What Is Menopause? An A to Z

“I have two women sitting right next to each other in a focus group,” recalls Melissa Melby, PhD, a medical anthropologist at the University of Delaware. “One says, ‘Menopause is great. It means I can have sex with my husband and not worry about getting pregnant anymore.’ Her friend laughs. And she’s like, ‘To me, menopause means I never have to have sex with my husband again.’ For both of them, there was this sense of freedom, but for the exact opposite reason.”

As the ovaries start closing for business, it’s a different story for every woman depending on her physiology, her health, what’s going on in her life, the culture she lives in (Melby’s focus group was in Japan). And “freedom” is not always the first thing that comes to mind. For some of us, menopause feels more as if the body, hormonally tipped off to the impending egg shortage, is on a panicky bank run with alarms going off everywhere—hot flashes, joints afire, parched vaginas and sleep-interrupted nights, mental clarity going up in smoke.

To help you navigate this new reality, we’ve grilled experts, from Harvard researchers to Maori healers, to create an owner’s manual—all the way from A to Z. “Every woman will go through menopause if she lives long enough, absolutely, guaranteed,” says Irene Aninye, PhD, chief science officer at the Society for Women’s Health Research (SWHR). “Don’t fear it. Walk into it like a boss.”

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Average Age

Fifty-one. You officially reach menopause 12 months after your periods stop—which means the ovaries slow down production of estrogen and progesterone and no longer release eggs (one thing to check off the to-do list). It doesn’t happen on a dime, though. Four to 10 years before, these hormones start fluctuating in perimenopause, a phase when your periods become irregular and most of the signs of menopause start showing up. Once you hit the 12-month no-period milestone, you’re entering postmenopause. None of this qualifies as a disease, by the way, but the changes it causes may need treatment.

Bone density

At menopause, your bones start breaking down faster than they’re being built up, increasing your risk of osteoporosis. Lynn Pattimakiel, MD, a physician at Cleveland Clinic in Ohio, suggests getting a baseline bone density test after the first two years or so of menopause and, if you’re not already doing it, adding a weight-bearing component to your workout. “Definitely exercise,” she says.

Brain fog

This is one of the earliest signs. It’s often dismissed by doctors (“It’s probably stress,” they say), but you know it’s way too real as you start losing words and forgetting the obvious, and suddenly a simple instruction sheet looks like string theory because the information is not getting into your head. We’re used to our bodies going UFO on us, but having our minds abducted by some alien force? “There are some women whose brains are exquisitely sensitive to changes in estrogen in terms of their cognitive function,” says Pauline Maki, PhD, a professor of psychiatry, psychology, and obstetrics and gynecology at the University of Illinois at Chicago. Brain fog is also often related to your sleep being disturbed by night sweats, and if that’s the case, menopausal hormone therapy (see M for MHT) could help; otherwise, it’s not so clear. What does improve things, says Maki, is aerobic exercise, restricting alcohol, and challenging your brain by learning something new. One bright note: For many women, in the first year or two of postmenopause, the fog lifts.

Chin hairs

So now you’re growing a beard (and other weird sproutings) and—is this a joke?—going bald. It’s all about the hormones: Estrogen, which promotes scalp hair growth, is declining, and your androgen (male sex hormone) is a little more prominent, which partly explains why the hair starts thinning on top and growing on your face.

Cultural attitudes

Say “menopause,” and most people think of a slow downward slide. That’s not true in some countries. “I am known as Maori, but we call ourselves Tangata Whenua, people of the land,” says Atarangi Muru, who, like other traditional healers in New Zealand, sees ruahinetanga (menopause) as part of a life journey to honor and prepare for. She leads a workshop called Kawa Ariki—The Goddess Returns that offers different exercises and teachings for each phase of a woman’s reproductive life, starting with girls ages 8 to 12 “to ripen” the body for their “first bleed” and going all the way till the end of menstruation, when you become a wise leader. “Most patients are excited to get to ruahinetanga,” explains Christine Bullock, also a Rongoa Maori healer and teacher in New Zealand. “It’s a time when women come into their power. Many find their life purpose, follow dreams and ambitions. And for some, they start anew.”

