Understanding Menopause and Perimenopause

Menopause is when menstrual cycles no longer occur. All people with ovaries go through this process—whether it is medically induced or age-related—marking the end of their reproductive years. Menopause typically comes on gradually as hormone levels start to change during the period called perimenopause. Hot flashes, night sweats, and changes in mood and sexual function may be minor for some people, and they may significantly affect quality of life for others.

There are a number of effective hormone-based and herbal options for symptom relief. However, there are still questions about the safety of using hormones like estrogen for long periods of time. After the potential dangers of oral hormone replacement therapy (HRT) were reported in 2002, most research has been directed at finding safer forms and doses of hormones (and not focused on alternative treatment modalities). The data is promising but not complete. Many medical practitioners and scientists seem to believe that it’s essential to find a solution to menopausal symptoms, and that HRT is the only real option.

Is menopause just something to be suffered through? We tend to focus on our symptoms and whether they make us or others uncomfortable. We worry about our sexuality and whether our partners will continue to find us attractive. But there is another dimension to menopause that needs to be more fully appreciated. Many women report feeling relief when their periods stop, and they may experience increased sexual desire. Hormonal changes that affect the brain can be freeing. Keeping the peace at home or work may no longer seem as important as voicing unspoken desires and standing up for your rights. Irritability may reflect dissatisfaction with inequalities in a relationship that you are no longer willing to tolerate. Menopause can be a time to celebrate the end of hormone-induced docility: a time for meaningful change and growth (Avis & Crawford, 2007; Northrup, 2012; Ussher et al., 2015).

Primary Symptoms

The cessation of menstrual cycles defines menopause. The average age that people go through menopause in the US is fifty-one, with it typically occurring between the ages of forty-five and fifty-five. Early menopause is defined as occurring before age forty-five. African and African American women are reported to go through menopause six to twelve months earlier than women of European descent.

The period preceding menopause when hormone levels start to change, periods become irregular, and symptoms begin occurring is called perimenopause. Symptoms may start by age forty, and it’s not abnormal to start experiencing changes earlier than that. Seven years is the typical amount of time for perimenopause to last, but it could last as long as fourteen years. Symptoms start during perimenopause and may extend past menopause and into the postmenopausal period.

Symptoms

1. • Menstrual periods become irregular and eventually cease. During perimenopause, you may skip a period or several periods, and pregnancy is still possible. Periods may be heavier or lighter than usual, and symptoms of PMS (premenstrual syndrome) may be more severe than usual.

2. • Hot flashes and night sweats, also called hot flushes or vasomotor symptoms, are a sudden feeling of intense warmth, typically in the upper body, that lasts about one to five minutes with or without noticeable sweating. The air may feel unbearably stuffy, and you might find yourself removing clothes and opening windows. You may have difficulty concentrating. Sometimes hot flashes are followed by cold chills.

3. • Emotional symptoms may include mild depression, anxiety, mood swings, and irritability. Be sure to talk to your doctor about other possible reasons for depression, such as low thyroid hormone.

4. • Low energy levels

5. • Difficulty sleeping

6. • Thinning hair

7. • Dry skin

8. • Vaginal dryness and discomfort, and urinary bladder problems, which may be minor or severe. These symptoms are referred to as genitourinary syndrome (GSM).

9. • Other symptoms may include facial hair growth, headaches, difficulty concentrating, minor memory problems, weight gain, and low libido.

How Menopausal Status Is Determined

Menopause is the time when you have ceased having menstrual periods. If you’ve gone twelve months without menstruating, you are considered to have gone through menopause. Declining levels of estrogen and increasing levels of follicle-stimulating hormone (FSH) are indicative of menopause, although levels of these hormones also vary during the menstrual cycle.

There’s usually no need to carry out diagnostic tests. However, when menopause is early, before age forty-five, your doctor may wish to carry out tests to rule out other conditions, such as thyroid or autoimmune diseases. Hypothyroidism can cause symptoms that overlap with menopause: infertility, thinning hair, irregular periods, and weight gain.

Questionnaires are used to rate the frequency and severity of menopausal symptoms and quality of life. The Menopause Rating Scale (MRS) and the Kupperman Index are two tools used for this purpose (Mayo Clinic Staff, 2020a; Schneider et al., 2000).

What Causes Menopause and Related Symptoms?

Menopause occurs when the ovaries’ cyclical production of estrogen and progesterone declines and the ovaries stop releasing an egg every month. This is a natural part of middle age but can sometimes happen prematurely for unknown reasons. Menopause can also be caused by surgery and by some treatments for cancer.

Oocyte Depletion

Menopause is said to occur when the ovaries’ supply of eggs (oocytes) is depleted. We don’t make oocytes as adults: Our eggs are formed by the time we are five months old in utero. But things probably aren’t as simple as running out of eggs. It’s been estimated that women should have enough eggs to keep ovulating to age seventy. One possibility is that eggs have a shelf life of around fifty years, and that menopause may happen because the eggs are past their expiration date, so to speak (Huber & Fieder, 2018; Schmidt, 2017).

Changing Hormones

In a normal menstrual cycle, the ovaries produce estrogen and progesterone, which promote the maturation and release of an egg. Eggs mature in ovarian structures called follicles. Secretion of hormones by the pituitary gland is also involved: FSH promotes the maturation of the egg in the follicle, and luteinizing hormone (LH) causes ovulation, which is the release of the mature egg. Once the egg is released, if it is not fertilized, hormone production plunges and menstruation is initiated.

Perimenopause is when this cycle stops occurring each month. When women reach their late thirties, the ovaries start making less estrogen and progesterone. When estrogen production is low, the pituitary gland tries to stimulate the ovaries by secreting high levels of FSH and LH. Eventually production of hormones and eggs cannot be maintained (Huber & Fieder, 2018; Schmidt, 2017).

What’s Happening during a Hot Flash?

Menopausal women experience hot flashes and night sweats and may also be subject to chills. During a hot flash, for reasons not understood, temperature regulation by the hypothalamus is abnormal. Even when the core body temperature is normal and there is no need to cool down, the body sometimes acts as if it is imperative that heat be dispelled. In order to dissipate heat, the circulation of blood to the skin is ramped up. Increased blood flow to the skin results in a loss of heat from the body and in feeling intensely hot. And when the flash is over, the heat loss may result in your feeling cold (Bansal & Aggarwal, 2019; Glovinsky & Zavrel, 2018).

Medically Induced Menopause

Medically induced menopause is a common consequence of treatments for breast cancer. Many breast cancer cells grow in response to estrogen, so removing or blocking this hormone is an effective treatment to block tumor growth. Cells that grow in response to estrogen are called estrogen-receptor (ER) positive. In order to treat ER-positive cancers, drugs may be used to block estrogen production by the ovaries, which induces menopause temporarily.

Surgical removal of the ovaries—because of breast or ovarian cancer—results in a sudden drop in hormone levels and brings on menopause immediately. Hysterectomy—surgical removal of the uterus— will cause menstruation to stop. But it doesn’t usually cause the ovaries to stop making hormones, and it does not induce menopause. The ovaries can also be damaged by radiation therapy, but only if it is directed at them. Radiation to other parts of the body won’t induce menopause.

As part of the gender transition, transgender men receive testosterone therapy for its masculinizing effects and some form of progesterone to suppress menstruation. In addition, sex reassignment surgery may include the removal of the uterus and ovaries. Some transgender men who have had their ovaries removed experience hot flashes and night sweats. In one case study, a trans man experienced frequent severe hot flashes after removal of his ovaries. His estrogen level was found to be below the normal range for men. The hot flashes stopped after he was treated with low doses of transdermal estrogen. He was able to maintain his normal testosterone regimen, and masculinization was not affected (Casimiro & Cohen, 2019; Mayo Clinic Staff, 2020b; Rachlin et al., 2010).

Early and Premature Menopause

Early menopause refers to menopause before age forty-five, and premature menopause is before age forty. Premature menopause—also called primary ovarian insufficiency (POI)—occurs in around 1 percent of women. It’s not always clear why some women experience menopause early. It may result from having few ovarian follicles at birth, from follicles being lost, or from follicles functioning poorly.

