Am I in the menopause yet?

Part 1 of 12 · All topics on the menopause

There is no switch that is flipped at 50

Medically, the menopause is a precise point in time: the last menstrual period, identified in hindsight once twelve months have passed without another period – provided the bleeding has not stopped for other reasons, such as pregnancy or certain hormonal treatments. The menopause years, by contrast, describe the longer transition around that point. [1] [2]

In everyday speech these terms often blur together. That is understandable, but it leads to misunderstandings. When someone says, “I’m in the menopause already,” she may mean that her cycle has been fluctuating for some months, that her last period was a year ago, or that she has lived without a period for years. Medically, these are different situations.

The perimenopause begins with the menopausal transition and also includes the first period of time after the last bleed. The postmenopause refers to the time of life afterwards. The international STRAW+10 criteria describe in more detail how these phases are divided. They are based mainly on changes in bleeding patterns, supplemented by hormonal and other biological findings. [2]

What matters here is not the exact label but the practical question: Which changes can occur in this phase, and what follows from them? A woman with varying cycle lengths, occasional hot flushes and a regular sex life may need different information from a woman whose last period was eight years ago and who suffers from vaginal dryness.

Why the perimenopause is often hard to recognise

The body does not change in a straight line. As reproductive ageing progresses, the function of the ovaries becomes more irregular. Oestrogen levels can fluctuate considerably rather than simply falling slowly. Ovulation no longer takes place in every cycle with its former regularity. As a result, periods can come earlier or later and be heavier or lighter. Individual cycles can also be missed.

This is an important difference from a simplified explanation according to which there is “less and less oestrogen from 40 onwards”. The actual transition can resemble a changeable course more than a steady decline. This is precisely why it often makes little sense to derive a woman’s overall menopausal status, or the cause of all her symptoms, from a single hormone value. [1] [3]

Symptoms do not have to appear in step with one another either. One woman may suffer from night sweats years before her last period. Another develops urogenital symptoms only later. Some have no pronounced symptoms at all. There is no binding timetable of symptoms against which you would have to measure yourself.

The French E3N cohort provides interesting data on the course of events: in an analysis of around 27,900 women followed for about ten years, the risk of a newly occurring cluster of menopausal symptoms was higher in the year after the last period than in the year before. The study is valuable because it examines the timing of events, but it does not replace an individual prediction. [4]

Which first changes are typical?

Three areas help with initial orientation.

First: the cycle. It may become more irregular. The intervals between periods can vary, individual periods can be missed and the amount of bleeding can change. At this age, however, other causes can also lie behind unusual bleeding. Anything that does not seem typical, or is new and heavy, should not be dismissed with a reference to the menopause years.

Second: temperature regulation. Hot flushes and night sweats can come on suddenly. Sometimes they last only a short time; sometimes they considerably affect sleep and daily life. Not every sensitivity to warmth is a hot flush, however.

Third: other changes in wellbeing. Sleep difficulties, mood swings, joint complaints or sexual changes may be reported more often in this phase. But two things happening at the same time does not prove that one causes the other. For example, thyroid disorders, iron deficiency, medicines, psychological strain or sleep disorders can trigger similar symptoms. [1] [5]

In an international meta-analysis, women in the perimenopause reported muscle and joint pain more often than women before the perimenopause. The differences were clear, but the observational studies involved were very varied. It cannot be concluded from this that every joint complaint is caused by hormones. [6]

Isn’t 40 too early?

No – but age changes how things are investigated. Many women go through the natural menopausal transition in their forties. However, a woman who reaches the menopause between the ages of 40 and 44 belongs medically to the group with an early menopause. A loss of ovarian function before 40 is called premature ovarian insufficiency and needs particularly careful diagnosis and advice. Surgery or certain cancer treatments can also cause a premature or abrupt loss of hormones. [3] [7]

In women aged 45 and over with typical symptoms and cycle changes, the perimenopause can often be recognised from the medical history. Between 40 and 45, additional investigation may be worthwhile, because the situation is less clear-cut diagnostically and other causes have to be taken into account. For women under 40 with suspected loss of ovarian function, separate recommendations apply. [1] [3]

A single FSH value is therefore neither a universal “menopause test” nor always useless. Whether it helps depends on age, medical history and any hormone products being used. This distinction is explained in more detail on the page Bleeding and diagnosis.

