Perimenopause and Menopause: A Systems View
Level 2, Intermediate
In brief
The menopause transition affects almost every body system: vasomotor symptoms, sleep, mood, cognition, joints, the genitourinary tract, bone, metabolism and cardiovascular risk. Diagnosis in women over 45 is usually clinical. Menopausal hormone therapy is the most effective treatment for vasomotor symptoms, with a favourable balance for most healthy women under 60 or within 10 years of menopause, while non hormonal medicines, cognitive behavioural therapy and lifestyle measures offer alternatives. Compounded bioidentical hormones lack evidence of safety and efficacy.
Menopause is a universal event for women who live long enough, yet for generations it was barely discussed in clinical training and often dismissed in consultations. That has changed rapidly, and with the change has come a flood of information, some excellent, some misleading. The transition is best understood not as a gynaecological event but as a systemic one, affecting the brain, bones, blood vessels, metabolism, skin, joints and genitourinary tract. A systems view helps practitioners recognise its many presentations and coordinate care.
Stages and hormonal changes
The internationally used STRAW staging system describes reproductive ageing in stages. In simplified terms:
| Stage | Features |
|---|---|
| Late reproductive | Subtle changes in cycle length and flow; rising follicle stimulating hormone |
| Early perimenopause | Persistent variation in cycle length of 7 days or more |
| Late perimenopause | Intervals of 60 days or more without a period; symptoms often most prominent |
| Menopause | The final menstrual period, identified after 12 months without menstruation; average age around 51 in many populations |
| Postmenopause | The years that follow, with continuing changes in the early years and stabilisation later |
Perimenopause is not simply a gradual decline in oestrogen. Oestrogen levels fluctuate widely, sometimes higher than in earlier years, while progesterone falls as ovulation becomes irregular. These fluctuations explain why symptoms can be erratic and why blood tests during perimenopause are often unhelpful.
Symptoms across systems
| System | Common changes |
|---|---|
| Vasomotor | Hot flushes and night sweats, experienced by most women, lasting 7 years or more on average in one large study, with wide variation |
| Sleep | Difficulty staying asleep, often but not only due to night sweats |
| Mood | Increased risk of depressive symptoms in perimenopause, anxiety and irritability |
| Cognition | Subjective difficulties with memory and concentration, usually temporary |
| Musculoskeletal | Joint pain and stiffness, loss of muscle mass |
| Genitourinary | Vaginal dryness, painful intercourse, urinary urgency and recurrent urinary infections, together called the genitourinary syndrome of menopause; tends to progress without treatment |
| Skin and hair | Dryness, thinning, changes in hair |
| Cardiac | Palpitations, usually benign but worth assessing |
Symptom experience varies with ethnicity, culture and circumstances. A large American study found differences between ethnic groups in the frequency and duration of vasomotor symptoms.
Long term changes
- Bone: accelerated bone loss in the years around menopause increases later fracture risk.
- Metabolism and body composition: fat distribution shifts towards the abdomen, and LDL cholesterol rises.
- Cardiovascular risk: increases after menopause, particularly with early or premature menopause.
- Genitourinary changes: progressive without treatment.
Diagnosis
In women over 45 with typical symptoms and changes in menstrual pattern, guidelines such as those from NICE recommend diagnosing perimenopause and menopause clinically, without blood tests, because hormone levels fluctuate. Testing follicle stimulating hormone may be considered in women aged 40 to 45 with symptoms, and is important in women under 40, in whom premature ovarian insufficiency must be diagnosed, as it has significant long term implications and usually warrants hormone replacement until at least the average age of menopause. Other causes of symptoms, such as thyroid disease, should be considered where appropriate.
Menopausal hormone therapy
Menopausal hormone therapy is the most effective treatment for vasomotor symptoms and also prevents bone loss.
The history
The Women’s Health Initiative trials, reported from 2002, found increased risks of breast cancer, stroke and venous thromboembolism with combined oral hormone therapy in older postmenopausal women, and hormone therapy use fell sharply worldwide. Later analyses showed that the balance of risks and benefits depends strongly on age and time since menopause. For women who start before 60 or within 10 years of menopause, absolute risks are low and benefits, particularly for symptoms and bone, often outweigh them.
Current understanding
- Women with a uterus need a progestogen alongside oestrogen to protect the endometrium.
- Transdermal oestrogen, through patches or gels, does not appear to increase the risk of venous thromboembolism to the same extent as oral oestrogen.