Complex genetic factors contribute significantly to the likelihood of premature menopause. If your mother had premature menopause, you are six times more likely than average to experience it. Autoimmune diseases, including thyroid disease and Addison’s disease, also increase the chances of premature menopause. Other factors implicated in premature menopause include cigarette smoking, physical trauma to the ovaries, and infections, such as mumps, contracted as a fetus or as a child.

Early menopause is linked to low body weight and in particular to low body weight with severe weight cycling. As part of the Nurses’ Health study, 78,000 premenopausal women were followed over time to see if age at menopause was correlated with body weight. Participants considered underweight were 30 percent more likely to undergo early menopause than those considered normal weight. Odds of early menopause were 20 to 30 percent lower in those considered overweight.

Early menopause results in estrogen levels that are low for a longer-than-average period of time. This is thought to be why early menopause is associated with increased risks of heart disease, osteoporosis, osteoarthritis, and mortality. It’s important to work with your health care practitioners to help minimize risk factors for these concerns. There is one very significant benefit for women experiencing early menopause: Their risk of breast cancer is significantly lower than that of women of the same age who haven’t yet gone through menopause (Chapman et al., 2015; Collaborative Group on Hormonal Factors in Breast Cancer, 2019; Okeke et al., 2013; Szegda et al., 2017).

During perimenopause and menopause and when postmenopausal, it’s important to continue with regular health care and screening for cervical and breast cancers, and heart and bone health. Menopause is associated with increased risks of developing heart disease and osteoporosis. An early age at menopause is associated with greater risks of these conditions, and a later age at menopause is associated with longevity and better overall health (Gold, 2011).

Abnormal Bleeding

Changes in your periods are to be expected during perimenopause. However, the cause may be something other than perimenopause, such as pregnancy, fibroids, or hormonal changes. If your periods have become more frequent, very heavy, or significantly longer-lasting than usual or contain blood clots, discuss this with your medical doctor. Bleeding after menopause should also be discussed with your doctor.

Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) is a new term, dating to 2014, that refers to symptoms caused by physical changes in the vagina, vulva, and urinary tract. (The vulva is the genital tissues on the outside of the body: the clitoris, labia, and opening to the vagina.) Terms formerly used were vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. “Atrophy” means a decrease in size or wasting away. Vaginal and vulval symptoms include genital dryness, decreased lubrication during sex, discomfort during sex, postcoital bleeding, lower arousal and orgasm, and irritation or itching. Urinary tract symptoms include urine leakage especially when coughing, sneezing, laughing, or exercising. More frequent urges to urinate may be followed by involuntary urination (incontinence). Urinary tract infections may become more frequent.

Physical changes can occur in the labia majora and minora, clitoris, vagina, urethra, and bladder. These may include thinner and less elastic vaginal and vulval tissues, narrowing of the vaginal opening, thinner pubic hair, reduced vaginal secretions, a higher (less acidic) vaginal pH, and decreased bladder capacity. Pelvic floor muscles may become weak or may be unable to relax, which is called nonrelaxing pelvic floor dysfunction. Prolapse of the vagina—meaning that the top of the vagina collapses into the vaginal canal—may be related to GSM. Also related to GSM is uterine prolapse, when weakened pelvic floor muscles allow the uterus to slip down into the vagina.

Most of the symptoms of GSM are attributed to low levels of estrogen. Symptoms tend to become gradually more intense in the years after menopause, significantly affecting quality of life, especially for those who are sexually active. Questionnaires, such as the Vulvovaginal Symptoms Questionnaire and the Day-to-Day Impact of Vaginal Aging (DIVA) Questionnaire, can be used to help assess the severity of symptoms. Diagnosis should also include a physical pelvic exam. Other possible causes of overlapping symptoms may include eczema, dermatitis, inflammation (vaginitis), an imbalance in bacteria (vaginosis), malignancies, and chronic pelvic pain (Angelou et al., 2020; Faubion et al., 2017; Garavaglia et al., 2020; Palacios et al., 2018).

Heart Disease

Women generally have lower rates of heart disease than men. But after menopause, the risk of heart disease goes up, and it is the leading cause of death in women as well as in men. Lifestyle is important in determining risk factors for heart disease. These include high blood pressure, high blood cholesterol, high blood sugar, inflammation, lack of physical activity, and smoking. The goop PhD article on heart disease discusses risk factors, lifestyle changes, and treatment options for heart disease. The risk of heart attacks and stroke may be higher than average in women who report the most hot flashes. Be sure to discuss your risk factors with your doctor (Thurston et al., 2021).

Osteoporosis

Our bone density peaks around age thirty, then gradually lessens over time. Estrogen helps preserve bone density, so the rate of bone loss speeds up at menopause. Between menopause and age sixty, women lose an average of 25 percent of bone mass. This increases the risk of osteoporosis, which is when bones are so weak that they are likely to break from a fall. Your doctor may wish to measure the density of your bones. Nutritional support for healthy bones is discussed in the nutrients and supplements section of this article (Cleveland Clinic, 2019).

Slowing Metabolism

If you think your metabolism is slowing down, it is not merely your imagination. You may gain weight even though you aren’t eating more than you used to. This is a universal phenomenon due to aging that is probably not linked to menopause. The slowing of metabolism is associated with having fewer mitochondria, the part of the cell that burns fuels and harvests energy. In 1995, research was published claiming that after menopause, metabolism slows significantly. Women who had gone through menopause reportedly burned about a hundred fewer calories each day than women of the same age who had not gone through menopause. This article was retracted because the data appeared to have been made up. Subsequently, it was reported by one other group that the metabolism of menopausal women is lower than that of premenopausal women, but additional research is needed to verify this finding.

During perimenopause, some women gain weight, but this is not universal. In the Study of Women’s Health Across the Nation (SWAN) study, carried out at multiple sites in the US, body composition was measured in women from multiple ethnic and racial groups over the perimenopausal and postmenopausal periods. In White women, average body weight and body fat increased steadily during the five years preceding and two years following menopause. After the final menstrual period, body weight tended to stabilize. Black women did not gain weight or fat, and Japanese and Chinese women lost weight and fat tissue (Dasgupta et al., 2012; Greendale et al., 2019; Kitazoe et al., 2019; Mayo Clinic Staff, 2020b).

Dietary Changes for Menopause

A whole-foods diet may help with symptoms of menopause and can help reduce your risk of medical conditions that are of concern after menopause.

Whole Foods and Diet Patterns

We don’t know a lot about the effects of specific foods on hot flashes and other menopausal symptoms. Some correlations have been found between regularly consuming certain foods and having frequent hot flashes or night sweats, but the effects are small. In one study, women eating the most sugar and fat were around 20 percent more likely to report experiencing hot flashes than women with the least sugar and fat in their diets. And those eating the most fruit or adhering the most closely to a Mediterranean diet were about 20 percent less likely to report hot flashes than those eating the least fruit or adhering the least closely to a Mediterranean diet. These are correlations: We do not know whether diet has a direct effect on menopausal symptoms or if the association is coincidental.

A whole-foods diet is the best way to reduce the risk of heart disease and to get the calcium and other minerals and vitamins needed for healthy bones. High bone density does not depend on eating dairy products. Plenty of vegetables, fruits, legumes, nuts, seeds, and other whole foods provide the nutrients that support optimal bone health. There’s more information on diet and nutrition in our goop PhD articles on heart disease and diabetes. Nutrients and supplements for bone health are discussed below (Herber-Gast & Mishra, 2013).

Soy and Phytoestrogen-Containing Foods

Women who eat the most soy foods tend to have the fewest hot flashes. This has been attributed to compounds in soy called isoflavones, which have weak estrogen-like activity. Plant compounds that are estrogen-like are called phytoestrogens. A controlled trial also provided evidence in favor of soy: Substituting soy for other sources of protein in the diet resulted in fewer hot flashes and improvements in other menopausal symptoms. Other foods also contain phytoestrogens, and to relieve menopausal symptoms, the Cleveland Clinic suggests trying phytoestrogen-containing foods such as chickpeas, lentils, flaxseed, grains, beans, fruits, and vegetables in addition to soybeans. There’s more about phytoestrogens in the Nutrients and Supplements section below.