Maori women have hot flashes, dryness, and joint pain like anyone else (and use natural remedies for each), and Bullock has observed that their main complaint about menopause is that they feel disconnected. Treatment includes counseling, karakia (prayers or chants), and multilayered body work using specific oils and balms to align and balance women’s physical, mental, emotional, and spiritual energy so they’re calmer, more connected, and in control, Bullock says. Who’s ready to move to New Zealand?

There’s a similar mindset in Japan, says Melissa Melby, the medical anthropologist. It may be partially why women there report fewer hot flashes than here (see Y for Yay or nay to yams and soy?). The Japanese word for menopause is konenki, which means a turning point, like your first period and getting pregnant. “One big cultural difference,” says Melby, “is that in the U.S., we tend to medicalize a lot of these turning points and think, There’s one cure, and I need to find it. The women in Japan I studied expected physiological changes, but almost all of them said it’s a period of unbalance and that once you get through it, you will settle into a new equilibrium and it’ll be fine. That’s because old age is something to be embraced–you’re done raising the kids, maybe done taking care of parents, and so to some extent, each hot flash is signifying, Hey, I’m almost to that time where I get to do me.”

Dry AF

The estrogen plunge saps moisture from everywhere, even your vagina (see G for GSM), and it feels like you’re getting wrinkles and crepey elbows overnight. Let’s just take the face. We tried a few of the new menopausal skincare lines, but Keira Barr, MD, integrative dermatologist and menopause specialist, keeps it simple, suggesting that you use a cream or gel stocked with humectants like hyaluronic acid and ceramides that also has occlusives (shea butter, petroleum jelly, coconut oil) to hold the moisture in. Even more importantly, though, look at your life. The stress hormone, cortisol, in no short supply these days, “will chomp up your collagen and elastin and prevent repair,” she says. “So it’s really a matter of taking stock of what you need as a menopausal woman. And that might be going to bed at 8 or getting off social media. Or telling your spouse that they need to wash their own GD dishes.”

Estrogen

By now you’ve got the idea. This powerful sex hormone is breaking up with us–not cold turkey or entirely, but it’s phasing out, and playing a lesser and lesser part in our lives. It’s a major blow because estrogen is—and this is not an overstatement—a woman’s life essence. Not only does it regulate our reproductive health, it also affects the urinary tract, the cardiovascular system, bones, breasts, skin, hair, brain, weight, and fat distribution, among other things—we have receptors for it all over our bodies. So its loss is cause for heartache, yes, but more technically, it’s linked to increased risk of heart disease and osteoporosis, along with pretty much all these other changes we’re feeling.

Fatigue

It’s the number one menopausal complaint around the world, according to a large global survey. Probably the last thing you want to do when you’re exhausted is get out every day and exercise, but it does give you energy. Even a walk helps.

GSM

It stands for genitourinary syndrome of menopause—a mouthful that refers to vaginal dryness (the medical word is atrophy), painful sex, urinary incontinence, and increased UTIs (more on these below). GSM, all caused by the estrogen drought, affects somewhere around 50 to 70 percent of women, and if left untreated, it can get progressively worse. A word on vaginal dryness: “It’s not just about sexual pleasure,” says Makeba Williams, MD, an associate professor at Washington University in St. Louis School of Medicine, who founded a menopause clinic there. “I have patients who are unable to sit, ride a bike. Who cannot wear pants. It impacts their whole quality of life.” As for the urinary problems? Estrogen deprivation also dries out part of the urethra, which can cause dribbling, peeing eight times a night (did we mention fatigue?), and recurring UTIs. Low-dose topical estrogen (via cream, tablets, or ring) can help all these issues whether or not you’re not on MHT.