- Combined therapy is associated with a small increase in breast cancer risk that rises with duration; oestrogen alone in women without a uterus carries little or no increase. Observational studies suggest micronised progesterone may carry lower breast cancer risk than some synthetic progestogens.
- Low dose vaginal oestrogen treats genitourinary symptoms with minimal systemic absorption and is considered safe for most women.
- Decisions are individual, based on symptoms, preferences, age, time since menopause and personal risk factors, made with the prescriber.
Non hormonal options
- Neurokinin 3 receptor antagonists, such as fezolinetant, reduce vasomotor symptoms and have been approved in several countries.
- Some antidepressants and other medicines reduce hot flushes and can help mood.
- Cognitive behavioural therapy has good evidence for reducing the impact of vasomotor symptoms and improving sleep and mood.
- Lifestyle: regular exercise, weight management, reducing alcohol and caffeine where they trigger symptoms, and cooling strategies.
- Herbal and dietary supplements: evidence for products such as black cohosh, soy isoflavones and others is inconsistent, product quality varies and some carry risks, including liver injury reported with black cohosh.
Compounded bioidentical hormones
Bioidentical hormones, those chemically identical to human hormones, include regulated products such as micronised progesterone and oestradiol patches and gels. Compounded bioidentical hormones, custom mixed by pharmacies, often based on salivary testing, are different. A report from the United States National Academies of Sciences, Engineering and Medicine concluded that there is insufficient evidence to support their safety and effectiveness, that their dosing can be inconsistent, and that salivary testing to guide doses is not reliable. Regulated preparations of body identical hormones are available and preferable.
A systems approach
- Recognise the transition in its many presentations, including new anxiety, joint pain or insomnia in a woman in her forties.
- Assess all systems: vasomotor, sleep, mood, cognition, genitourinary, musculoskeletal, cardiometabolic and bone.
- Discuss options for symptom relief, including referral for hormone therapy where appropriate.
- Protect long term health: resistance and weight bearing exercise for bone and muscle, protein and calcium intake, cardiovascular risk assessment, reducing alcohol.
- Address mediators: sleep, stress, caring responsibilities, work pressure.
- Coordinate with the prescribing clinician and, where needed, mental health professionals and physiotherapists.
An illustrative case
A 48 year old accountant presents with anxiety, poor sleep, forgetfulness and joint pain, fearing early dementia. Her periods have become irregular over the past year, and she has night sweats she had not connected to her other symptoms. Her thyroid function and blood count are normal.
Her symptoms are recognised as perimenopause. After discussion with her doctor, she starts transdermal oestrogen with micronised progesterone. Cognitive behavioural therapy for insomnia helps her sleep, a strength training programme addresses her joints and muscle, and she reduces evening wine. At 3 months her night sweats have largely resolved, her sleep and concentration are better and her anxiety has eased. Her fear of dementia, driven by symptoms nobody had connected, has gone.
A transition, not a disease
Menopause is a natural transition, but its symptoms and long term effects deserve active, informed care. A systems view recognises its many presentations, offers effective treatments, and uses the transition as an opportunity to protect bone, muscle, heart and brain for the decades ahead.
Menopause questions
How is perimenopause diagnosed?
Is menopausal hormone therapy safe?
Are compounded bioidentical hormones better?
References and guidelines
- Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4).
- Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition (SWAN). JAMA Internal Medicine. 2015;175(4).
- Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal hormone therapy and long term all cause and cause specific mortality: the Women’s Health Initiative randomized trials. JAMA. 2017;318(10).
- The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7).
- National Institute for Health and Care Excellence. Menopause: identification and management (NG23). London: NICE; 2015, updated 2024.
- National Academies of Sciences, Engineering, and Medicine. The clinical utility of compounded bioidentical hormone therapy: a review of safety, effectiveness, and use. Washington, DC: The National Academies Press; 2020.
- Lederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate to severe vasomotor symptoms associated with menopause (SKYLIGHT 1). The Lancet. 2023;401(10382).
Continue your learning
Supporting women through the menopause transition
Sex hormones and the menopause transition are covered in the Hormones 2: Male and Female module of IIFM’s 6 month Functional Medicine and Clinical Nutrition program, including BHRT and how to coordinate care with prescribing clinicians.
This article is for the education of healthcare professionals. It is not a substitute for individual medical advice, diagnosis or treatment, and does not change any practitioner’s scope of practice. Regulation and guidelines differ between countries.