Menopause series · Part 1
Understanding the stages and challenges of menopause
Women go through remarkable physical changes throughout their lives. In this series, I focus on what happens to the body before, during, and after menopause — starting here with the stages, the hormones behind them, and the challenges you can expect.
Key takeaways
Menopause unfolds in four stages: premenopause, perimenopause, menopause, and postmenopause.
Five hormones drive it — FSH, LH, GnRH, progesterone, and estrogen; late in menopause, estrogen/progesterone fall while FSH/LH stay high.
Falling estrogen touches many systems: urinary, vaginal, brain, temperature regulation, joints, and metabolism.
Thyroid and blood sugar problems often hide behind “it’s just menopause” — both are worth checking.
In this article
I. The four stages of menopause
II. The role of hormones
III. Changes that occur through the stages
IV. Challenges during menopause
V. Common questions
The four stages of menopause
Menopause indicates the end of reproduction for a woman. There are several stages, and the whole process can take a few years. Most women reach menopause in their 40s or 50s, but the average age in the United States is 51.1
01Premenopause
Before any menopausal symptoms. Periods continue (regular or irregular) and reproductive years are ongoing. Hormonal changes can begin 8–10 years before menopause — often in the 40s, sometimes the 30s. I like to start checking hormones around age 35 to be sure they’re adequate, and sooner if symptoms or illness warrant it.
02Perimenopause
“Around or near menopause.” Symptoms of hormonal change begin. The average length is about four years — for some just a few months, for others longer. Pregnancy is still possible during this stage.
03Menopause
Reached when a woman has gone 12 consecutive months without a period. The ovaries have stopped releasing eggs and have stopped producing most of their estrogen. Average age: 51.
04Postmenopause
Once it has been over a year since the last menstrual cycle, a woman is postmenopausal — and remains in this stage for the rest of her life.
Symptoms and challenges of perimenopause can be very similar to those of menopause and postmenopause.
The role of hormones
Hormones are chemical messengers secreted into the blood or other fluids; they carry instructions to target sites around the body. Five hormones are central to menopause. Here’s what each one does before we get to the challenges.
Follicle-stimulating hormone (FSH)
Controls much of the menstrual cycle and stimulates the growth of eggs in the ovaries. Levels vary through the cycle and peak just before an egg is released.
Luteinizing hormone (LH)
Helps control the menstrual cycle and triggers the release of an egg from the ovary. Both FSH and LH stimulate estrogen production — specifically estradiol.
Gonadotrophin-releasing hormone (GnRH)
Released by the hypothalamus to stimulate the pituitary’s release of FSH and LH.
Progesterone
Prepares the endometrium (the uterine lining) for a potential pregnancy and stops uterine contractions that would reject an egg. If pregnancy occurs, levels stay high and prevent ovulation; if not, they fall and the cycle continues.
Estrogen
A major player from puberty onward. Mostly made by the ovaries, with small amounts from the adrenal glands and fat tissue. Estrogen is responsible for:
Breast growth in puberty
Pubic and underarm hair growth
Onset and regulation of the cycle
Cholesterol control
Protection of bone health
Health of brain, heart & skin2
As perimenopause and menopause begin, hormone levels can still look somewhat normal. But in the later stages, estrogen and progesterone are low while LH and FSH climb, trying to stimulate estrogen — and FSH and LH then stay high for the rest of a woman’s life.
The hormone feedback loop
Hypothalamus
releases GnRH
→
Pituitary
releases FSH & LH
→
Ovaries
make estrogen & progesterone
In menopause the ovaries stop responding, so there’s not enough estrogen to “switch off” FSH and LH — and they stay elevated for good.
Changes that occur through the stages
Here are the major shifts happening in a woman’s body as she reaches menopause:
1
Follicles are exhausted. Ovarian follicles hold egg cells released at ovulation; over time they steadily decline. In perimenopause some remain and pregnancy is still possible (though harder); by menopause they are significantly fewer.
2
Ovaries stop releasing eggs. The hallmark of menopause. Periods and ovulation grow irregular as you approach it, then ovulation stops entirely.
3
Ovaries stop making estrogen and progesterone. Estrogen now comes from adrenal production and fat cells. Lower estrogen slows the metabolic rate at which women use starches and carbs, contributing to menopausal weight gain.
4
LH and FSH rise. With little estrogen to turn them off, FSH and LH levels increase and remain high.
Challenges during menopause
These changes can bring a range of challenges — from the classic hot flashes to mood swings to UTIs. Here’s an overview of what to expect; later articles in this series go deeper on how I help patients address each one.
Urologic challenges
Estrogen strengthens the bladder’s surface layer; as it falls, the urethra and bladder lining thin, forming folds where infections thrive — so UTIs become more common. Some women have painful urination (dysuria); others have no symptoms yet show a UTI on urinalysis. Continual UTIs slowly wear down the immune system, opening the door to more inflammation and infection.
Vaginal changes
Lower estrogen can make the vulvar tissues and vaginal lining thinner, drier, and less elastic (vulvovaginal atrophy), with less lubrication — causing dryness, itching, burning, irritation, or pain, and uncomfortable intercourse.3 Timing varies widely. Similar symptoms can also point to a yeast or bacterial infection or a UTI. I like to use all-natural vaginal suppositories while we work on regulating hormones and other factors.