Because soy contains estrogen-like compounds, there’s been concern that dietary soy might promote breast cancer. This possibility has been well-researched, and the evidence is good that eating soy does not promote cancer and may even be protective against breast cancer. People who eat the most soy tend to develop less breast cancer than those eating the least soy. This is thought to be because phytoestrogens are quite different from estrogen. They bind weakly to cells and may even prevent the more powerful estrogen from binding.

Soy also contains protein, healthy fats, fiber, and other nutrients that contribute to good health. Soy in the diet is linked to higher bone density, translating to stronger bones. Consuming around two or three servings of soybeans daily has positive effects on risk factors for heart disease, such as inflammation and oxidation of fats (Cleveland Clinic, 2019; Okekunle et al., 2020; Perna et al., 2016; Sathyapalan et al., 2017; Welty et al., 2007).

Nutrients and Supplements for Menopause

We can promote bone health and help make up for the absence of estrogen by eating the well-characterized bone-supporting nutrients in food or supplement form. And soy isoflavones may address a number of menopausal symptoms including hot flashes.

Soy Isoflavones

Some of the best-studied phytoestrogens—plant chemicals with very weak estrogen-like activity —are the isoflavones in soybeans: daidzein, equol, and genistein. Soy isoflavone supplements are thought to have benefits for heart, bone, and muscle health as well as for menopausal symptoms, although results of clinical studies have been somewhat mixed. Whether people respond to isoflavones may depend on their gut bacteria being able to convert daidzein to equol, a more bioactive form.

A number of clinical trials, but not all, have reported significant reductions in hot flashes and other menopausal symptoms resulting from soy isoflavone supplements. Some research has suggested that isoflavones from soy may be helpful for vaginal dryness and pain, but significant benefits remain to be demonstrated. Doses of purified isoflavone supplements used in studies are typically around 45 to 160 milligrams, and they appear to be safe and beneficial for overall health. It’s not clear how isoflavones exert their effects, but the most likely explanation is that they bind to estrogen receptors and generate weak signals. Isoflavones also have antioxidant activity (L.-R. Chen et al., 2019; Ghazanfarpour et al., 2016; Perna et al., 2016; Sathyapalan et al., 2017).

Nutrients for Bones

Loss of bone density results from low estrogen levels. It’s worth optimizing nutrient intake by eating primarily whole, unprocessed foods. For insurance, you can also take daily supplements.

1. • Dietary protein is needed to provide the amino acid building blocks for your body to make collagen, which forms the scaffolding in bones. Include protein from beans, eggs, meats, or dairy products in most meals.

2. • Calcium is a major component of the “mortar” that is used to fill in the collagen scaffolding. The RDAs (Recommended Dietary Allowances) for calcium are 1,000 to 1,300 milligrams for most teenagers and adults. A typical diet contains 300 to 500 milligrams of calcium, and a serving of milk or cheese may contain 300 milligrams. So depending on your diet, you may wish to take a supplement with around 500 to 1,000 milligrams at most. Calcium citrate is easily absorbed. Antacids may prevent absorption of other forms of calcium.

3. • Vitamin D is crucial for using the calcium that you eat. Without sufficient vitamin D, you cannot absorb calcium from food. The classic symptoms of vitamin D deficiency are weak, malformed, and porous bones. It’s difficult to get enough vitamin D from food. Most of our vitamin D is made by our skin when it’s exposed to sunshine—and sunshine is blocked by sunscreen, clothing, and dark skin. More information about vitamin D can be found in this goop article.

4. • Vitamin C is necessary for the production of collagen, so it supports healthy bones as well as skin. In addition, vitamin C is important for the activities of bone-forming cells: It promotes the expression of genes needed to make bone. In one study, postmenopausal women taking vitamin C supplements were found to have higher bone mineral density than women not taking a supplement. The highest bone densities were in women taking vitamin D, calcium, and estrogen. The RDAs for vitamin C are 65 to 120 milligrams in adults, depending on age and sex, and many people do not consume this much. Based on their blood level, 7 percent of Americans are deficient in vitamin C. A supplement containing 100 to 1,000 milligrams can help support healthy bones.

5. • Vitamin K contributes to several aspects of bone formation, and it supports the deposition of calcium in bone rather than in arteries. Higher amounts of vitamin K in the diet are correlated with higher bone density. And in healthy people, K1 and K2 supplements have been shown to increase biomarkers that indicate bone is being built instead of being broken down. Vitamin K1 (phylloquinone) is found in green vegetables, and vitamin K2 (the menaquinones) is found in natto and aged cheeses. If you don’t eat these foods regularly, you may wish to take a supplement containing at least the RDA: 90 to 120 micrograms, depending on age and sex. (Aghajanian et al., 2015; Morton et al., 2001; Office of Dietary Supplements, 2021a, 2021b, 2021d, 2021c; Palermo et al., 2017; Schleicher et al., 2009)

Bee Pollen

There has been some research on the use of bee pollen for menopause, but much of it has not been blinded or well-controlled. One study suggested that bee pollen supplements may be as helpful as isoflavone supplements for the relief of hot flashes and for improving quality of sleep. However, another study found bee pollen plus honey to be no more effective than honey alone for menopausal symptoms brought on by treatments for breast cancer. More research is needed on bee pollen and on royal jelly (De Franciscis et al., 2020; Münstedt et al., 2015; Münstedt & Männle, 2020).

Lifestyle Support for Menopause

A sedentary lifestyle and smoking cigarettes are among the lifestyle factors associated with intensity of hot flashes. Smoking also impacts your vaginal and vulvar tissues. It may be helpful to keep track of lifestyle factors that seem to trigger your hot flashes. Hot flashes may be brought on by hot weather or a warm room, alcohol, caffeine, spicy foods, and stress.

Drinking, Smoking, and Sex

In the long term, smoking cigarettes and drinking alcohol are associated with increased probabilities of having hot flashes. Having a daily drink has been correlated with having more hot flashes and bothersome night sweats. The happy news is that by quitting smoking, you can reduce your chances of having hot flashes by almost half. The unfortunate news is that if you’ve ever smoked regularly, you may be more than twice as likely to suffer from hot flashes.

Smoking has been linked to lower estrogen levels and to vaginal changes. Quitting smoking may be helpful for GSM and for vaginal or urinary tract symptoms. Maintaining sexual activity may also be helpful, as sexual arousal can stimulate lubrication, which in turn can help maintain healthy tissues (Angelou et al., 2020; Mayo Clinic Staff, 2020a; Sievert et al., 2006; Smith et al., 2015).

Exercise

Being sedentary is associated with more-frequent hot flashes. And exercise is beneficial for heart health, bone health, mood, energy level, and other menopause-associated concerns. In one controlled study, for three months, women were provided with nutrition education, aerobic exercise, both education and exercise, or neither. Those receiving nutrition education plus aerobic exercise reported the most significant improvements in menopausal symptoms and quality of life. However, in another study, some women who participated in moderate-intensity exercise reported more hot flashes than a control group of women assigned to stretching exercises. It seems worthwhile trying various types of exercise and determining what works best for you (Aiello et al., 2004; Asghari et al., 2017).

Support Groups

Many people say that they are more comfortable talking about menopause these days than their mothers were twenty-five years ago. Online forums can connect you with others who understand what you are going through. Menopause Matters is hosted by medical doctors in the UK, and you can join online discussion groups on multiple menopause-related topics. Red Hot Mamas is an organization that has provided support and education on all aspects of menopause and women’s midlife health for more than twenty years. It’s free to sign up for its menopause support group. Red Hot Mamas is recommended by the Endocrine Society, which can help you find an endocrinologist—a medical practitioner specializing in hormones.

Cognitive Behavioral Therapy (CBT)

Several types of CBT have been successful in helping with menopausal symptoms, including when menopause is induced by treatments for breast cancer. CBT-Meno is a protocol consisting of twelve weekly sessions teaching strategies for dealing with hot flashes, depression, anxiety, trouble sleeping, and sexual concerns. In a controlled clinical trial, CBT-Meno was helpful for women who had sought help with menopausal symptoms. Compared to those who did not receive the therapy, women who did receive it reported being less impacted by hot flashes, depression, and other complaints.

