The 3 stages of menopause and what to expect from each one

The process of menopause generally refers to the point at which an individual has their last menstrual period, signaling the end of their ability to become pregnant. This phase of life is often spoken of as a single, undifferentiated stretch of time. In reality, however, medical professionals recognize three separate phases of the process, each with certain characteristic signs and symptoms. It may be helpful to understand the stages of menopause if you’re nearing or undergoing this midlife transition. This guide will break down the three stages of menopause so you can get an idea of what to expect. 

Stage 1: Perimenopause

The initial onset of menopause symptoms is known as perimenopause. This is the point at which menstrual cycles begin to happen irregularly, with more and more time between each one. That’s why someone who always had irregular cycles throughout their life may not realize that perimenopause has begun until other symptoms appear. A perimenopausal person may also notice a heavier menstrual flow than they’re used to. 

The irregularity of a person’s cycle at this stage occurs because their ovaries are nearing the end of their supply of egg cells. In general, people who are assigned female at birth are born with all of their eggs and ovarian follicles already in place, and they will release them throughout their life during each ovulatory cycle. With fewer and fewer follicles remaining, it’s more difficult for the usual hormonal cycles to trigger ovulation. 

As the ovaries begin releasing fewer eggs, they also decrease their production of estrogen. This leads to changes in a wide range of different bodily processes that respond to estrogen signaling.

Signs and symptoms of perimenopause

In addition to irregular periods, a person may also experience mood swings in perimenopause as their hormone levels begin to fluctuate erratically. Difficulty concentrating and feelings of irritability and sadness are common. The American Council on Aging estimates that around four in 10 people experience mood-related symptoms in perimenopause. 

That said, perhaps the most common symptom of perimenopause is hot flashes, or episodes of sudden heat, flushing, and sweating. Hot flashes can be experienced while awake or during sleep, with the latter usually being referred to as night sweats. 

Other symptoms that may begin in perimenopause include:

• Sleep disruption. Many people find that they have a harder time sleeping through the night during perimenopause. This can be partly due to night sweats, but even people who don’t experience them may notice disturbed sleep.
• Depression. The early and middle stages of menopause may carry an elevated risk of depression. It’s not clear whether this is due to hormonal factors, distress related to the changes in one’s life and body, or both. Regardless, monitoring your mental health and looking out for warning signs of depression in particular during menopause can be beneficial. 
• Genitourinary syndrome of menopause (GSM). Decreasing estrogen levels during perimenopause can lead to changes in both the sexual organs and the urinary system. Vaginal dryness, thinning of the vaginal walls, and shrinking of the vaginal canal are all common. These may result in irritation, pain, or even bleeding during sexual intercourse and/or urination.
• Loss of libido. Along with physical difficulties commonly associated with sexual activity during this time, the drop in hormones associated with perimenopause may reduce a person’s sexual desire. 
• Migraines. Some people experience migraines or more frequent migraines as perimenopause sets in.
• Uterine symptoms. The same hormonal changes that can lead to heavier menstrual periods during perimenopause may also increase the risk of benign (but sometimes painful) growths in the uterus as well as endometriosis.
• Weight changes. Many people experience unwanted weight gain during perimenopause and beyond. A shift in the distribution of weight is also common, such as more fat tissue settling at the waist and belly than the hips and thighs.

Perimenopause onset and duration

The time at which a person begins menopause can vary depending on several different factors, including:

• Their mother’s age at menopause onset
• The age at which they entered puberty
• Use of hormonal birth control
• Number of past pregnancies
• Ethnicity
• Socioeconomic status
• Use of alcohol and tobacco
• Level of physical activity

That said, most people begin perimenopause between the ages of 40 and 58. If it begins before age 45, it’s considered “early menopause,” which can represent a significant risk factor for health complications such as type 2 diabetes, heart disease, and osteoporosis. Perimenopause can last anywhere from one to 10 years, with the average duration being three to four years.

Maintaining healthy lifestyle habits during perimenopause may help preserve your well-being through the remaining stages of this transition. For instance, exercising and eating nutritious foods during this stage may be much more effective in preventing unwanted weight gain than at any later point. Also note that those who choose to engage in hormone therapy to help manage menopause symptoms are generally advised to speak to their doctor about beginning the regimen during this stage.