Heart palpitations

Many women feel their heart racing, pounding, or beating erratically— and for obvious reasons, they panic. Oprah even took medication for it, until she finally learned that it’s actually a common sign you’re heading into menopause and harmless. That’s not to say you shouldn’t check in with your doctor to make sure it’s just that.

Hot flashes and night sweats

These are what bring most women to the brink—and to the doc (easy to laugh until your body gives new meaning to “atmospheric river”). Not only are they wretched, they also cause collateral damage to sleep, cognition, work, mood, and relationships. In the U.S., 75 to 80 percent of women report having hot flashes. They may go away eventually, and often become less bothersome, but they can also last 10 or 20 years, and it’s worse for Black women (see R for Race). They actually start in the brain—specifically in the hypothalamus, which regulates body temperature, and even more specifically, in KNDy (ironically, pronounced “candy”) neurons there. Scientists have shown that if you give women neurokinin B (that’s what the N stands for), you can trigger a hot flash within minutes, which sounds evil but has led pharmaceutical companies to explore non-hormonal drugs that block it, explains Hadine Joffe, MD, professor of psychiatry at Harvard Medical School, who studies menopause and has been involved in some of the research. Astellas Pharma’s drug is already under FDA review, so we could see a new option within the next year—perhaps you saw the Super Bowl ad. Bayer has one in development, too. (See M for MHT and N for Non-hormonal treatments, for what’s available now.)

In a mood

Cranky, irritable, quick to anger—essentially, the B-word. It’s the fluctuations in estrogen as it declines, says Maki, that make us go off when stressed. Depression is more serious. The risk of a major clinical episode—the kind that can stop you from functioning—increases around menopause, especially if you have a history of depression, so it’s something to pay attention to and get treated for. But there’s also a subtler blah-ness that can settle in like mold. Maki describes it as feeling, I’m not as engaged. I’m not finding pleasure anymore in what I used to love–seeing friends, hiking, playing with the dog. A trained professional can help you untangle whether it’s hormonal or something more.

Insomnia

We know that not getting enough shut-eye takes a toll on your body—and that certainly happens when you’re woken up by drenching sweats and having to pee a million times and can’t get back to sleep. But in the menopausal period, says Harvard’s Joffe, you have two more strikes against you (who dreams this stuff up?). First, research shows that you can wake up in the middle of the night even if you don’t have night sweats. But say you have them—even when you slip back to sleep and get a full eight hours, you’re still likely to suffer.“If somebody had two flashes last night,” she says, “we’ve shown that the non-hot flash part of their sleep is usually very poor. It’s bad sleep because the temperature changes are all off.” That can make your brain foggy, mood worse, and energy flag while firing up the old appetite hormones, which leads to weight gain. Focusing on consolidated sleep is key, she says, ideally without sleep medications. Cognitive behavioral therapy for insomnia has been shown to be just as effective as sleep medication, with zero side effects.

Joint pain

Is chronic tennis elbow or a bum knee bringing you down? There are a number of possible culprits, but the usual suspect is definitely one of them. “Estrogen receptors are in muscle cells, and they are in bone cells—and a decline can cause pain,” says Williams at Washington University. “When we treat women who have hot flashes with hormone therapy, we often see relief in the joints.”

Ka-ching!

Enter the “meno-preneurs!” It’s a $17 billion-and-growing global market. Maybe you don’t want to fork over your paycheck for the fancy products, but they’re paving the way for more solutions, both luxe and affordable. And all that modern branding is going a long way to destigmatize menopause.

Kegels

Do them standing in line at the ATM or at your desk (imagine you’re peeing and pull up and in to stop the flow, hold, and repeat) to make your orgasms more intense and help stop any leakage when you jump around or sneeze. “Highly recommended,” says Pattimakiel.

Layers

Wear them so you can peel them off! There’s nothing worse than being trapped in a turtleneck sweater with nothing but a bra underneath. Also consider a portable fan or a fancy facial mist.