It’s even been reported that providing CBT in a booklet with no additional guidance can result in significant benefits. A booklet on self-help CBT was provided to women through human resources departments where they worked. Compared to women who did not receive the booklet, those who did receive it reported improvements in beliefs and behaviors around menopause. And they were bothered less by menopausal symptoms.

An internet-based CBT program—either self-managed or with guidance from a therapist—was shown to work well for women who were menopausal as a result of treatment for breast cancer. Compared to those who did not receive CBT, participants reported significantly better sleep and meaningful reductions in the impacts of hot flashes and night sweats. Ask your health care team about CBT resources available to you (Atema et al., 2019; Green et al., 2019; Hardy et al., 2018; Hunter, 2021).

Temperature Regulation

To deal with hot flashes, the usual advice is to dress in layers. However, it’s difficult to throw off or add blankets at night without waking up. The clinical trials section of this article describes a pajama fabric that can conserve or dispel heat depending on your sleep position. Despite research into fabrics that help regulate temperature, dressing in layers is still the best advice we have to offer (Bansal & Aggarwal, 2019; Glovinsky & Zavrel, 2018).

Biomedical Treatment Options for Menopause

Menopause is not a medical condition and does not require treatment. It cannot be prevented or stopped, but treatments are available to help manage symptoms. Hormone replacement therapy (HRT) with estrogen can be very helpful but comes with possible risks that are the subject of ongoing research.

Hormone Replacement Therapy Basics

HRT has been shown to provide relief from symptoms of menopause including hot flashes, night sweats, vaginal dryness, mood swings, urinary bladder symptoms, and hair loss. It also slows the loss of bone that can result in osteoporosis and fractures.

HRT consists of various forms of estrogen—sometimes plus progesterone—in oral, transdermal, or vaginal formulations. Women who do not have a uterus can take estrogen alone. People who do have a uterus who wish to take estrogen must also take progesterone. The endometrial lining of the uterus grows in response to estrogen unless the estrogen is opposed by progesterone. So taking estrogen without progesterone increases the risk of endometrial cancer.

HRT comes with benefits but also with side effects and risks. Side effects depend on the formulation and may include headache, nausea, swollen breasts, and vaginal discharge. Long-term health risks associated with oral equine estrogen pills are blood clots, stroke, heart attack, and breast cancer. The largest, best-controlled clinical trial on HRT, the Women’s Health Initiative (WHI), used oral conjugated equine estrogen and the synthetic form of progesterone, MPA. The trial found that postmenopausal women given equine estrogen with or without MPA had more strokes and blood clots than women given a placebo. Further, women given equine estrogen plus MPA had more heart attacks and a higher rate of invasive breast cancer. Since these findings were published, in 2002, the use of HRT has plummeted. Because of the risks, doctors recommend using the lowest effective dose of HRT for a limited time.

In the WHI, the women were fifty to seventy-nine years of age and used HRT for around five years. It’s hypothesized that HRT may be safer for younger women who are more recently menopausal. It’s also thought to be worthwhile for women who undergo early menopause. The benefits of HRT are thought to outweigh the risks for women who undergo menopause before age forty-five.

It’s likely that the risks of HRT differ depending on the formulation. Low-dose vaginal estrogen does not seem to increase the risk of blood clots. And there is some evidence that the estrogen skin patch may be less likely than oral estrogen to cause blood clots or increase the risk of heart disease. Low and ultralow HRT formulations are being studied, and there is some evidence that they may be safer than the formulations used in the WHI trial.

The sections below on treating specific symptoms contain more information about various kinds of HRT. The North American Menopause Society recommends careful consultation with your medical doctor that takes into account your individual symptoms, needs, and risk factors before you decide on treatment options (Cleveland Clinic, 2019; Harvard Health Publishing, 2006; Hermann et al., 2005; Levin et al., 2018; Mayo Clinic Staff, 2020a; North American Menopause Society, 2017; Rossouw et al., 2002).

Hot Flashes and Night Sweats

You may hear the term vasomotor symptoms: It refers to hot flashes and night sweats. Oral HRT and transdermal estrogen—even at low doses that are likely safer than the high doses used in the WHI study—can be effective for managing vasomotor symptoms. A high-dose vaginal ring may also be effective, while vaginal suppositories and rings that provide lower doses of estrogen are not likely to be helpful. It has been proposed that progesterone alone may be an effective treatment for menopausal symptoms, but the data in support of this are limited. One controlled study reported that oral progesterone significantly reduced the number of hot flashes and night sweats and improved sleep. A few studies looked at the use of topical progesterone cream for hot flashes and other symptoms and did not find significant benefits.

In addition to HRT, there are a few drugs that may be helpful for hot flashes. Bazedoxifene is a selective estrogen receptor modulator (SERM) drug that can be used together with estrogen. Low doses of selective serotonin reuptake inhibitor (SSRI) antidepressants, such as paroxetine, can be used to help manage hot flashes. (The article on depression in our goop PhD library discusses the pros and cons of antidepressant drugs.) Clonidine is a drug used for high blood pressure that may be helpful for hot flashes. Gabapentin is a drug used for seizures and pain that can also be useful for nighttime hot flashes (Faubion et al., 2017; Mayo Clinic Staff, 2020a; Nolan et al., 2021; Prior, 2018).

Vaginal Symptoms and Sexual Function

Around menopause, your sex life is likely to be affected by multiple changes in mind and body. There may be a decrease in libido: interest or desire in sex. Or you may not become physically aroused. And sex may be painful. If this is the cause of serious distress, which is not uncommon, the condition may be referred to as hypoactive sexual desire disorder (HSDD). A decline in sexuality is not inevitable, however, and some women report increased libido. Hormone levels are important, but so are psychological factors, including relationship context.

Without estrogen, the lining of the vagina and vulva become dryer, thinner, and less elastic. The production of natural lubrication is reduced. As a result, sexual intercourse may be uncomfortable and involve fewer pleasurable sensations. If you aren’t having sex regularly, you may not notice the physical changes that are taking place gradually during the menopausal transition. You may find the resumption of sexual activity to be surprisingly uncomfortable.

Regular sexual activity, dilators, and vibrators can be helpful to gently stretch and stimulate vaginal and vulvar tissues to help maintain function. Regular use of moisturizers is recommended to increase vaginal moisture and to reduce vaginal pH (increase acidity). HyaloGyn is a gel used for moisture and lubrication that contains hyaluronic acid. Revaree is a moisturizing suppository that contains hyaluronic acid. For short-term relief, a water-, oil-, or silicone-based lubricant can be applied to the vagina, vulva, and penis to increase comfort during sexual activity. There is some concern that oil-based lubes may promote vaginal infections.

If moisturizers and lubricants are not sufficient, the standard treatment for vaginal symptoms and for GSM is low-dose estrogen treatment with vaginal tablets (suppositories), rings, or creams. Local application of estrogen is helpful to build up vaginal and vulval tissues and to increase lubrication. Individual preference will dictate which product to use: Creams may be soothing but are messy, and it is difficult to measure an accurate dose. It may take a few weeks of regular use to feel the benefits, but these products can be used for long periods of time. Use of these low-dose estrogen treatments is reported to result in more-satisfying sex and an improved sex life.

Low-dose vaginal estrogen is safer and more effective than oral estrogen for genital and urinary tract support. The effects of these products are quite local, as little estrogen enters the bloodstream. Even if you have a uterus, you do not typically need to take progesterone along with the low-dose estrogen. However, if you have a history of a cancer that is sensitive to estrogen, your oncologist will evaluate the use of any estrogen-containing product.

Instead of estrogen itself, a precursor of estrogen, dehydroepiandrosterone (DHEA), can be used vaginally for tissue health and to treat symptoms of GSM. It is converted to estrogen in the vagina but not in the uterus, so is thought not to promote uterine endometrial growth and may not need to be taken together with progesterone. The brand name of the vaginal suppository is Intrarosa. In addition, oral DHEA may be helpful for increasing libido. Blood levels of DHEA tend to be lower than normal in women with low sexual desire.

