Last updated: November 8, 2023

Summarytoggle arrow icon

Menopause is the permanent cessation of menstruation (diagnosed after 12 months of amenorrhea) and is a normal part of the aging process. Perimenopause, sometimes called the menopausal transition, is characterized by gradually decreasing ovarian function resulting in less frequent menstruation and decreased production of female sex hormones until menstruation ceases altogether (usually between 45 and 56 years of age). Induced menopause (due to surgery and chemotherapy) leads to a swift decline in hormones, with menopause occurring earlier and more rapidly compared to physiological menopause. While menopause is defined as an absence of menstruation, it also leads to multiple other physiological changes because of the decline in sex hormones, leading to significant vasomotor symptoms, changes to the genitourinary tract, and neuropsychiatric symptoms (e.g., mood swings, sleep disturbance). In individuals with a characteristic history (e.g., the typical age of menopause with vasomotor symptoms and amenorrhea), a diagnosis of perimenopause or menopause can be made clinically. Diagnostic tests are reserved for individuals with premature menopause (i.e., before the age of 40 years) or if the clinical history requires the exclusion of alternative diagnoses. Nonpharmacological interventions are recommended for mild symptoms. Pharmacological therapy is used for moderate to severe symptoms that impair quality of life and for patients with premature, early, or induced menopause who are at increased risk for complications of menopause.

Definitiontoggle arrow icon

The female reproductive period comprises the following phases: [1][2][3]

  • Premenopause: begins with menarche and ends with the onset of perimenopause
  • Perimenopause (also called the menopausal transition): the length of time from the first occurrence of irregular menstruation cycles ; to 12 months after the final menstrual period (FMP) [1][2]
    • Fluctuating hormonal levels lead to increasingly infrequent, lighter menstruation and vasomotor symptoms. [4][5]
    • Duration: variable; median length 4 years [4]
  • Menopause: the date of an individual's FMP
    • Retroactively determined after 12 months of complete amenorrhea [1][6]
    • Onset: usually from 45–56 years of age (average is 51 years of age); earlier average age in smokers [5][6][7][8]
    • Physiological menopause is the normal age-related loss of ovarian function with no other identified cause [2]
  • Postmenopause: the time after the FMP; the first 12 months are called early postmenopause. [1]

Perimenopause begins with the onset of irregular menstrual cycles, includes the date of the FMP (i.e., menopause), and ends after the first year of postmenopause (i.e., early postmenopause). [4][5]

Physiology of menopausetoggle arrow icon

Underlying physiology of menopause symptoms [4][5]
Symptoms Underlying mechanism
Menstrual irregularities and amenorrhea [4][5]
Vasomotor symptoms [4][5]
Genitourinary symptoms [9]

Clinical featurestoggle arrow icon

The onset and intensity of symptoms depend on the phase of menopause and vary greatly between individuals. Symptoms begin during perimenopause and typically peak during the first 1–2 years of postmenopause. [4]

Clinical features of menopause [4][5]
Common symptoms
Menstrual abnormalities
Vasomotor symptoms of menopause (VMS)
Genitourinary syndrome of menopause) (GSM) [9][11]
Neuropsychiatric symptoms [12]
  • Impaired sleep (e.g., from insomnia and/or night sweats)
  • Anxiety/irritability
  • Mood swings or depression [7]
  • Vertigo [13]
Other symptoms [14]

In the US, more intense and longer-lasting vasomotor symptoms are reported for Black individuals than individuals of other racial or ethnic groups. [4][5]

In menopausal individuals, estrogen production mainly results from the conversion of adrenal androgens by peripheral aromatase in adipose tissue. The onset of menopause may occur later in individuals with obesity, who have additional estrogen from adipose stores. [4][11][16] ; Menopausal HAVOCS: Hot flashes/Heat intolerance, Atrophy of Vagina, Osteoporosis, Coronary artery disease, Sleep impairment.

Subtypes and variantstoggle arrow icon

Induced menopause [2][6]

Induced menopause is the permanent loss of ovarian function as a result of medical interventions.


Clinical features [14]


Premature menopause [7][14]

Premature menopause is the permanent cessation of ovarian function and menses before the age of 40 years.