Libido

(Yo, where’d you go?) Dwindling hormones can evaporate your lust, for sure. But sexual desire is so enigmatic, at times headstrong and other times evasive, it’s hard to pin down what’s making it dip. Hypertension medications, antidepressants, caretaking stress, and not having a minute to yourself could all be killing the mood. Also, how’s your relationship going? “People want me to write a prescription,” says Williams. “But nothing I prescribe is going to be helpful if you don’t like your partner.”

MHT (menopausal hormone therapy)

To hormone or not to hormone is often the big question. The current thinking is that it’s quite safe to start taking for women who are newly menopausal or within 10 years postmenopause, unless they have a history or high risk of breast cancer or cardiovascular disease. “It’s also appropriate for women in their late 40s still in perimenopause with severe hot flashes,” says endocrinologist Kathryn A. Martin, MD, at Massachusetts General Hospital, who combs through research as a senior editor of UpToDate, an online clinical reference for physicians. Typically, doctors prescribe the lowest effective dose for the shortest time while recalculating the risks and benefits.

There are a number of hormonal drug options, including bioidenticals approved by the FDA. Martin says a go-to is the bioidentical 17-beta estradiol, “the same estrogen that the ovary makes—you can take it orally, transdermally, as a gel, vaginally.” If you’re among the third of women in the U.S. who get a hysterectomy, that’s all you need. However, because estrogen increases the risk of endometrial cancer, if you have a uterus, you also need progestin (see P). Click for more on the safety of these therapies and how to get affordable access.

Non-hormonal treatments

Antidepressants like Paxil in low doses can relieve hot flashes (though not as effectively as MHT). Gabapentin, a seizure medication, is also prescribed sometimes. For non-drug options, cognitive behavioral therapy for hot flashes can also work, as does a very specific form of hypnosis, says Maki. Or try an essential oil. Bullock, the Maori healer, recommends the following formula with ingredients you can use in massage or body work: 10 drops of clary sage, 11 drops of geranium, 7 drops of lemon, 2 drops of sage; dilute in 1 ounce of carrier oil.

Odors

It’s a thing. Your body odor can change. Experts at Harvard chalk it up to sweat from hot flashes nourishing underarm bacteria or your testosterone getting the upper hand (See C for Chin Hairs), which can attract more bacteria to that sweat. But they also point out that our sense of smell can change, “making us think we stink even when we don’t.” Just amp up the deodorant and soldier on.

Ovaries

The inside girls responsible for all this havoc (they not only stop releasing eggs but also mess with your estrogen and progesterone). If you have surgery to remove them, you will go into menopause immediately.

Progesterone

Consider it estrogen’s ride-or-die: The two hormones go down together like Thelma and Louise as you approach menopause. When it’s paired with estrogen as part of MHT, it comes in various forms—often in the FDA-approved bioidentical micronized progesterone. If you’ve had a Mirena, the IUD that delivers progestin (synthetic progesterone), your doctor may keep you on it and simply add estrogen if you start getting hot flashes.

Questions to ask your gynecologist or internist

To get the most out of a visit, track your period: when it starts and ends, how heavy it is, and any symptoms (cramps, hot flashes etc.) that come with it, says SWHR’s Irene Aninye. It will help pin down when you are actually in menopause (since even without brain fog, it’s hard to remember when your last period was). If your doc suggests MHT or other drugs, says Aninye, ask: How long before I should expect relief? What does relief look like? What are the risks? What are the side effects? “If you don’t feel heard, and you’ll probably know that halfway through the appointment, you should find another doctor.” To locate one, check out The North American Menopause Society or The American College of Obstetricians and Gynecologists. Other good resources: National Menopause Foundation and SWHR’s tool kit.