Oral or vaginal estrogen can help with some aspects of sexual function, but for improved libido, the testosterone patch is most effective. The testosterone skin patch is used specifically for loss of sexual desire in postmenopausal women. Clinical studies have shown that the testosterone patch can improve libido, satisfaction, pleasure, physical arousal, vaginal blood flow, and frequency of orgasm. It has been used along with or independent of estrogen therapy. (A high dose may have the side effect of increasing the growth of nonscalp hair.) The Endocrine Society, a professional organization of scientists and physicians specializing in hormones, states that while there isn’t enough evidence for the safety and efficacy of testosterone for a variety of other purposes, its use in the treatment of HSDD is supported by clinical results. It might seem logical that the blood level of testosterone would be a diagnostic for HSDD, but this is not true, so testosterone levels should not determine diagnosis or treatment.

For people experiencing vulvar pain or pain during intercourse, the drug Ospemifene may be used to prevent discomfort. Ospemifene is a SERM drug that has both estrogen-like and estrogen-blocking effects. It acts like estrogen in promoting healthy vaginal and vulval tissues, and it improves the pH of the vagina, making it more acidic. Ospemifene doesn’t appear to stimulate breast cells, making it possibly safer for those with a high risk of developing breast cancer, although this remains to be determined. Other SERM drugs, such as tamoxifen, which is used to treat and prevent breast cancer, do not have the same vaginal benefits.

If you are not helped by these therapies, consult your doctor about other possible causes of your symptoms, such as infections, inflammation, or multiple other medical conditions. If treatment has helped other symptoms of GSM but sexual intercourse is still painful, ask to be evaluated by a physical therapist for nonrelaxing pelvic floor dysfunction (Angelou et al., 2020; Davis et al., 2008; Faubion et al., 2017; Foster et al., 2010; Goetsch et al., 2014; Islam et al., 2019; Mayo Clinic Staff, 2020a; Ussher et al., 2015; Wierman et al., 2014).

Urinary Tract Symptoms

In menopause, women may find themselves urinating more frequently and may have more-frequent bladder infections. Urination may be painful. Hormone therapy with either oral estrogen or local estrogen can be helpful for incontinence. Local treatment may be more effective than oral estrogen for urinary tract support, including maintaining a healthy microbial flora.

Pelvic floor physical therapy may also be helpful. Strengthening the muscles of the pelvic floor with Kegel exercises can help prevent leakage and incontinence. A Kegel exercise refers to contracting the muscles of the pelvic floor: the muscles that support the bladder, bowel, uterus, and vagina. You should feel a contraction around a finger inserted in the vagina and not feel a contraction in the abdominals or buttocks. An intravaginal device, the vFit, uses red light, heat, and vibration to stimulate vaginal tissues. In a controlled study, the vFit was shown to reduce urinary incontinence in women.

You can find information on exercising—and just as important, relaxing—the pelvic flood muscles in our interview with Lauren Roxburgh. Our interview with Rebecca Nelken, MD, describes medical procedures used to treat incontinence. The pelvic health division of the American Physical Therapy Association can help you find a physical therapist near you (de la Torre & Miller, 2017; Faubion et al., 2017; Mayo Clinic Staff, 2020a, 2020b).

Mood

Hormonal changes that come with menopause can affect mood and need to be taken into account in treating depression and anxiety. After the results of the WHI study on the risks of HRT were published, many women stopped their HRT regimen. The Women’s Health Network at the University of Toronto reported that at in the wake of the study’s publication, they started seeing more women with depression. The women were successfully treated by either restarting HRT or increasing their dose of antidepressant medications.

Evidence that HRT is helpful for depression and anxiety in postmenopausal women was provided by the Kronos Early Estrogen Prevention (KEEPS) trial. All women receiving estrogen—either oral equine estrogen or bioidentical estrogen patches—also received micronized progesterone for the first twelve days of each month. After four years of treatment, women were tested for various aspects of mood, and scores were significantly better for depression, anxiety, and tension in women who had received either type of estrogen compared to those receiving a placebo.

Antidepressant medications are used in menopause to treat mood disorders and to reduce the number of hot flashes. Elsewhere in this article, we describe lifestyle and herbal treatment options to support a healthy mood during menopause (Cleveland Clinic, 2019; Raz et al., 2016; Stewart et al., 2004).

Estrogen and Your Brain

There is evidence that verbal memory—basically memory of words—decreases during menopause, however it’s not clear whether this is a transient or long-lasting phenomenon. It may get better as your body adapts. Scientists hypothesize that estrogen has protective effects for neurons, and that a decrease in estrogen during menopause may leave the brain vulnerable to disease.

People have clung to the theory that taking estrogen as part of HRT should prevent or reverse postmenopausal cognitive decline. Bolstering this theory was an observation that when women who chose to use HRT early in menopause were compared with those who did not use HRT, those who used HRT ended up with fewer cases of dementia. Was it the HRT that was responsible for protection against dementia, or was it that women who can afford to use HRT also have better access to health care and healthy lifestyles? When controlled trials were finally carried out, HRT did not protect against dementia. We do not know why taking HRT was associated with less dementia in the earlier survey data. It could have been that the women taking HRT had better access to health care, or it could have been due to some other factor. This is a useful lesson about the limitations of surveys that attempt to link a particular behavior or food or drug to a health outcome. In this research, referred to as observational, epidemiological, or population studies, it’s impossible to know whether the behavior (for example, taking HRT) causes the outcome (in this case, less dementia), or whether their association is coincidental. Observational studies are useful for generating hypotheses but not for proving cause and effect.

Controlled clinical trials have shown that HRT is at best neutral and at worst harmful as far as effects on the brain. A continuation of the WHI study, called WHIMS, found that HRT increased the risk of dementia in women over sixty-five. Compared to subjects getting a placebo, subjects getting equine estrogen (either alone or with MPA) were more than twice as likely to end up with dementia or mild cognitive impairment. In an attempt to find some safe use for HRT, it was speculated that the trial was simply not begun early enough in menopause. The critical-window hypothesis is that women who take HRT at the menopausal transition may see cognitive benefits or at least won’t have increased risk for dementia, as was the case for women over sixty-five.

This theory was not borne out by the KEEPS study, in which women were given estrogen plus micronized progesterone within three years of their last period in order to not miss the critical window. In the four years of follow-up, the researchers did not find benefits for cognition and they found likely—depending on how you compare the numbers—shrinkage in the brains of the women taking estrogen plus progesterone. This was true whether the women were given conjugated equine estrogen or transdermal bioidentical estradiol. Treatment was discontinued, and three years later, the differences in brain structure were no longer statistically significant except for one measure in the brains of women who had received equine estrogen. One positive result was reported: The women who took bioidentical estrogen lost less of their prefrontal cortex over time compared to the other groups. The prefrontal cortex is where higher-level complicated decisions take place. From this study, it appears that transdermal bioidentical estrogen would be preferable to equine estrogen but that neither treatment has clear overall benefits (Henderson, 2014; Kantarci et al., 2016, 2018; Mosconi et al., 2017; Nebel et al., 2018; Shumaker et al., 2004).

Our goop PhD article on Alzheimer’s disease also discusses the implications of HRT for brain health and cognition.

Sleep

Difficulty getting a good night’s sleep is commonly associated with menopause. However, there are many reasons for poor sleep, and while hormonal changes and hot flashes may contribute, other factors associated with aging are also to blame. Sleep can be disrupted by acid reflux, thyroid problems, medications, alcohol, and urinary incontinence. One type of sleep disorder documented in menopausal women is obstruction of the upper airway, meaning a narrowing or swelling between the nose and the larynx that makes it difficult to breathe. Another type of sleeping disorder common in menopausal women is periodic limb movement disorder, described as periodic twitching, cramping, or jerking movements during sleep. It may be linked to antidepressant medications or breathing problems.

For women who have hot flashes and night sweats, HRT has been shown to be helpful in improving quality of sleep. Most studies on HRT and sleep have looked at estrogen plus progesterone, but there’s also evidence that either hormone alone can help. Several studies have showed that micronized progesterone shortens the time it takes to fall asleep and probably helps you stay asleep longer. Natural micronized progesterone appears to be more effective than medroxyprogesterone. Progesterone works like the sedative valium, by stimulating GABA receptors in the brain.