Neurologic challenges
Brain cells carry estrogen receptors, so reduced estrogen means reduced signaling — leaving the brain more susceptible to dysfunction. Research increasingly shows a connection between menopause and Alzheimer’s, and menopause can also bring headaches, mood changes, memory loss, depression, and anxiety.4,5
Hot flashes & night sweats
A sudden feeling of warmth, usually around the face, neck, and chest, sometimes with a rapid heartbeat, flushing, anxiety, or sweating — typically lasting about five minutes, often followed by a chill. Night sweats can cause long-term sleep disruption. The likely mechanism: lower estrogen makes the hypothalamus (your thermostat) more sensitive to small temperature changes, triggering a “cool-down.”6
Joint pain
Low estrogen is associated with more joint pain — old injuries may ache again, and joints may hurt overall. Estrogen is thought to reduce inflammation, so its loss may let inflammation (and pain) rise.
Weight gain
With estrogen now coming from fat cells and adrenals, the body processes starches and carbs differently. Weight that once settled on the thighs and buttocks (subcutaneous fat) tends to move to the abdomen as visceral fat — which makes little estrogen and is more inflammatory. Thyroid function can also decline now, and because hypothyroidism shares symptoms with menopause (fatigue, mood swings, sleep issues), it’s often missed — which is why a proper thyroid panel matters.7 Blood sugar can dysregulate too, as shifting estrogen and progesterone change how cells respond to insulin — covered in depth in effects of menopause on blood sugar.8
Postmenopausal women often do well with a lower-carb diet and nutritional support to keep blood sugar normal and stay at their optimal weight. These challenges can feel overwhelming — but our caring, skilled practice can help. I would love to support you in meeting your health goals and feeling like yourself during this important transition.
When to seek medical care
Any bleeding after menopause (12+ months without a period) should always be evaluated by a physician. Also seek care for recurrent UTIs, severe mood changes or depression, or symptoms that disrupt daily life. Menopause is normal — but its symptoms deserve real attention, not dismissal.
The menopause series
Part 1
Understanding the stages and challenges of menopause (you’re here)
Common questions
What are the four stages of menopause?
Premenopause (reproductive years, before symptoms), perimenopause (“around menopause,” when symptoms of hormonal change begin, averaging about four years), menopause (12 consecutive months without a period), and postmenopause (the rest of life after that point).
At what age does menopause usually happen?
Most women reach menopause in their 40s or 50s; the U.S. average is 51. Hormonal changes can begin 8–10 years earlier, which is why checking hormones around age 35 — or sooner if symptoms warrant — can be valuable.
Which hormones change during menopause?
Five are central: FSH and LH (which stimulate estrogen and control the cycle), GnRH (which signals the pituitary to release FSH and LH), progesterone, and estrogen. Late in menopause, estrogen and progesterone are low while FSH and LH rise and stay high.
Can menopause symptoms be confused with thyroid problems?
Yes. Hypothyroidism shares symptoms with menopause — fatigue, mood changes, and sleep disturbances — and women aren’t always tested for thyroid disease because the symptoms get attributed to menopause alone. A full thyroid panel helps tell them apart.
References (8) ▾
- Gold EB. The timing of the age at which natural menopause occurs. Obstet Gynecol Clin North Am. 2011;38(3):425-440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285482/
- Estrogen: physiology and systemic roles. J Clin Endocrinol Metab. 2014;99(4). https://academic.oup.com/jcem/article/99/4/31A/2537122
- Portman DJ, Gass MLS; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause. Menopause. 2014;21(10):1063-1068. https://pubmed.ncbi.nlm.nih.gov/25160739/
- Mosconi L, Berti V, Quinn C, et al. Perimenopause and emergence of an Alzheimer’s bioenergetic phenotype in brain and periphery. PLoS One. 2017;12(10):e0185926. https://pubmed.ncbi.nlm.nih.gov/29016679/
- Estrogen, mood, and cognition across the menopausal transition. PubMed. https://pubmed.ncbi.nlm.nih.gov/16688016/
- Freedman RR. Menopausal hot flashes: mechanisms, endocrinology, treatment. J Steroid Biochem Mol Biol. 2014;142:115-120. https://pubmed.ncbi.nlm.nih.gov/24012626/
- Del Ghianda S, Tonacchera M, Vitti P. Thyroid and menopause. Climacteric. 2014;17(3):225-234. https://pubmed.ncbi.nlm.nih.gov/24215243/
- Slopien R, Wender-Ozegowska E, Rogowicz-Frontczak A, et al. Menopause and diabetes: EMAS clinical guide. Maturitas. 2018;117:6-10. https://pubmed.ncbi.nlm.nih.gov/30314563/
This article is educational and is not medical advice, diagnosis, or treatment. Menopause care should be personalized with a qualified practitioner.
Told it’s “just menopause” — but you don’t feel like yourself?
We test hormones, thyroid, and metabolism together and build a plan for this transition — so symptoms get investigated, not dismissed.