Long-term studies reveal what women can expect during menopause
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More than ever before, women today may have more information — and misinformation — about menopause.
“Most women understand that menopause is defined by an absence of periods, generally happening around age 50 and often associated with night sweats or hot flashes,” Barbara DePree, MD, NCMP, MMM, director of the Women’s Midlife Services at Holland Hospital, Michigan, told Endocrine Today. “Beyond that, there’s a general gap in knowledge around the variety of symptoms that might also be associated with menopause, and that some of those symptoms can start in what we would call the perimenopausal time as well.”
Photo by Max Pincus. Printed with permission.
Women tend to receive information about menopause from family, friends and social media rather than from health care providers and may not have a good idea of what symptoms to expect and what symptoms can be treated, DePree said.
“Health care practitioners are letting women down by not informing them about what to expect, what symptoms are common and what treatments are evidence-based and available to them,” Sheryl A. Kingsberg, PhD, a licensed clinical psychologist, chief of the division of behavioral medicine in the department of obstetrics and gynecology at University Hospitals Cleveland Medical Center and professor in the department of reproductive biology at the Psychiatry and Urology Case Western Reserve University School of Medicine, Cleveland, told Endocrine Today. “Since this often is not happening, partly because clinicians are not trained or educated about menopause, women are forced to find their own information.”
That information often comes from Instagram, Twitter or TikTok. Although there is medically accurate, evidence-based expert advice available online, many websites focusing on menopause spread misinformation as fact or are used to sell products that are not proven safe or effective, Kingsberg said.
Long-term data from several large studies of menopause are now available. Endocrine Today talked with experts about what information women should be receiving.
Common, but not universal, symptoms
Studies have found variations in menopause symptoms dependent on age, race or ethnicity and other demographic factors.
“There is wide variation in symptoms from woman to woman,” Nanette F. Santoro, MD, professor in the divisions of reproductive endocrinology and infertility and reproductive sciences in the department of obstetrics and gynecology and the E. Stewart Taylor Chair of OB/GYN at the University of Colorado School of Medicine, Aurora, told Endocrine Today. “Some women report no hot flashes, but they are relatively few. There are also large differences in how much symptoms affect a woman’s quality of life.”
Menopause is considered the final menstrual period, which occurs on average at age 51 to 52 years for women in the U.S., but perimenopause — the transition from premenopause to menopause — varies in length, according to Santoro. The early transitional stage involves increased menstrual cycle irregularity, with at least one period within the past 3 months, and occurs at a median age of 47 years for women in the U.S. During the late transition, at least 60 days have passed without a menstrual period. This stage occurs at a median age of 49 years.
In the U.S., about 7% of women aged 40 to 49 years use hormonal contraception, which means it can be impossible for these women to tell when they are menopausal unless they stop their hormonal contraception and wait to see if they have a menstrual period. If a year passes without a period, then these women are truly menopausal. Santoro advises women to use a backup birth control method during this wait-and-see stage.
In the Melbourne Women’s Health Project, conducted in the 1980s and 1990s, researchers assessed 438 women in Australia aged 45 to 55 years to identify hormonal changes related to perimenopause and how these changes affect quality of life, bone mineral density, body composition, cardiovascular risk and memory. The study defined menopause transition stages based on tracked menstrual cycles.
The Rotterdam Study, based in the Netherlands, began in 1990 and continues to evaluate data from 15,000 women followed through and beyond their perimenopausal years to assess causes of disease for older women and risk factors.
The Study of Women’s Health Across the Nation (SWAN) has followed 3,300 women during the past 25 years, including women of different racial and ethnic groups. Almost half of participants at baseline were Black, and Chinese American, Japanese American and Hispanic women each made up about 7% of the study population. Researchers assessed how the experience of menopause differed across groups. SWAN also provided an analysis of bone density changes, and several substudies focus on reproductive hormones, heart health and psychiatric aspects of menopause.
In the Penn Ovarian Aging Study, begun in 1996, researchers followed 450 women aged 35 to 47 years at baseline through perimenopause to evaluate hormone dynamics and menopausal symptoms. Researchers focused on hormonal and psychological changes over time and found evidence supporting late perimenopause as a time of high risk for depression.
The primary symptoms reported by women during perimenopause are vasomotor: hot flashes and night sweats. Less often reported, but still common, are vaginal dryness, moodiness, depressive symptoms, anxiety and worsening sleep.
Menopause symptoms are broad, so health care providers need to “think outside of the box” when a perimenopausal woman mentions symptoms like joint pain, weight gain and declining libido, which may fall under possible menopause-related symptoms, DePree said.