Exercise may also help you sleep. One sleep study on hundreds of menopausal women with hot flashes showed that poor sleep quality and mild insomnia were common. The researchers tested whether aerobic exercise or yoga could improve the participants’ sleep quality. The women reported better sleep after twelve weeks of supervised aerobic exercise three times per week. Women also benefited from twelve weeks of weekly in-person yoga classes, with practice at home in between those sessions. Other exercise studies have yielded mixed results as far as sleep outcomes. While it may not be a surefire cure for sleep problems, try finding an exercise program you enjoy and judge its value for yourself (Buchanan et al., 2017; Cintron et al., 2017; Hachul et al., 2008; Joffe et al., 2010; Lindberg et al., 2020; Nolan et al., 2021; Polo-Kantola et al., 2003; Shaver & Woods, 2015).

Bone Health

Estrogen therapy helps slow down the loss of bone that accelerates during menopause. In the WHI study, women taking HRT had denser bones and fewer broken bones, including fewer hip fractures, than the placebo group did. HRT may even help preserve the collagenous discs that cushion the spinal vertebrae. But overall, the adverse effects of HRT outweighed the benefits, and HRT is no longer considered the best choice for prevention of osteoporosis. More recently, the North American Menopause Society—made up of scientists and researchers—said in its 2017 position statement that there are circumstances in which the benefits of HRT for hot flashes and bone health will outweigh the risks, such as for women who are younger than sixty or who are less than ten years past the onset of menopause.

The estrogen patch and low-dose estrogen pills have been shown to increase bone density and appear to have fewer worrisome side effects than the high-dose HRT used in the WHI study. Estrogen skin patches have been shown to increase bone density within one to two years of use. Ultralow-dose oral micronized estradiol also resulted in increased bone density in postmenopausal women.

The WHI study also looked at the value of calcium (1,000 milligrams) and vitamin D (400 international units) supplements for bone health. Compared to those taking a placebo, those taking the supplements had higher bone density. Overall rates of broken bones weren’t much improved, but the women who adhered most closely to the regimen did have significantly fewer fractures.

Your doctor may prescribe other medications, such as bisphosphonates, to help prevent osteoporosis. Raloxifene and bazedoxifene are SERM drugs used to treat osteoporosis and breast cancer. If you have low bone density, you’ll want to discuss the pros and cons of these hormones and drugs with your doctor (Cauley, 2003, 2013; Faubion et al., 2017; Jackson et al., 2006; Levin et al., 2018; North American Menopause Society, 2017).

Herbal and Holistic Treatment Options for Menopause

Plants contain numerous bioactive compounds that act on multiple pathways in the body. The benefits of black cohosh for menopausal symptoms have been demonstrated in multiple clinical trials. And promising research supports possible benefits from a number of other herbs, as well as from acupuncture and aromatherapy.

Working with Traditional Medicine, Herbalists, and Holistic Healers

Holistic approaches often require dedication, guidance, and close consultation with an experienced practitioner. Functional, holistic-minded practitioners (MDs, DOs, and NDs) may use herbs, nutrition, meditation, mindfulness practices, and exercise to support the entire body and its ability to heal itself.

Traditional Chinese medicine (TCM) degrees include LAc (licensed acupuncturist), OMD (doctor of Oriental medicine), and DipCH (NCCA) (diplomate of Chinese herbology from the National Commission for the Certification of Acupuncturists). Traditional Ayurvedic medicine from India is accredited in the United States by the American Association of Ayurvedic Professionals of North America and the National Ayurvedic Medical Association. There are several certifications that designate an herbalist. The American Herbalists Guild provides a listing of registered herbalists, whose certification is designated as RH (AHG).

Herbs Used to Treat Menopausal Symptoms

A number of herbal formulations have been used traditionally and in clinical research to treat symptoms of menopause. Plants contain a wide variety of bioactive compounds, and each herb may work in more than one way. Plants contain compounds called phytoestrogens that have structures similar to that of estrogen. These may act like a very weak estrogen or may block the effects of estrogen. Plants also contain compounds that are related to progesterone, compounds that may affect the formation of estrogen by our bodies, and compounds that affect neurotransmitter pathways.

Some of the more researched botanicals are described below. Additional research is needed on lemon balm (Melissa officinalis), valerian, chasteberry (Vitex agnus-castus), Ginkgo biloba, and St. John’s wort (Hypericum perforatum. As always, discuss any approach that sounds interesting to you with your health care practitioner, especially if you have a history of or are at high risk for a hormone-responsive cancer such as breast cancer (Koliji et al., 2021).

1. • Black cohosh (Cimicifuga or Actaea racemosa) is one of the best-studied and most effective herbs used for relief of menopausal symptoms. It is native to the eastern US, where extracts of the rhizome have been used by Indigenous people for gynecologic concerns, including premenstrual and menopausal symptoms. Multiple double-blind clinical trials have demonstrated that extracts of black cohosh rhizome reduce the severity and frequency of hot flashes, night sweats, mood changes, and other symptoms. A detailed report by the European Medicines Agency Committee on Herbal Medicinal Products evaluated the results of twenty clinical studies involving more than 6,000 participants who received black cohosh supplements and concluded that cohosh improves menopausal symptoms including hot flashes. The WHO has concluded that there is clinical data to support the use of black cohosh extracts for menopausal symptoms including hot flashes, sweating, and sleep and mood disturbances. The doses used are small: 6.5 to 13 milligrams of extract (from approximately 40 to 140 milligrams of rhizome) (European Medicines Agency, 2018; Mohammad-Alizadeh-Charandabi et al., 2013; Osmers et al., 2005; Shahnazi et al., 2013; WHO Health Systems Library, 2012).

2. • Red ginseng (Panax ginseng) has been used for over 1,000 years in Asian traditional medicine and is considered to be an adaptogen that strengthens the body’s resistance to psychological and physical stressors. The Korean Ministry of Food and Drug Safety has approved the claim that Red ginseng is useful for treating symptoms of menopause. Red ginseng differs from white or raw ginseng in the way it’s prepared—steaming and drying—and in its properties.

3. A double-blind study reported a number of significant benefits for women who took Korean red ginseng supplements. Postmenopausal women forty-five to sixty years old were given three grams of red ginseng daily for twelve weeks or a placebo. Compared to those receiving the placebo, women receiving the ginseng reported significant improvements in their menopausal symptoms. Tests also revealed improvements in blood cholesterol and in arterial health.

4. In some but not all studies, red ginseng has been found to be helpful for hot flashes, sexual function, overall mood and well-being, and stress hormone levels. The quality of the research has been variable, and the results are not uniform; it isn’t entirely clear who will benefit most from this herb or what the optimal dose and formulation are (Chung et al., 2015; M.-S. Kim et al., 2013, 2013; S. Y. Kim et al., 2012; Lee et al., 2015; So et al., 2018).

5. • Rhodiola (Rhodiola rosea) is an adaptogen that helps the body manage routine stressors like menopause. It supports a healthy mood and helps ease fatigue. Double-blind placebo-controlled clinical studies have demonstrated significant benefits for mood and stress-related fatigue—symptoms commonly associated with menopause. The combination of rhodiola root extract and black cohosh rhizome extract was more effective for overall menopause relief than black cohosh alone in one double-blind clinical trial. The trial was sponsored by the manufacturer of the product used: Menopause Relief (Amsterdam & Panossian, 2016; Pkhaladze et al., 2020).

6. • Fennel (Foeniculum vulgare) has been used in oral and cream formulations to treat menopausal symptoms. Several well-controlled clinical studies have reported significant benefits from fennel extracts for postmenopausal women. A double-blind study demonstrated that a fennel-containing cream improved vaginal health in postmenopausal women and had a desirable effect on vaginal pH, increasing acidity. The cream was used daily for eight weeks. Another study demonstrated significant benefits of a fennel-containing cream for sexual function, including arousal, lubrication, and orgasm. Further, taking fennel essential oil orally has been shown to reduce menopausal symptoms significantly (Abedi et al., 2018; Rahimikian et al., 2017; Yaralizadeh et al., 2016).

7. • Fenugreek (Trigonella foenum-graecum) is used in China to relieve menopausal symptoms. In two double-blind studies, a fenugreek husk supplement resulted in significant improvements in menopausal symptoms and quality of life and increased blood estrogen levels. In the first study, 1,000 milligrams of the fenugreek extract, FenuSMART, was taken daily for three months. In the second study, 500 milligrams of the extract was taken daily for six weeks (Begum et al., 2016; Thomas et al., 2020; Wu et al., 2020).