Why the same symptoms do not have to have the same cause

In the middle of life, many changes happen at once. Sleep can get worse because of work, caring for relatives or stressful events. The thyroid and metabolism can cause symptoms. Depression or anxiety disorders can also appear for the first time or need treatment again. On top of that, physical risks change with age – regardless of the menopause.

This page therefore does not suggest that you diagnose all of your symptoms as hormonal yourself using a long checklist. Rather, it helps you to recognise patterns and to decide specifically when a conversation, an examination or a treatment makes sense.

Three distinctions are decisive for the practical questions:

• Typical and mild: changes that can be observed and do not pose any recognisable risk.
• Distressing or persistent: symptoms for which effective treatments and supportive measures should be discussed.
• Unusual or potentially dangerous: symptoms that must be checked by a doctor rather than written off as “just the menopause”.

Examples of the third group are very heavy bleeding or new, unusual bleeding, bleeding after the menopause has already been completed, chest pain, fainting, shortness of breath or neurological deficits. Here, prompt medical assessment – or, depending on the symptom, immediate assessment – matters more than the question of menopausal status. [1]

The duration cannot be reduced to a birthday

The SWAN study shows impressively how differently symptoms can run their course. Among 1,449 women with frequent vasomotor symptoms, the median total duration was 7.4 years. After the last period, they lasted a further 4.5 years at the median – in the corresponding subgroup in which this point in time could be observed. The women whose symptoms had begun before or in the early perimenopause were often affected for longer. [8]

“Median” means: in the group studied, half had symptoms for longer and the other half for a shorter time than the stated value. This figure is not a countdown that every reader should transfer to her own calendar. Above all, it helps to correct the false expectation that symptoms are over after a few months as a rule.

Another point: the SWAN study was carried out in the USA in a diverse population that is not, however, universally representative. Studies from France and Spain also show that the course, quality of life and frequency of symptoms vary widely. Their results cannot be compared one to one, however, because of different measuring instruments and study populations. [4] [9]

The transition does not begin in the same way for all women

If you hear the word perimenopause for the first time in your early forties, it can feel surprisingly early. Perhaps you learned that the menopause years begin only when the periods stop. In fact, the years before are often the phase in which most of the questions arise. The cycle can get longer or shorter. One woman mainly notices waking at night, another notices nothing yet. Yet another has hot flushes although her periods still come regularly. There is no single test that reliably sorts all of these experiences. For putting things in context, the stage of life, the changes over time and possible other explanations all matter together. [1] [2]

The average last period falls at around the age of 51 in many European populations, but averages must not be confused with a personal deadline. Family history, certain illnesses, smoking and medical procedures can play a role. Even so, the onset of the natural menopause cannot be fixed on the calendar for an individual woman. If your periods change at 42, the question is not only whether that would be early for the menopause years, but also whether there are other causes, which symptoms actually exist and whether further advice would be helpful.

Sometimes it helps to distinguish between a course and a snapshot. A single bad month says little about the coming years. But if you observe over six or twelve months that the intervals between periods fluctuate more, that sleep and your sense of heat are changing and that new symptoms are appearing, the overall picture becomes more informative. That does not mean keeping a symptom diary every day. For most women, a few recurring observations are enough: the date of the period, unusually heavy bleeding, interrupted sleep, hot flushes and changes that really limit daily life.

A common worry is: “If it starts now, will it only go downhill for the next ten years?” No. The menopause years are not a linear decline. Some symptoms increase and decrease again; others appear only later; some do not occur at all. Long-term studies provide average curves, but not an individual prediction. Above all, they help you not to see unusually distressing symptoms as a personal failing. You do not have to prove or dramatise your symptoms in order to seek support.

Two women, two different stories

Mara, 43, still has her period, but over the past eight months her bleeding has become more irregular. She has also become more easily irritated after a stressful period at work. She googles a hormone test and wonders whether the result would finally bring clarity. In her case, a conversation about the course of her cycle, her symptoms, medicines and possible causes would make sense first. Depending on the examination, an FSH value can be considered in women between 40 and 45. But it does not replace the clinical assessment and is not a precise statement about the timing of the last period. [1]

Sabine, 52, has had no period for a year. She has hardly had any hot flushes, but she now notices dryness in the intimate area. Her stage needs to be classed differently; the relevant topic for her is not proving a perimenopause but treating a specific symptom. These two examples are invented, but they illustrate a central message: not all readers need the same information, and not the same treatment either.

