Hormonal health
Key facts
Menopause is one of the stages in the continuum of women’s* lives and marks the end of the years during which they can conceive a child. After menopause (i.e. once a woman is postmenopausal), she can no longer become pregnant, except in rare cases where specialized fertility treatments are used.
Most women(1) experience natural menopause between the ages of 45 and 55 as part of normal biological ageing.
Menopause is caused by the cessation of the ovarian follicular cycle and a fall in circulating oestrogen levels in the blood.
The transition to menopause can be gradual, usually beginning with changes in the menstrual cycle. Perimenopause refers to the period starting from when these signs are first noticed and ending one year after the last menstrual period.
Perimenopause can last several years and can affect physical, emotional, mental and social well-being.
A range of hormonal and non-hormonal interventions can help relieve perimenopausal symptoms.(2)
Menopause can also result from surgical or medical interventions.
How menopause occurs
For most women, menopause is marked by the end of their monthly menstrual cycles (also called menses or periods) due to the cessation of ovarian follicular function. This means the ovaries stop releasing eggs for fertilization.
The regularity and length of the menstrual cycle vary across a woman’s reproductive life, but the age at which natural menopause occurs is generally between 45 and 55 years for women worldwide.
Natural menopause is considered confirmed after 12 consecutive months without periods, in the absence of other obvious physiological or pathological causes and clinical interventions.
Some women experience menopause earlier (before age 40). This early menopause can be due to certain chromosomal abnormalities, autoimmune disorders or other still unknown causes.
It is not possible to predict exactly when a woman will reach menopause, although there are links between age at menopause and certain demographic, medical and genetic factors.
Menopause can also be induced by surgical interventions involving the removal of both ovaries, or by medical interventions that stop ovarian function (for example, radiotherapy or chemotherapy).
Many women have already stopped having periods before reaching menopause, for example those who have undergone certain surgical procedures (hysterectomy or surgical removal of the uterine lining), as well as those using certain hormonal contraceptives and other medicines that suppress or reduce menstrual bleeding. They may nevertheless experience other changes related to the transition to menopause (perimenopause).
Changes associated with perimenopause and menopause
The hormonal changes associated with the perimenopausal transition and menopause can affect physical, emotional, mental and social well-being. Symptoms experienced during perimenopause and after menopause vary widely from person to person. Some women have few or no symptoms. For others, symptoms can be severe and affect daily activities and quality of life. Some people may experience symptoms for many years.
Symptoms associated with perimenopause and menopause include:
Hot flashes and night sweats: a hot flash is a sudden sensation of heat in the face, neck and chest, often accompanied by skin flushing, sweating, palpitations and intense physical discomfort that can last several minutes;
Changes in menstrual cycle regularity and flow, eventually leading to the complete cessation of periods;
Vaginal dryness, pain during sexual intercourse and incontinence;
Sleep disturbances/insomnia; and
Mood changes, depression and/or anxiety.
Perimenopause and menopause can also be accompanied by changes in body composition and altered cardiovascular risk. The advantage that women have over men in terms of cardiovascular disease decreases progressively as oestrogen levels fall significantly after menopause.
Menopause can also lead to weakening of the pelvic support structures, increasing the risk of pelvic organ prolapse. Loss of bone density at menopause contributes significantly to the higher rates of osteoporosis and fractures.
A range of hormonal and non-hormonal interventions can help relieve perimenopausal symptoms. Symptoms that affect health and well-being should be discussed with a health-care provider in order to determine the available options for management, taking into account medical history, values and preferences.
During perimenopause, pregnancy is still possible. Contraception is recommended to avoid an unintended pregnancy until 12 consecutive months have passed without menstruation. Pregnancy after menopause is unlikely without fertility treatment involving the use of donor eggs or previously frozen oocytes.
During perimenopause and after menopause, it is still possible to acquire sexually transmitted infections (STIs), including HIV, through unprotected sexual contact, including oral, anal and vaginal sex. Thinning of the vaginal wall after menopause increases the risk of injury and tearing, and therefore the risk of HIV transmission during vaginal intercourse.
The importance of understanding perimenopause and menopause
It is essential to see menopause as one stage in the continuum of women’s lives. The health status of a woman entering perimenopause is largely determined by her medical and gynaecological history, lifestyle and environmental factors. Symptoms in perimenopause and postmenopause can disrupt personal and professional life, and the changes associated with menopause will affect a woman’s health as she grows older. Consequently, care during perimenopause plays an important role in supporting healthy ageing and good quality of life.
Menopause can be a major transition socially as well as biologically. Socially, a woman’s experience of menopause may be influenced by gender norms, family and sociocultural factors, including how women’s ageing and the transition to menopause are perceived in her culture.
Worldwide, the population of postmenopausal women is increasing. In 2021, women aged 50 years and over represented 26% of all women and girls globally, a rise of 22% compared with 10 years earlier.(i) In addition, women are living longer. Globally, a woman aged 60 years in 2019 could expect to live, on average, a further 21 years.(ii)
Menopause can offer an important opportunity to review one’s health, examine lifestyle and reconsider goals.
Public health issues related to perimenopause and menopause
Women in perimenopause need access to quality health services and to communities and systems that can support them. Unfortunately, both awareness of and access to information and services related to menopause remain limited in most countries. It is common for menopause not to be discussed in families, communities, workplaces or health-care settings.
Women may not realize that the symptoms they are experiencing are related to the perimenopausal transition or to menopause, or that they can obtain advice or treatments that will help relieve these symptoms. People with menopausal symptoms may sometimes feel embarrassed or ashamed to draw attention to what they are going through and to ask for help.
Health-care providers are not always trained to recognize symptoms of perimenopause and postmenopause and to advise patients on treatment options and ways to stay healthy after the transition to menopause. In many health worker training programmes, menopause currently receives only limited attention.
The sexual well-being of postmenopausal women is neglected in many countries. This means that common gynaecological effects of menopause, including vaginal dryness and pain during sexual intercourse, may not be treated. Similarly, older women may not see themselves as being at risk of sexually transmitted infections, including HIV, or may not receive appropriate counselling from health-care providers on safer sexual practices or on testing.(iii)
Many governments lack health policies and funding that would allow diagnostic, counselling and treatment services related to menopause to be included in routine services. Services related to menopause are a difficult challenge in settings where there are often other urgent, competing priorities for health funding.
WHO action
WHO considers that social, psychological and medical support during the transition to menopause and afterwards should be an integral part of health care. WHO is committed to improving understanding of menopause by:
raising awareness of menopause and its impact on women at individual and societal levels, and on the health and socioeconomic development of countries;
advocating for the inclusion of diagnosis, treatment and counselling related to the management of menopausal symptoms within universal heal
promoting the inclusion of training on menopause and treatment options in the initial curricula of health workers; and
emphasizing a life-course approach to health and well-being (including sexual health and well-being), ensuring that women have access to appropriate health information and services to support healthy ageing and a high quality of life before, during and after perimenopause and menopause.
Notes
(1) While most personal experiences of menopause are those of cisgender women (who are assigned female at birth and identify as women), transgender men and some people who do not identify as either men or women also go through menopause.
These guidance notes on menopause refer to “women” in line with the available data, which do not systematically identify gender identity. There are few readily available data on the menopausal experiences of transgender people and people of diverse gender identities. As they age, these people have unique health needs that clinicians should take into account, including by referring them to specialized services when needed.
(2) Although menopause is not a disease, these guidance notes refer to the experiences of perimenopause and postmenopause as “symptoms”, because they can cause levels of discomfort that negatively affect quality of life.