Clinical features



Early menopause [11][14]

  • The occurrence of physiological menopause between 40 and 45 years of age with no other identified cause [11]
  • Affects 5% of women [6]
  • Clinical features and diagnostics are the same as for older patients.
  • Systemic HRT is usually recommended to reduce risks associated with early menopause, e.g.: [14]
    • Increased risk of heart disease
    • Dementia
    • Increased risk of overall mortality

Smoking is associated with earlier onset of menopause. [4][7][19]

Diagnosticstoggle arrow icon

General principles [7][11]

The effects of oral contraceptives can mask the signs and symptoms of menopause. [21]

Supportive studies to confirm menopause [1][7][11]

These studies are typically determined by a specialist; there is significant controversy regarding which tests are appropriate. [7][11][17]

If FSH levels are needed to verify menopause in individuals using oral contraceptives, discontinue oral contraceptives at least 2 weeks prior to testing. [6][21]

Studies to exclude differential diagnoses of menopause [23]

Individuals with hyperthyroidism and menopause have similar symptoms. Maintain a low threshold for checking serum TSH in individuals with heat intolerance, irregular menstruation, and disturbed sleep. [23]

Studies for complications of menopause

These studies are not routinely part of the menopause workup but if performed, findings may show characteristic changes.

Differential diagnosestoggle arrow icon

Differential diagnoses of common menopause symptoms
Hot flashes or night sweats [7]
Irregular menses
Genitourinary symptoms [9]
Neuropsychiatric symptoms

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

The information in this section is on the management of physiological menopause in individuals aged > 45 years. For the management of premature menopause, early menopause, and induced menopause, see “Subtypes and variants.”

Approach [5][11][14]

Questionnaires, e.g., the menopause-specific quality of life scale, may help to determine the severity of symptoms and guide treatment.

Hormone replacement therapy is not indicated for all patients but should be prescribed for premature menopause, early menopause, and patients with moderate to severe symptoms of menopause. [11]

Symptom-specific management of menopausetoggle arrow icon

For further information on indications, contraindications, and dosages, see “Pharmacological therapy for menopause.”

Overview of menopause management [4][7][11]
Symptom-specific nonpharmacological interventions for menopause Symptom-specific pharmacological therapy for menopause
Vasomotor symptoms of menopause [5][14]
  • Avoid dietary triggers (e.g., caffeine, spicy foods, alcohol).
  • Manage environmental temperatures (e.g., using fans, layering clothing).
  • Decrease stress.
  • Preferred: systemic HRT
  • Alternatives: nonhormonal therapy, e.g.,
Genitourinary syndrome of menopause [5][9]
Menstrual symptoms
  • N/A
Psychological symptoms [4][32]
Other [8]
  • Weight gain [6]
    • Dietary changes
    • Increase exercise.
    • Behavioral support
  • Hirsutism: hair removal [6][33]

Evidence does not support the use of alternative medical therapies for menopause, e.g., soy, black cohosh, omega-3 supplementation, and acupuncture. [5][7]

Pharmacological therapy for menopausetoggle arrow icon

Systemic hormone replacement therapy (HRT) [7][11][14]

General principles

  • HRT should be titrated to the lowest effective dose. [5][7][11][14]
  • Reevaluate patients on HRT yearly. [4]
  • Short-term use (< 5 years) may be preferred to reduce the risk of adverse effects (e.g., breast cancer). [5][14][34]

Indications [7][14]

Multiple medical societies do not recommend systemic HRT solely for the prevention of chronic diseases (e.g., osteoporosis and cardiovascular diseases) in menopausal individuals. [7][30]

Options [4][7][14]

Unopposed systemic estrogen can increase the risk of endometrial hyperplasia and endometrial cancer. In individuals with a uterus, add an agent that protects the endometrium (e.g., progestins, bazedoxifene). [5][14]

Some clinicians prescribe compounded bioidentical hormones; however, these are not FDA-approved and are not recommended by any major societies as there is no evidence they are superior to standard HRT. [5][7][14]

Contraindications [7][14]

Adverse effects [14]

Vaginal hormone therapy [7][9][14]

Vaginal hormone therapy is indicated for moderate to severe genitourinary symptoms of menopause.


Contraindications [9]

In consultation with oncology, low-dose vaginal estrogen may be considered in individuals with a history of breast cancer. [9][14][31]

Adverse effects [9]

As low-dose vaginal estrogen is generally not associated with endometrial hyperplasia, additional progestin is typically not added for endometrial protection. However, patients should be advised to immediately report any vaginal bleeding. [5][7][14]

Nonhormonal therapy [5][9][31]


  • Alternative treatment for patients who decline, or have contraindications to, HRT
  • Second-line treatment for moderate to severe menopausal symptoms


Contraception during perimenopausetoggle arrow icon

Complicationstoggle arrow icon

Associated conditions

Always evaluate postmenopausal bleeding, especially in individuals using systemic HRT. [7]

We list the most important complications. The selection is not exhaustive.