8. • Sage (culinary sage, Salvia officinalis) has been used in European traditional medicine to treat sweating. A controlled clinical trial reported substantial benefits for hot flashes, night sweats, mood, and sleep after ten weeks of 300 milligrams of sage extract daily (Ghorbani & Esmaeilizadeh, 2017; Zeidabadi et al., 2020).

9. • Red clover (Trifolium pratense) contains phytoestrogens and other bioactive compounds. In several but not all controlled clinical trials, forty to eighty milligrams of dried red clover taken daily has resulted in improvements in menopausal symptoms, including sexual function (del Giorno et al., 2010; Shakeri et al., 2015).

10. • Bindii (Tribulus terrestris) was reported to increase sexual function in menopausal women in a controlled clinical trial. Women taking 750 milligrams daily reported higher scores of sexual desire, arousal, and comfort than women who received a placebo. However, other clinical studies reported results that were less convincing (de Souza et al., 2016; Koliji et al., 2021; Postigo et al., 2016; Tadayon et al., 2018).

11. • Combinations¬¬ of herbs are common in herbal medicine, and numerous different combinations have been used for menopausal symptoms. A proprietary combination of soy isoflavone, black cohosh, chasteberry, and evening primrose oil extracts yielded impressive results within six to twelve weeks in a well-controlled study of postmenopausal women. The severity of hot flashes was significantly reduced in the women receiving the treatment, and improvements were documented in mood, vaginal lubrication, and sexual function. Postmenopausal women received 1,000 milligrams daily of the blend made by Max Biocare, Australia, which also funded this study. On the other hand, a clinical trial found that a combination of St. John’s wort and chaste tree berry was not better than a placebo for menopausal symptoms. The quality of herbal formulations can vary greatly, and consultation with an experienced professional is recommended (Rattanatantikul et al., 2020; van Die et al., 2009).

Acupuncture

Acupuncturists may provide traditional acupuncture, electroacupuncture, ear acupuncture, laser acupuncture, acupressure, and moxibustion, which consists of burning mugwort leaves near the skin in order to warm acupuncture points. Clinical trials assessing acupuncture for treating symptoms of menopause have yielded inconsistent results. In some studies, acupuncture has been compared to no treatment, and in other studies, it has been compared to sham (simulated) acupuncture. A meta-analysis concluded that acupuncture was effective for reducing the frequency and severity of hot flashes and improving quality of life. However, when acupuncture was compared to sham acupuncture, benefits were small or not statistically significant. Since acupuncture appears to be safe and has been demonstrated to be more helpful than doing nothing, it may be a worthwhile approach to try (Befus et al., 2018; He et al., 2020).

Aromatherapy

Aromatherapy with essential oils can be administered via inhalation or massage, and both approaches may be helpful for menopausal women. There are not many controlled studies, but a review of the existing research concluded that aromatherapy can be helpful for menopausal symptoms, stress, and depression. It’s not clear whether inhalation or massage is preferable or what the best oil to try is, but you could start with lavender or neroli.

In a randomized controlled trial, the effects of inhaling neroli oil twice a day for five minutes were compared to the effects of inhaling almond oil. Neroli oil aromatherapy resulted in a significant improvement in sexual desire and in lower blood pressure. In another study, women who inhaled lavender oil for twenty minutes twice a day reported fewer hot flashes than a control group did. There’s even a report that aromatherapy can affect testosterone levels. Testosterone was measured in saliva before and after perimenopausal women smelled one of ten different essential oils for twenty minutes. Oils of jasmine absolute, clary sage, and Roman chamomile led to small increases in testosterone, but other oils tested did not (J. Choi et al., 2018; S. Y. Choi et al., 2014; Kazemzadeh et al., 2016; S. Kim et al., 2016; Tarumi et al., 2019).

New and Promising Research on Menopause

With so much research being conducted on menopause, it’s frustrating that we don’t even know what causes hot flashes and that there are still unanswered questions about the long-term safety of estrogen therapy. Research is ongoing on premature menopause, new treatments for vaginal and urinary tract health, hormonal and herbal treatments for mood and sleep, and temperature regulation gone awry during hot flashes. Potentially dangerous treatments such as laser therapy and injections into the vulva or vagina are gaining popularity, but their safety and efficacy have not been adequately established.

Deconstructing Hot Flashes

Hot flashes are surprisingly poorly understood. There seems to be some disturbance in the body’s temperature regulation and set point. The sensation comes on suddenly, with intense heat spreading through the upper body accompanied by sweating, that is sometimes followed by chills. During hot flashes, the temperature of the skin may exceed 105 degrees Fahrenheit. They typically last one to five minutes but can last longer. The American Society for Reproductive Medicine has a nice infographic here.

Researchers can tell when a hot flash is occurring by measuring sweating on the sternum (breastbone). Shortly before that, there are increases in heart rate and blood flow to the skin. The increased blood flow to the skin is what causes the skin to become hot and sweaty. You may hear the term vasodilation, which means that blood vessels dilate, becoming larger so that more warm blood flows to the skin. Normally this would happen when our core body temperature goes up and there is a need to cool off by releasing heat through the skin. In menopause, this happens without significant changes in core body temperature—when there is no need to cool the body. One theory is that in menopause the body overreacts to tiny increases in the temperature in the core of the body, resulting in an unnecessary diversion of blood to the skin. However, some research argues against this explanation: An increase in core temperature turns out not to be very predictive of a hot flash.

Why might the brain overreact to small changes in core temperature? What could be other explanations for hot flashes? We don’t know, but researchers are looking into the roles of the sympathetic nervous system, hormones (estrogen and FSH), neurotransmitters (serotonin and norepinephrine), and the processes by which the brain regulates body temperature (Bansal & Aggarwal, 2019; Carpenter et al., 2005; Jones et al., 2019; Luo et al., 2020; Randolph et al., 2005).

Platelet-Rich Plasma: O-Shot

Research on the safety and efficacy of platelet-rich plasma (PRP) for vaginal health must still be considered preliminary at this point. PRP is used as a source of growth-promoting factors, and it is injected directly into damaged tissues for its healing properties. PRP is prepared from your own blood. Red blood cells are removed, and platelets—the tiniest type of white blood cell—are concentrated into a small volume of plasma. Platelets are key to the body’s tissue-repair processes, so this procedure takes advantage of natural healing mechanisms. Although this may not seem intuitive, PRP injections are considered noninvasive.

Small clinical trials have reported on the use of PRP injections for vaginal health and sexual function. PRP injections into the vagina—after application of an anesthetic cream—are called O-Shot therapy. They’ve been used for treating sexual dysfunction, thin vaginal tissues, and urine leakage. However, there isn’t enough published controlled research at this point to judge the efficacy of these treatments. In one preliminary study, after vaginal PRP injections, women reported improvements in stress urinary incontinence for the following six-months. There was no untreated control group for comparison, so we don’t know whether the improvements were due to time, a placebo effect, or how the surveys were conducted. In another study, injections of PRP plus hyaluronic acid were used to treat women with a history of breast cancer who were experiencing vaginal dryness and pain. The women reported improved sexual function and vaginal health—but again, there was no control group in this pilot study (Dawood & Salem, 2018; Hersant et al., 2018; Long et al., 2021).

Endocrine Disruptors and Early Menopause

There is growing evidence that exposure to endocrine-disrupting chemicals (EDCs) is linked to early menopause. Exposure to EDCs has also been linked to cancer, early puberty, lower sperm quality, and infertility. Our exposure to thousands of chemicals through air and water pollution, personal-care products, and household items is relatively recent in human history. Some of these chemicals persist in the environment and build up in our bodies, and some of them can mimic or block hormones. It’s difficult to determine the effects these chemicals are having on our bodies, and it has not been demonstrated that they are safe under the current conditions of exposure.