Perhaps you also know a friend who had no symptoms at 56 and wonders why you are so exhausted. Comparisons rarely help here. Symptoms are neither a measure of resilience nor proof that someone is living rightly or wrongly. Different baseline health, sleep, medicines, working environment and biological variation all contribute to the same stage of life being experienced very differently.

Which signs are particularly informative?

From around the age of 45, the typical combination of newly occurring hot flushes and changes in the menstrual pattern can often be assessed clinically without routine hormone laboratory tests. This is neither a cost-saving measure nor a lack of regard for your symptoms: hormone values fluctuate so much in this phase that a single measurement often brings more confusion than insight. There are exceptions, for example where an early menopause is suspected or in special medical circumstances. [1]

The most informative questions are those about your usual pattern. What was normal a year ago? How much has it changed? Do the symptoms occur daily or only occasionally? What exactly limits you? One person, for example, may have a high number of hot flushes but cope well with them. For another, three night-time episodes a week can be enough to disturb sleep considerably. The number alone does not fully describe how much someone suffers.

Also watch for symptoms that are not typical or that develop differently from what you would expect. Very heavy bleeding, bleeding after a long time without periods, new severe pain or noticeable general symptoms do not automatically belong to the normal transition. The page Bleeding and diagnosis describes what doctors look for in those cases. You do not have to have every change in how you feel medically examined, but you should not explain everything away with the label “menopause years” either.

What does “early” mean?

The terms are easy to confuse. A menopause at the age of 40 to 44 is often called an early menopause. A loss of ovarian function before the 40th birthday is called premature ovarian insufficiency or POI. That is something different from an ordinary perimenopause at 48. With POI, it is not only a matter of short-term symptoms but also of fertility and of bone, cardiovascular and long-term health. International specialist guidelines therefore recommend targeted diagnosis and advice, which differ markedly from standard advice at 52. [7]

A menopause brought on by surgery or medication can also run a different course. If both ovaries are removed, hormone production drops comparatively abruptly. Cancer treatment can affect ovarian function temporarily or permanently. These situations often need specialist care, because symptoms, risks and possible treatments depend on the individual history. Not every recommendation for the natural transition can simply be carried over.

If the last period stops at 42 or 43, the news can carry a lot of emotional weight, especially if a wish for children has gone unfulfilled. But even a woman who no longer wants children can find the loss of a familiar bodily function a turning point. Good advice therefore does not deal only with measured values. It also makes room for questions about self-image, relationships, sexuality and the future.

A reliable compass instead of perfect certainty

Social media gives the impression that every woman must have a comprehensive laboratory profile done at around 40 in order to “optimise” her “hormone balance”. Such offers often mix up three levels: biological changes, the recording of specific symptoms, and the decision about treatment. These levels belong together, but they are not interchangeable. A laboratory value is not a treatment plan; and a treatment can sometimes make sense without the “right” result having appeared on a hormone test beforehand.

A good compass consists of five questions: What symptoms do you have? How strongly do they affect your life? What other causes come into question? Which measures work for exactly these symptoms? And which options fit your risks and wishes? The following pages go through these questions one after another. You will find that not every uncertainty has to be removed before you can make a good decision.

One minute of self-orientation

Think back over the past four weeks. Was there a change you did not know before? Is it merely noticeable, or really distressing? Would you like to know more about it, or do you mainly need support in daily life? A brief note is enough. Perhaps your most important question is: “Why do I feel so tired in the evening?” Or: “Is this bleeding normal?” Or: “Do I still need contraception?”

This is the personal question to keep in mind as you read on. You do not need to have every symptom to use these pages. And there is just as little need to try to solve everything alone. Good information is not there to turn your life into a medical project. It is meant to give you room to decide again.

Why the time of the last period is only known in hindsight

In the natural menopause there is no single day on which a doctor can say with certainty: “Tomorrow is the last period.” The term refers instead to the last event in a series, whose meaning becomes visible only when no bleeding occurs for a longer time afterwards. For people without a particular medical context, the rule of thumb is twelve months without a period. Hormonal contraception, surgery, pregnancy, breastfeeding or certain illnesses can, however, change the assessment. [1]

This definition in hindsight sounds cumbersome but is medically useful. It separates the phase of unpredictable ovarian activity from the time afterwards. The distinction does not say which symptoms you will have, and it is not a moral milestone either. Some women feel relieved when irregular bleeding ends. Others feel sadness or uncertainty. Neither reaction is required.