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Referencestoggle arrow icon

  1. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms. JAMA. 2023; 329 (5): p.405.doi: 10.1001/jama.2022.24140 . | Open in Read by QxMD
  2. NAMS. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022; 29 (7): p.767-794.doi: 10.1097/gme.0000000000002028 . | Open in Read by QxMD
  3. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015; 100 (11): p.3975-4011.doi: 10.1210/jc.2015-2236 . | Open in Read by QxMD
  4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014; 123 (1): p.202-16.doi: 10.1097/01.AOG.0000441353.20693.78 . | Open in Read by QxMD
  5. Santoro N, Roeca C, Peters BA, Neal-Perry G. The Menopause Transition: Signs, Symptoms, and Management Options. J Clin Endocrinol Metab. 2020; 106 (1): p.1-15.doi: 10.1210/clinem/dgaa764 . | Open in Read by QxMD
  6. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020: p.m3873.doi: 10.1136/bmj.m3873 . | Open in Read by QxMD
  7. The Women's Health Initiative Steering Committee. Effects of Conjugated Equine Estrogen in Postmenopausal Women With Hysterectomy. JAMA. 2004; 291 (14): p.1701.doi: 10.1001/jama.291.14.1701 . | Open in Read by QxMD
  8. Pinkerton JV. Hormone Therapy for Postmenopausal Women. N Engl J Med. 2020; 382 (5): p.446-455.doi: 10.1056/nejmcp1714787 . | Open in Read by QxMD
  9. North American Menopause Society. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020; 27 (9): p.976-992.doi: 10.1097/gme.0000000000001609 . | Open in Read by QxMD
  10. ACOG. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer. Obstetrics & Gynecology. 2021; 138 (6): p.950-960.doi: 10.1097/aog.0000000000004601 . | Open in Read by QxMD
  11. Hill DA, Crider M, Hill SR. Hormone Therapy and Other Treatments for Symptoms of Menopause. Am Fam Physician. 2016; 94 (11): p.884-889.
  12. Markopoulos MC, Kassi E, Alexandraki KI, Mastorakos G, Kaltsas G. MANAGEMENT OF ENDOCRINE DISEASE: Hyperandrogenism after menopause. Eur J Endocrinol. 2015; 172 (2): p.R79-R91.doi: 10.1530/eje-14-0468 . | Open in Read by QxMD
  13. Shifren JL, Gass MLS. The North American Menopause Society Recommendations for Clinical Care of Midlife Women. Menopause. 2014; 21 (10): p.1038-1062.doi: 10.1097/gme.0000000000000319 . | Open in Read by QxMD
  14. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10. Menopause. 2012; 19 (4): p.387-395.doi: 10.1097/gme.0b013e31824d8f40 . | Open in Read by QxMD
  15. Ambikairajah A, Walsh E, Cherbuin N. A review of menopause nomenclature. Reprod Health. 2022; 19 (1).doi: 10.1186/s12978-022-01336-7 . | Open in Read by QxMD
  16. Menopause Glossary. Updated: January 1, 2023. Accessed: January 9, 2023.
  17. Samar R. El Khoudary, Gail Greendale, Sybil L. Crawford, Nancy E. Avis, Maria M. Brooks, Rebecca C. Thurston, Carrie Karvonen-Gutierrez, L. Elaine Waetjen, Karen Matthews. The menopause transition and women's health at midlife. Menopause. 2019; Publish Ahead of Print.doi: 10.1097/gme.0000000000001424 . | Open in Read by QxMD
  18. Menazza S, Murphy E. The Expanding Complexity of Estrogen Receptor Signaling in the Cardiovascular System. Circ Res. 2016; 118 (6): p.994-1007.doi: 10.1161/circresaha.115.305376 . | Open in Read by QxMD
  19. Munro M. Investigation of Women with Postmenopausal Uterine Bleeding: Clinical Practice Recommendations. The Permanente Journal. 2013.doi: 10.7812/tpp/13-072 . | Open in Read by QxMD
  20. Van den Bosch T, Ameye L, Van Schoubroeck D, Bourne T, Timmerman D. Intra-cavitary uterine pathology in women with abnormal uterine bleeding: a prospective study of 1220 women.. Facts, views & vision in ObGyn. 2015; 7 (1): p.17-24.