Stage 2: Menopause

Menopause is the stage in which ovulation and menstrual cycles permanently cease. Since periods are likely to already be highly irregular at this point, it’s often hard to pinpoint exactly when this stage begins. That said, doctors generally won’t consider menopause to have ‘officially’ started until a person has gone a full 12 months without menstruation. This means that true menopause is almost always the shortest of the three stages. In most cases, it’s very difficult to distinguish from perimenopause until it’s over.

It’s also worth noting that menopause may be induced artificially for medical reasons. This can happen if the ovaries or uterus are surgically removed, and it may also be a side effect of certain kinds of chemotherapy for cancer. In some cases, chemically induced menopause may only be temporary, with ovulatory activity resuming after treatment stops. 

Compared to natural menopause, induced menopause may lead to a more rapid and intense onset of menopausal symptoms. The hormonal shifts generally happen in a much shorter time frame, which may make the transition more difficult. As with premature menopause, induced menopause may place a person at higher risk for certain negative health outcomes.

Signs and symptoms of menopause

In general, the effects of menopause are the same as those of perimenopause. The main exception is the symptom of irregular and heavy periods—because during menopause, the menstrual cycle stops completely. Meanwhile, other symptoms may increase in intensity. Hot flashes, sleep disruptions, uterine growths, depression, and migraines are often at their worst during the transition from perimenopause to menopause.

Menopause onset and duration

A large-scale survey conducted in 2019 reports that the average age of menopause onset is currently 51.4 years. However, this time frame can vary from person to person based on many different factors.

The length of this phase is defined differently by different sources. Some medical professionals consider it a transitional marker rather than a distinct time period. For the purpose of this article, stage two of menopause spans the last year or so following your final menstrual period.

Stage 3: Postmenopause

Postmenopause is usually the longest phase of the three, encompassing the remainder of one’s life following menopause. Once a postmenopausal person is no longer undergoing monthly hormonal cycles, their body should begin to settle into a new equilibrium.

This may not happen all at once. Some menopause symptoms—like hot flashes, migraines, sleep disturbances, and depression—may persist for several years during the postmenopausal period. In many cases, though, they’ll begin to decline gradually as the body adjusts.

Signs and symptoms of postmenopause

Again, certain symptoms tend to increase in severity during postmenopause rather than decrease. For instance, the tendency toward weight gain may slow, but postmenopausal people will likely continue to accumulate belly fat in the absence of healthy lifestyle changes.

Since estrogen levels generally remain low, genitourinary syndrome becomes even more common in this stage. Even people who didn’t experience symptoms like vaginal tightening or dryness at younger ages may begin to notice them in postmenopause, which may contribute to difficulties with sexual intercourse. Osteoporosis, or the loss of bone density, is also a common feature of postmenopause. This can leave a person more vulnerable to bone fractures and related injuries. 

For many people, it’s possible to reduce and/or manage many of these symptoms and lead a healthier, more comfortable life. Lifestyle factors like regular physical activity, a nutritious diet, time spent outdoors, and the reduction of alcohol and tobacco consumption can often slow the advance of osteoporosis and weight gain, for example. Additionally, according to the North American Menopause Society, engaging in regular sexual activity may help reduce the decline in vaginal health. Various non-prescription vaginal lubricants and moisturizers can help make this more practical and enjoyable. For support with menopause-related health concerns, contact your doctor.

Navigating menopause with the guidance of a therapist

The changes described above may be stressful and disorienting, and it can be helpful to reach out for support during this time. Connecting with friends who are in the same life stage or joining a support group are two options. Another is meeting with a therapist, who can offer you a safe space to express your emotions and provide you with healthy coping mechanisms for managing the challenges of this time.

People who live in rural areas or who don’t have reliable transportation often find it difficult to receive traditional, in-person care from a therapist. In such situations, online therapy can represent a more convenient way to connect with this type of provider. A virtual therapy platform like BetterHelp can make it even easier, since you can fill out a brief questionnaire online and then can get matched with a licensed provider who you can meet with via phone, computer, or tablet from home. Research suggests that online therapy can be as effective as in-person care for addressing a variety of mental health challenges. 

Takeaway

The intensity and frequency of symptoms can shift throughout the three stages of menopause, but they tend to have many features in common. Effects like hot flashes, mood fluctuations, sleep disturbances, and changes in vaginal health are usually a part of each phase. Everyone experiences menopause differently, including symptoms, onset, and duration. Reaching out for social support or the support of a trained therapist can be helpful as you navigate this transitional period, and connecting with your doctor for health advice is also recommended.