Natural menopause (primary natural ovarian failure) is clinically defined as 12 consecutive months of amenorrhea (complete absence of menstrual bleeding), excluding other physiological or pathological causes. The average age of menopause is from 45-55 years old. It marks the permanent depletion of ovarian follicules and eggs primarily due to aging.​

 

There are other primary causes of menopause including surgical menopause from bilateral ovary removal and iatrogenic menopause from pelvic radiation or certain medications like chemotherapy. Secondary causes of amenorrhea occur too, where the eggs and follicles do not run out--they are just dormant. Secondary central (hypothalamic/pituitary) causes include functional hypothalamic amenorrhea (driven by low energy availability, extreme exercise, rapid weight loss, or severe psychological stress), hyperprolactinemia (pituitary adenomas, psychiatric medications, hypothyroidism...), severe systemic disease (e.g., uncontrolled diabetes), and physical hypothalamic-pituitary damage (trauma, radiation, tumors, or postpartum ischemia from severe blood loss/Sheehan syndrome). Secondary peripheral and metabolic causes include chronic anovulatory disorders, like polycystic ovary syndrome (PCOS) and severe obesity. A high LH to FSH ratio will typically be present. 

 

Perimenopause is the period before a woman's final menstrual period. It can occur years prior to menopause. It is characterized by erratic hormonal fluctuations, irregular menstrual cycles, and the onset of vasomotor and systemic symptoms. The vasomotor symptoms usually peak leading up to menopause and then usually decrease over the next few years. 

 

What happens in the body during this time is that is ovarian egg reserve diminishes, leading to decreased production of progesterone and estradiol. Estrogen receptors are distributed throughout the brain, cardiovascular system, bone matrix, genitourinary tract, and skin, explaining the widespread systemic nature of menopausal symptoms.

Common Symptoms

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• Vasomotor Symptoms (VMS):

  • Hot flashes and night sweats

• Genitourinary Syndrome of Menopause (GSM):

  • Vaginal dryness, burning, irritation, and dyspareunia (painful intercourse)

  • Urinary urgency and frequency

  • Recurrent urinary tract infections (UTIs)

• Neuropsychiatric & Cognitive Changes:

  • Mood disturbances, irritability, anxiety, depressive symptoms, sleep disturbances, and brain fog.

• Somatic & Metabolic Changes:

  • Fatigue, joint and muscle aches, weight redistribution over abdomen, and accelerated bone mineral density loss.

Diagnostics

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• History and Physical Exam

• Pregnancy Test

• Other Laboratory Assessment (not always Indicated, but it should be for women under 45 years of age):

  • FSH, LH, prolactin, estradiol levels

  • Thyroid-Stimulating Hormone (TSH) 

Management & Treatment

Non-Hormonal & Lifestyle Interventions

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• Environmental & Lifestyle Modifications: Layered clothing, maintaining a cool ambient temperature, avoiding known triggers (spicy foods, caffeine, alcohol), regular aerobic exercise, and smoking cessation.

• Non-Hormonal Pharmacotherapy: For patients with contraindications to hormone therapy or those who prefer non-hormonal options:

  • Low-dose SSRIs / SNRIs: (e.g., paroxetine, venlafaxine) to reduce vasomotor symptom frequency and severity.

  • Neuromodulators: Gabapentin or pregabalin for nocturnal vasomotor symptoms and sleep disruption.

  • NK3 Receptor Antagonists: Non-hormonal agents (e.g., fezolinetant) specifically designed to target the thermoregulatory center in the hypothalamus to reduce hot flashes.

Hormone Replacement Therapy

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• The Gold Standard for VMS: Hormonal therapy remains the most effective treatment for moderate-to-severe vasomotor symptoms and the prevention of bone loss when initiated within 10 years of menopause onset or before age 60 (the "window of opportunity").

• Estrogen-Alone vs. Combined Therapy:

  • Estrogen Therapy (ET): Prescribed for women without a uterus (hysterectomy) to eliminate the risk of endometrial hyperplasia.

  • Estrogen-Progesterone/Progestin Therapy: Prescribed for women with an intact uterus to protect the endometrium from unopposed estrogen-induced hyperplasia and malignancy.

• Routes of Administration: Transdermal estrogen patches, gels, or sprays are often preferred over oral formulations due to a lower risk of venous thromboembolism (VTE) and neutral triglyceride profiles.

• Genitourinary Management: Low-dose vaginal estrogen preparations (creams, rings, or tablets) provide targeted relief for GSM with minimal systemic absorption, making them safe for many women who cannot take systemic hormone therapy.

Bone Health & Cardiovascular Protection
 

• Bone Mineral Density Monitoring: Baseline DEXA scans for postmenopausal women aged 65 and older (or younger postmenopausal women with clinical risk factors for osteoporosis/fragility fractures with high FRAX score).

• Calcium and Vitamin D: Ensuring adequate daily intake to support bone matrix integrity.

• Cardiovascular Risk Reduction: Emphasizing blood pressure control, lipid management, regular physical activity, and a heart-healthy diet to mitigate postmenopausal increases in cardiovascular risk.