  21. P Paramsothy, SD Harlow, GA Greendale, EB Gold, SL Crawford et al. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women's Health Across the Nation (SWAN): a prospective cohort study. BJOG. 2014; 121 (12): p.1564-1573.doi: 10.1111/1471-0528.12768 . | Open in Read by QxMD
  22. Santoro N, Epperson CN, Mathews SB. Menopausal Symptoms and Their Management. Endocrinol Metab Clin North Am. 2015; 44 (3): p.497-515.doi: 10.1016/j.ecl.2015.05.001 . | Open in Read by QxMD
  23. Ogun OA, Büki B, Cohn ES, Janky KL, Lundberg YW. Menopause and benign paroxysmal positional vertigo. Menopause. 2014; 21 (8): p.886-889.doi: 10.1097/gme.0000000000000190 . | Open in Read by QxMD
  24. Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020.doi: 10.7759/cureus.7586 . | Open in Read by QxMD
  25. Szegda KL, Whitcomb BW, Purdue-Smithe AC, et al. Adult adiposity and risk of early menopause. Human Reproduction. 2017; 32 (12): p.2522-2531.doi: 10.1093/humrep/dex304 . | Open in Read by QxMD
  26. American College of Obstetricians and Gynecologists. Committee Opinion Number 605: Primary Ovarian Insufficiency in Adolescents and Young Women. Obstet Gynecol. 2014; 124 (1): p.193-7.doi: 10.1097/01.AOG.0000451757.51964.98 . | Open in Read by QxMD
  27. Genazzani AR, Brincat M. Frontiers in Gynecological Endocrinology. Springer ; 2014
  28. Whitcomb BW, Purdue-Smithe AC, Szegda KL, et al. Cigarette Smoking and Risk of Early Natural Menopause. Am J Epidemiol. 2017; 187 (4): p.696-704.doi: 10.1093/aje/kwx292 . | Open in Read by QxMD
  29. Lumsden MA, Davies M, Sarri G. Diagnosis and Management of Menopause. JAMA Intern Med. 2016; 176 (8): p.1205.doi: 10.1001/jamainternmed.2016.2761 . | Open in Read by QxMD
  30. ACOG. ACOG Committee Opinion No. 773 Summary: The Use of Antimüllerian Hormone in Women Not Seeking Fertility Care. Obstetrics & Gynecology. 2019; 133 (4): p.840-841.doi: 10.1097/aog.0000000000003163 . | Open in Read by QxMD
  31. Klein DA, Paradise SL, Reeder RM. Amenorrhea: A Systematic Approach to Diagnosis and Management.. Am Fam Physician. 2019; 100 (1): p.39-48.
  32. Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women.. Am Fam Physician. 2019; 99 (7): p.435-443.
  33. Pouresmaeili F, Kamali Dehghan B, Kamarehei M, Yong Meng G. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018; Volume 14: p.2029-2049.doi: 10.2147/tcrm.s138000 . | Open in Read by QxMD
  34. Curry SJ, Krist AH, et al. Screening for Osteoporosis to Prevent Fractures. JAMA. 2018; 319 (24): p.2521-2531.doi: 10.1001/jama.2018.7498 . | Open in Read by QxMD
  35. Karlamangla AS, Burnett-Bowie SAM, Crandall CJ. Bone Health During the Menopause Transition and Beyond. Obstet Gynecol Clin North Am. 2018; 45 (4): p.695-708.doi: 10.1016/j.ogc.2018.07.012 . | Open in Read by QxMD
  36. Gade AK, Olariu E, Douthit NT. Carcinoid Syndrome: A Review. Cureus. 2020.doi: 10.7759/cureus.7186 . | Open in Read by QxMD
  37. Zaman A, Rothman MS. Postmenopausal Hyperandrogenism. Endocrinol Metab Clin North Am. 2021; 50 (1): p.97-111.doi: 10.1016/j.ecl.2020.12.002 . | Open in Read by QxMD
  38. Contraception: You Need It Longer Than You May Think. Updated: January 1, 2023. Accessed: January 16, 2023.
  39. When Women Can Stop Using Contraceptives. Updated: February 1, 2017. Accessed: October 20, 2022.
  40. Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations. J Womens Health (Larchmt). 2019; 28 (2): p.117-134.doi: 10.1089/jwh.2018.27099.mensocrec . | Open in Read by QxMD
  41. Martin KA, Anderson RR, Chang RJ, et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. 2018; 103 (4): p.1233-1257.doi: 10.1210/jc.2018-00241 . | Open in Read by QxMD

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