Race

Williams at Washington University published compelling research showing that African American women have hot flashes more frequently and for longer—10 years compared to 6.5 on average for white women—and are less likely to receive MHT treatment. If you are Black, grinning and bearing it is the wrong message, she says. Instead, look at menopause as a wake-up call to learn about your body and become your own advocate. Talk to your doctor about how to prevent the risks of heart disease and other conditions that now go up. “This is an important time for us to optimize your health,” Williams says.

Sex

It can hurt. And sometimes a lot. Even when your libido is healthy, your vagina might as well have strep throat, it’s so dry. If an over-the-counter lubricant or daily vaginal moisturizer doesn’t help, doctors can prescribe low-dose estrogen as a local cream, tablet, or ring. The FDA also has approved a non-hormonal oral drug called Osphena that targets the tissues down there.

Telehealth

Today you can actually get hormonal drugs prescribed online. Midi Health does it through video visits with menopause-trained doctors and nurse practitioners, while at Alloy and Evernow, treatment is determined based on questions you answer, with clinicians you can follow up with via messaging. Maki is on the medical advisory boards for Alloy and Midi, but other experts we spoke with had mixed reactions. If you do take this route, make sure you tell your doctors everything.

Uptick in risks

It’s a good time to get checked for heart disease, diabetes, and osteoporosis because your odds of a problem go up at menopause. It’s also a good reason to start exercising if you’re not, because that can help all three, especially if it includes weight-bearing activity.

UTIs

Antibiotics may not be the remedy for UTIs in menopause because they’re usually due to dryness and thinning of the urethra. “Sometimes it’s just irritation,” Pattimakiel says. “But that can also predispose you to an infection as well. The gold standard for treatment, if it’s safe for you, is a local estrogen, like a cream.”

Vibrators

Playing with these buzzy toys may actually be good for your vaginal health, per a study out of Cedars-Sinai Medical Center. Benefits include increased sexual desire and satisfaction, stronger pelvic floor muscles, and less trouble with urinary incontinence.

Weight gain (and the disappearing waist)

Good news: It’s not the calories. Bad news: With estrogen’s exit, you lose muscle mass and your metabolism slows down. The fat rearranges itself, too, huddling more around the middle. You know what to do (exercise, eat healthy food in moderation), but if your muffin top is making you insane, try to go with the flow.

Gen X

Ages 43 to 58, is the generation hitting menopause right now—somewhere around 40 million women strong. Just as we latchkey kids figured out everything else on our own, we’re pioneering this beast, and doing it our way. We’re the first to speak out about it and do away with the stigma, while coming up with efficient solutions like ordering drugs online. Who has time to be debilitated by hot flashes and brain fog?

Yay or nay to yams and soy?

Wild yams have been thought to promote estrogen production in the body, but there’s little evidence they help menopausal symptoms (a study using it as a topical cream showed no statistical difference between that and a placebo). Soy contains phytoestrogens, which is why people got the idea that scarfing edamame and tofu could relieve hot flashes naturally, plus there’s the data on Japanese women, who eat a high-soy diet and have fewer hot flashes. But overall, the research shows it isn’t any more effective than a placebo.

Zenith

You are here. Physically, things are changing, but aren’t they always? This is your most powerful time. You’ve got wisdom, experience, and passion. And you never have to deal with a jammed tampon dispenser in the restroom again. Most of these bodily injustices can be treated; many will pass. And you have a world of female sisterhood who can relate. It’s time to focus on what you want. No more emotional zigzagging or zombie brain, just zest for life and the deep zen of knowing you’ve arrived.

Any content published by Oprah Daily is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. It should not be regarded as a substitute for professional guidance from your healthcare provider.

In a refreshingly candid conversation with Oprah Daily Insiders, Oprah, Maria Shriver, Drew Barrymore, and doctors Sharon Malone, Heather Hirsch, and Judith Joseph, we set the record straight on all things menopause. Become an Oprah Daily Insider now to get access to this conversation and the full “The Life You Want” Class library.