Interestingly, menopausal symptoms are not universal. For example, in the Philippines, the most common symptom women report is diffuse achiness, whereas women in the U.S. tend to report hot flashes, night sweats and insomnia. These differences also extend to racial and ethnic groups; Black women in the U.S. report the highest burden of hot flashes and Asian women report the smallest burden.
“I wish we knew why these folks had different symptoms,” Mary Jane Minkin, MD, FACOG,NCMP, clinical professor in the department of obstetrics, gynecology and reproductive sciences at the Yale School of Medicine and co-director of the Sexuality, Intimacy and Menopause for Cancer Survivors program at the Smilow Cancer Center, told Endocrine Today.
One hypothesis is that differences in symptoms may be due to diet, according to Minkin. For example, high soy content in Asian diets may mitigate certain symptoms. However, this hypothesis has not yet been confirmed, she said.
“What’s interesting about the hot flashes is that they do tend to get better over the course of time,” Minkin said. “The flip side of that is vaginal dryness, which is another classic symptom related to menopause. Although it can start before you skip a full menstrual period, it often starts 2 or 3 years after the last menstrual period, and often starts so late that women don’t even think about it being from menopause.”
Hot flashes linked with other diseases
Associations between vasomotor symptoms and CVD, metabolic syndrome and cognitive and sleep issues during perimenopause have been observed in various studies.
“We’ve also recently extended this work into the area of the brain and are looking at vascular health in the brain, which is important for stroke risk, dementia risk and the like,” Rebecca C. Thurston, PhD, FAMBR, FAPS, director of the women’s biobehavioral health program and professor of psychiatry, epidemiology, psychology and clinical and translational science at the University of Pittsburgh, told Endocrine Today. “We found that women who have more vasomotor symptoms, particularly overnight, have more white matter hyperintensities in the brain, which are markers of vascular risk in the brain, which are associated with increased risks for stroke, dementia and future mortality.”
When the WHI study was published in July 2002, it had a significant impact on women’s health in the U.S., Minkin said. This study included two arms: one enrolled women with a uterus who were given estrogen and synthetic progesterone to prevent overgrowth of the uterine lining, and the other enrolled women without a uterus who were given estrogen alone. This study was prompted by results of the Nurses’ Health Study, which found that 121,000 women who took estrogen for menopausal symptoms also experienced a lower risk for myocardial infarction. This supported the theory that estrogen therapy affects CV outcomes.
After 5.5 years, women in the WHI study who took estrogen plus synthetic progesterone experienced a slight increased risk for breast cancer. As a result of this finding, the number of women prescribed estrogen therapy plummeted in the following years. Even women who took estrogen alone — which was not associated with increased risk for breast cancer — discontinued hormone therapy, Minkin said.
In addition, the average age of women in the WHI study was 63 years. These women were not on estrogen therapy for hot flashes, but rather took estrogen to evaluate whether HT would prevent CVD.
“Basically, the WHI really didn’t study women going through menopause. It studied, in general, women substantially postmenopause, for initiating the therapy,” Minkin said. “And in those people, it did not show protection from heart disease.”
More recently, researchers investigating the link between menopausal vasomotor symptoms and CVD risk have observed that women with more frequent or persistent vasomotor symptoms also have more adverse CVD risk factors, such as elevated blood pressure, poor lipid profiles and greater insulin resistance, which are linked to an increased risk for MI, stroke and CVD mortality, according to Thurston. Her studies have also found that women with more vasomotor symptoms have greater underlying atherosclerosis, an indicator of poorer vascular health, even before experiencing clinical CVD. Finally, her studies have found that women with more frequent or persistent vasomotor symptoms over midlife have greater risk for CVD events later in life.
In some studies focusing on sleep problems during perimenopause, women with short or disrupted sleep had elevated CVD risk, specifically underlying atherosclerosis independent of vasomotor symptoms. There is also evidence that women who have more overnight vasomotor symptoms plus poor sleep have worse atherosclerosis risk, according to Thurston.
Women with more vasomotor symptoms experience poorer bone health, including lower bone density and greater bone turnover markers, which can be partially explained by hormonal changes that occur during menopause, Santoro said. Specifically, during the years surrounding the final menstrual period, researchers have observed rapid BMD declines.
Whether treating hot flashes will reduce risks for other diseases is an open question, according to Santoro.
“There is a prevailing narrative that menopause is all about estrogen, and estrogen has the magical power to reverse all the adverse changes that seem to accompany menopause. We need to just get past that. There is a lot of legitimate research still to be done on the precise role of estrogen in controlling symptoms and possibly helping avoid future disease, but it needs to stop being the dominant story,” Santoro said. “Hormone therapy has been proven in multiple clinical trials to not prevent disease later in life overall, so we need to do more focused studies on hormones, and we need to look at other ways of promoting the health of menopausal women.”
