the ‘hormones cause breast cancer’ fear solidly remains today.

The two hormones used in this study were oral conjugated equine estrogens and progestin medroxprogesterone acetate. The synthetic progesterone (progestin) was the hormone linked to the slight increased risk in breast cancer. New research indicates that non-synthetic progesterone does not carry that same risk. Also the risk for venous thromboembolism (stroke) is also reduced when the method of delivery is transdermal estrogen (patches/gels), not oral estrogen.

Important considerations from the 2002 WHI study

Research indicates that hormone therapy is the most effective treatment for symptoms of menopause. When hormone therapy is started before the age of 60 and within 10 years of entering menopause, there is also an important secondary consideration, and this is the overall long-term benefits to our health. New studies show that MHT is beneficial for the maintenance of bone, heart and brain health (among other things) and that MHT can lower risks for a number of diseases, and help keep our bodies healthy and active well into old age.

Breast cancer risk is something we all must all pay attention to regardless, but with advanced early detection screening tools, prognosis is excellent and survivability rates have significantly increased. The more serious issue for menopausal women is heart disease, and we should be more concerned about the higher risks of dying from CVD. The stats for women are scary, according to the World Heart Federation, 1:3 women will die from heart disease, but yet breast cancer still creates far more anxiety. Compared to breast cancer screening, heart disease detection is abysmal. Heart attacks are difficult to diagnose, mostly because health care professionals do not recognize that women’s symptoms are very different than men’s, therefore we are under-diagnosed, do not receive further testing or treatment. Misdiagnosis ultimately contributes to the fact that more women die from heart attacks compared to men. Breast cancer will always be something to watch for, but heart disease is what’s likely to kill us. The good news is that we can significantly lower our risks for heart disease by managing our health (lowering BP and cholesterol levels, increasing exercise, etc) and consider the potential long term benefits of MHT.

Interestingly, after women stopped taking estrogen due to the 2002 WHI’s findings, cardiologists noticed a distinct uptick in heart disease deaths in these women, concluding that estrogen is connected to maintaining heart health. Also, another study of 80,955 post menopausal women found that after they discontinued their MHT, there was a 55% increase in the risk of hip fracture. Hip fracture in postmenopausal women after cessation of hormone therapy

Further reading on hormone therapy:

Current recommendations from leading specialty societies endorse the use of MHT in recently menopausal women with appropriate indications. The evidence supports cardiovascular benefit for MHT initiated early among women with premature or surgical menopause and within 10 years of menopause in women with natural menopause. The benefits of MHT (ie, including lower rates of diabetes, reduced insulin resistance, and protection from bone loss) appear to outweigh risks for the majority of early menopausal women. Perimenopausal women should be provided individualized guidance on MHT and options for treatment, particularly when vasomotor symptoms are present.

MHT ameliorates most of the traditional CVD risk factors, with different effects, depending on the type, dose, route of administration and type of progestogen. MHT may reduce the risk of CVD events if prescribed within 10 years since the FMP or in postmenopausal women <60 years old and at low-moderate CVD risk. However, MHT should currently not be prescribed for the sole purpose of CVD prevention.

For those seeking menopause advice and treatment from gynecologists, it is important to keep in mind that these physicians may not necessarily be skilled in screening for Type II diabetes (which can significantly increase risk for heart disease), cholesterol levels and overall heart function. If your obgyn is not equipped to manage issues of heart care, then it’s important to follow up with another doctor for regular heart health screenings.

Where are we today with hormone therapy?

Hormone therapy is still not widely promoted today, largely because of the continued systemic fear generated from the WHI study, however that is slowly changing. There is a lot of misinformation out there, and unfortunately many doctors continue to perpetuate that misinformation. While we were always taught to respect professionals, especially ‘doctors know best’ (why wouldn’t they know everything about our bodies?) we need to wake up to the fact that doctors know almost nothing about menopause, and even less about treatment options. They hear the same fear-based information we do, and are reluctant to bring up hormone therapy, let alone prescribe it. We need to put ourselves first, look at all the options, and find a good doctor who actually understands the benefits of MHT in relation to our own health and needs.

Due to the ongoing concerns surrounding hormone therapy, we still do not have signficant, definitive research on all the risks and benefits. There is a need for high quality, long-term randomized clinical trials.

The bottom line, today

Menopause is for the rest of our lives; more than one-third (or half) of our lives will be spent in a menopausal ‘state’. We are living longer and quality of life is important as we age. Scientists are now looking at piecing together the first female medical genome as it relates to ovarian function, after realizing that for women, “estrogen is the central axis of their metabolism and that is why women age in a different way: they age twice as fast (as men) due to the lack of estrogen”. Another recent article (July 2023) by the Wall Street Journal poses the question, What if We Could Get Rid of Menopause?. These are new and exciting developments and it’s about time that a normal biological process (experienced by half the population) is finally gaining attention after largely going unnoticed for generations. Even on r/menopause, we’ve had more research projects and academic studies advertising for participants to discuss cognitive effects in menopause; experiences of menopause in the workplace; the relationship between menopause, memory and sleep; LGBTQ+ and menopause; mental health care and menopause; effects of estrogen on liver health in post-menopause; chronic pain in menopause; and many others!

We are all in this together, all one-billion of us! We are the sandwich generation, either caring for young adults, aging parents, and/or providing emotional and financial care to others. We may struggle to get through each day, whether that means maintaining employment, social activities, finding time (and energy) for exercise, proper nutrition, or simply trying to get out of bed every morning. We are worried about retirement, money, relationships, health, aging, our value to society, the future, and the world around us. For many, it may not feel like we are wholly supported in the menopause transition, especially when our main medical establishment is failing us … but we know the tides are changing. As more of us step onto this crazy menopause ride, we become a force to be reckoned with. We must demand more from our employers, businesses, and most importantly, our health care professionals, and insist attention be paid to our specific needs, so that the next generation doesn’t have to say “what is happening to me” or “why didn’t anyone tell me”?

Menopause creates a whole new unexpected emotional toll and that’s why it’s important to reach out to others, ask questions and get help. We simply cannot do it all, but we deserve quality of life, and to feel amazing and happy!

Finally … know that periods will stop, symptoms will settle down, and we will feel liberated to embrace this next stage of our lives!

It is our time.

Be sure to check-out the Resources page for further reading