The last period is likewise not a universal starting signal for health prevention. Blood pressure, exercise and bone health mattered before and continue to matter afterwards. Anyone who equates the period with a general expiry date is attaching to a biological term a meaning it does not have.

What studies mean by “pre”, “peri” and “post”

Scientific studies often divide participants into groups according to the timing of their bleeding. But not all of them use exactly the same definitions. One study may count women with first cycle fluctuations as early perimenopause, while another takes into account only bleeding that has been absent for longer. Such differences make it harder to compare directly how common a symptom is across different studies. [2]

A common media error arises when a study of postmenopausal women is summarised as if it had examined all women over 40. That changes the statement. A woman of 42 who still menstruates regularly does not automatically belong in the same group as a woman of 62 whose last period was more than ten years ago. The time of the menopause, the time since then and age itself are different quantities.

Living circumstances and medical histories also affect how far results can be transferred. In large cohorts, some population groups are better represented than others. When you hear a figure, therefore, ask: Who was studied? At what point in the transition? How were symptoms recorded? And was the study designed to prove a cause or only to describe an association?

A look at the numbers of your own

Imagine that in a study six out of ten women report sleep problems. First of all, this means that these symptoms are common in the group studied. It does not mean that six out of ten women sleep badly because of the menopause, nor that you personally have a probability of exactly 60 per cent. Perhaps it was an online survey in which women with symptoms were particularly keen to take part. Perhaps sleep was defined very broadly. Perhaps the participants were older or had more pre-existing conditions than the population as a whole.

Such limitations are not an argument against research. They help you to read its results sensibly. Large representative studies can estimate frequencies better; randomised controlled trials are suited to many questions about the effects of treatment. Observational studies over long periods can show how symptoms develop, even if they cannot isolate every cause. These different types of study complement one another.

Menopause after surgery or cancer treatment

A menopause that begins abruptly can feel different from a natural transition that unfolds over years. If both ovaries are surgically removed, hormone production changes immediately. Some cancer treatments can also severely impair ovarian function. The timing of the treatment and the underlying illness shape the individual situation. It is therefore not sufficient simply to fit the symptoms of such women into the average curve of the natural menopause.

If surgery or cancer treatment is coming up, a conversation beforehand is especially valuable. It should cover questions about possible fertility, expected symptoms, sexual health, bones and suitable treatments. After a hormone-dependent cancer, treatment options may be limited; that does not mean that no help is possible. Specialist care should explain the options and set priorities together with you. [3]

Women with an early menopause or premature ovarian insufficiency also need to be looked at separately. The effects of many years of hormone deficiency before the usual age of the menopause cannot be equated with the normal situation of a 55-year-old. Guidelines therefore distinguish these groups and deal with additional questions about fertility, long-term health and psychological strain. [7]

What you can say to a friend with different experiences

A useful sentence is: “Things are different for me right now, and that’s fine.” Perhaps a friend raves about a treatment that helped her. Perhaps she has no symptoms at all and does not understand why you are looking into it so intensively. Both experiences are possible. But neither is a reliable yardstick for your diagnosis or your treatment decision.

The diversity of the menopause years is also a social question. If only the stories of extremely affected women are told, the stage of life inevitably seems dramatic. If only women without symptoms are heard, problems that need treatment are played down. A balanced picture needs both perspectives. It can show that for many people the menopause years are a normal stage of life, and that some of them need medical support.

A good starting point for your own orientation

Before you read the next pages, you can describe your current situation in three short sentences: “My periods have changed in this way ...” “What bothers me most is ...” “The first thing I would like to find out is whether ...” If you have no symptoms, the second sentence can also be: “I would like to be well informed in case something changes.” That is a perfectly good reason to use these pages.

You do not have to write down a complete life story. The three sentences only help to relate the wealth of medical information to your present question. You can read them again later. Perhaps one symptom has gone by then, perhaps another has become stronger. Good orientation is flexible and does not need to know everything in advance.

Read on: The page Hormones explains what drives the changes biologically. Specific questions about hormone tests, bleeding and contraception follow on the page Bleeding and diagnosis.