Addressing menopausal symptoms
HT is the most effective treatment for vasomtor and genitourinary symptoms in menopause, according to a position statement issued last year by the North American Menopause Society (NAMS). Benefits of HT outweigh risks for most healthy women younger than 60 years who are within 10 years of onset of menopause, but treatment should be personalized and reevaluated periodically, according to the statement.
But many women who could benefit may not be receiving treatment.
“Women should be, but are not being, educated about the menopause transition by their primary care or gynecologist despite the fact that every single woman will experience menopause if she lives that long — she will spend almost half of her life as a postmenopausal woman,” Kingsberg said.
In a study published last year in Menopause, DePree and colleagues found that women tend to experience menopause symptoms for months before mentioning them to a provider.
“Even when women had multiple menopausal symptoms that were bothersome enough to have been reported to their physicians and documented in their medical record, they often delayed seeking care for 6 months or more,” DePree said.
Many women say they wish to go through menopause “naturally,” similarly to how women may hope to have a labor and vaginal delivery without medications. However, forgoing treatment for symptoms does not work for every woman, DePree said.
“A lot of women just sit by hoping that their symptoms improve, and that they can get by without requiring any treatment,” she said. “Then there are so many over-the-counter or online treatment options that women expend time and money exploring what’s being sold to them hoping to find a solution. So, it doesn’t surprise me that they might have had their symptoms persisting for some time before they come in.”
Due to cuts in menopause education, many physicians are not prepared to discuss menopause, menopausal symptoms or possible outcomes, Minkin said.
Beginning in 2002, residents’ hours were cut, and programs focused on obstetrics and gynecology residency programs greatly reduced menopause education. In 2013, a Johns Hopkins study surveyed U.S. and Canadian residency OB/GYN programs and found that only 20% of residency programs had a formal menopause curriculum. Thus, many physicians trained after 2002 received little menopause education, according to Minkin.
This left a knowledge gap, and women beginning to experience symptoms were unable to receive much help from younger gynecologists.
NAMS maintains a list of menopause providers that is searchable by zip code, according to Santoro.
“These providers are called ‘NAMS Certified Menopause Practitioners,’ and I often recommend patients start there if they want to find a clinician — doctor, nurse practitioner, nurse midwife or physician assistant — who is knowledgeable about menopause,” Santoro said.
In addition, there are also websites for advocacy groups that have blogs or resources that have been vetted for accuracy, such as letstalkmenopause.org, Kingsberg said.
Physicians should also continue educating women about perimenopause, including what to expect, most common symptoms and duration, and health risks associated with menopause, Thurston said. Because these conversations can be alarming for patients, Thurston suggests framing the conversation around what women can do.
“Our dream for menopausal women is that women would have more [formal] preparatory discussions around what might be ahead, and that’s not to say every woman experiences that, because they don’t, but for many women there can be some lost years of frustration and lessened quality of life because they just haven’t properly been treated,” DePree said.
In addition to HT, selective serotonin reuptake inhibitors (SSRIs), sleep medications and behavioral therapies are available for symptom management. And positive health behaviors, such as quitting smoking, creating an exercise regimen and tracking diet — especially since accelerated weight gain can be a symptom of menopause — can benefit a woman’s overall health. Women should be encouraged to seek help for things that may be significantly impairing their quality of life or their ability to function, Thurston said.
“Midlife can be a time where many women will say that they are feeling increases in self-awareness and self-confidence, and that they are not necessarily paying attention to or worrying as much about whether they fit into traditional societal expectations for women,” Thurston said. “It can be a time where folks are feeling better, as well as a time of challenge for the menopausal symptoms. Hang in there, it doesn’t last forever, and try to savor the positive aspects of midlife as well.”
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- References:
- Christianson MS , et al. Menopause. 2013;doi:10.1097/GME.0b013e31828ced7f.
- Dennerstein L, et al. Aust J Prim Health. 1999;doi:10.1071/PY99019.
- DePree B, et al. Menopause. 2022;doi:10.1097/GME.0000000000002095.
- Freeman EW, et al. Women Midlife Health. 2016;doi:10.1186/s40695-016-0014-2.
- The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;doi:10.1097/GME.0000000000002028.
- For more information:
- Barbara DePree, MD, NCMP, MMM, can be reached at barb.depree@gmail.com.
- Sheryl A. Kingsberg, PhD, can be reached at sheryl.kingsberg@UHhospitals.org; Twitter: @sherylkingsberg.
- Mary Jane Minkin, MD, FACOG, NCMP, can be reached at maryjane.minkin@yale.edu.
- Nanette F. Santoro, MD, can be reached at Nanette.Santoro@cuanschutz.edu.
- Rebecca C. Thurston, PhD, FABMR, FAPS, can be reached at thurstonrc@upmc.edu.
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