A link between early menopause and exposure to EDCs such as perfluorochemicals, PCBs, phthalates, and others has been demonstrated in multiple studies. In one study, blood levels of perfluoroalkyls were measured in over 1,000 women. Those with the highest levels subsequently went through menopause two years earlier than those with the lowest levels. In another study, researchers measured over 100 EDCs in blood and urine samples from 1,400 women. In some women, the levels were less than one part per billion (ppb), and in some women levels were thousands of ppb. The researchers found that women with the highest EDC levels went through menopause two to four years earlier on average than those with lower levels. Particularly striking were the findings with a number of PCBs and phthalates. Women who were significantly exposed to EDCs were up to six times as likely to be menopausal as women of the same age without exposure (Ding et al., 2020; Grindler et al., 2015).

Hyaluronic Acid Moisturizers

Moisturizing gels and suppositories containing hyaluronic acid are available commercially for treating vaginal symptoms of dryness and irritation. A review of five clinical trials concluded that hyaluronic acid–based products were as effective as estrogen-based products in improving vaginal pH (acidity), tissue health, and painful intercourse. One clinical study reported a hyaluronic acid–containing vaginal cream to be more effective than a conjugated estrogen cream for treating vaginal dryness, painful intercourse, tissue health, and urinary incontinence.

Very preliminary results were published on an alternate method of treating with hyaluronic acid: injections under the skin around the opening of the vagina. Women reported improvements in vaginal symptoms; however, there was no control group, and it’s common for people to report positive results even if they receive a placebo treatment (dos Santos et al., 2021; Garavaglia et al., 2020; Jokar et al., 2016).

Laser Tissue Regeneration

Loss of elasticity and thickness of vagina and vulval tissues is due to loss of collagen, elastin, and hyaluronic acid. Preliminary evidence suggested that lasers can help stimulate vaginal tissue regeneration and increase local blood circulation. A small study reported that three monthly treatments with a carbon dioxide pulsed laser led to improvements in vaginal comfort and tissue health. In another small study, the YAG laser was found to be more effective than intravaginal estriol for symptoms of GSM. However, additional research is needed on the safety and efficacy of laser treatments. The FDA has warned that the use of lasers—or any radiofrequency devices—is not cleared for vaginal rejuvenation or treatment of GSM. It cautions that the procedures have resulted in vaginal burning, scarring, and pain during intercourse (Faubion et al., 2017; Gordon et al., 2019).

Vaginal Probiotics

Maintaining a healthy vaginal microbiome is the subject of ongoing research. After menopause, along with low estrogen levels and thinning of vaginal tissues, the vaginal pH becomes less acidic and the microbial flora changes. Premenopausal women, and postmenopausal women using HRT, have higher numbers and types of vaginal Lactobacillus strains that can produce acid and prevent vaginal infections than postmenopausal women do. There’s preliminary evidence that vaginal probiotics containing Lactobacillus strains may be able to help prevent or treat vaginal infections that are caused by bacteria. Probiotics don’t appear to be useful for vaginal infections caused by yeast.

A vaginal suppository containing a very low dose of estriol (a naturally occurring weak form of estrogen) plus Lactobacillus acidophilus KS400 has been studied for support of vaginal health. The low dose of estriol acts locally without significant effects on hormone levels in the rest of the body. This combination has been reported to promote vaginal health and quality of life and to reduce pain, dryness, and urinary incontinence (Gliniewicz et al., 2019; Mueck et al., 2018; van de Wijgert & Verwijs, 2020).

Lidocaine for Painful Intercourse

An estimated one quarter to one half of menopausal women experience pain before, during, or after intercourse. Painful intercourse is called dyspareunia. And vulvodynia refers to pain localized to the part of the vulva opening into the vagina—the vulvar vestibule. Lidocaine, an anesthetic drug, may be used a few minutes before intercourse to prevent pain. In one trial, women were able to prevent pain by applying a lidocaine gel to the most sensitive part of the vulvar vestibule. The efficacy of the treatment was assessed by asking the women about pain experienced during intercourse or upon inserting a tampon. However, in another study, a lidocaine cream was no more effective than a placebo cream. There are many reasons for discrepancies from one study to another, such as different selection criteria for participants and differences in treatments or ways of assessing outcomes. Harvard Health Publishing lists lidocaine as a possible option for painful intercourse but cautions that the numbing action may affect your partner also (Foster et al., 2010; Goetsch et al., 2014, 2015; Harvard Health Publishing, n.d.).

Depression

Women who are perimenopausal or menopausal are more likely to report symptoms of depression than premenopausal women are. In the SWAN trial, women from multiple sites in the US were surveyed about their health and menopausal status. SWAN was designed to recruit and retain diverse groups of women. It found that the risk of depression started increasing in perimenopause and by menopause was nearly twice that seen in premenopausal women. Women who self-identified as Hispanic or Japanese scored higher on tests for depression than White, Chinese, or African American women. The factor most associated with depression was having experienced two or more upsetting life events in the previous year (Bromberger & Kravitz, 2011).

Ongoing Clinical Trials for Menopause

Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.

In general, clinical trials may yield valuable information; they may provide benefits for some people but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. To find studies that are currently recruiting for menopause, go to clinicaltrials.gov. We’ve also outlined some below.

A Supplement for Thinning Hair

The Ablon Skin Institute Research Center is recruiting peri- and postmenopausal participants with thinning hair to test a dietary supplement designed to support healthy hair. Nutrafol Women’s Balance capsules contain nutrients and botanicals including ashwagandha, curcumin, astaxanthin, capsaicin, biotin, zinc, iodine, selenium, and vitamins A, C, and D. In addition to self-assessment, the growth and quality of hair will be quantitated by measuring hair number, thickness, and strength. The first six months of the study will be double-blinded, and the supplement will be compared to placebo capsules. After six months, all participants will receive the daily supplement for an additional six months.

Green Tea Ointment for Pain

Lila Nachtigall, MD, of Dr. Lila Nachtigall Rapid Medical Research and NYU Grossman School of Medicine, is recruiting postmenopausal women in New York to test the efficacy of a green tea ointment for vulvar pain or pain with sexual intercourse. The ointment will be a diluted form of Veregen, a drug product made from tea leaves that’s used to treat external genital warts. An ointment containing green tea has been shown to reduce pain and to boost healing of episiotomy wounds. Participants will apply the ointment once a day for four weeks and will have three appointments with a gynecologist who will assess pain levels and tissue health (Shahrahmani et al., 2018).

Vaginal, Bladder, and Rectal Microbiomes

How does local vaginal estrogen therapy affect the microbiomes of the vagina, bladder, and rectum? In this clinical study, these three microbiomes will be analyzed before and after eight weeks of vaginal estrogen therapy with Premarin cream. Investigators will measure the abundance of Lactobacillus species, with the hypothesis that it will be increased as vaginal tissue health improves and the pH decreases. They will also measure markers of inflammation in all three tissues. The principal investigator is Kyle P. Norris, MD, at the University of Alabama at Birmingham.

Brain Wave Audio Feedback

A small pilot study suggested that our brains can be taught to modulate brain waves in a way that reduces hot flashes and other symptoms of menopause. Charles Tegeler, MD, at Wake Forest University Health Sciences is carrying out a controlled trial to follow up and confirm these benefits. The technique sounds space-age: high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM). A noninvasive device, Cereset, monitors brain rhythms, and an algorithm turn them into sounds: your personalized brain echo. The theory is that your brain hears itself, and this enables it to automatically relax and reset. Whatever the mechanism, in a pilot study of people suffering from post-traumatic stress, this technique was associated with clinically significant reductions in stress (Shaltout et al., 2018; Tegeler et al., 2015, 2017).

Aerobic Exercise after Breast Cancer

If you are postmenopausal and have completed treatment for early-stage breast cancer, you may wonder about the optimal exercise program for you. Jessica Scott, PhD, at the Memorial Sloan Kettering Cancer Center, is recruiting participants for aerobic training sessions of 150 to 300 minutes per week, lasting sixteen or thirty-two weeks. Some sessions will be supervised, and some will be unsupervised. The goal is to determine how cardiovascular fitness—measured by oxygen consumption—is affected by the different programs.

Legumes for Bone and Cardiovascular Health

Legumes—which include beans, lentils, and peas—are nutritious. The edible seeds of legumes are called pulses. They contain fiber, prebiotics that feed beneficial gut bacteria, protein, vitamins, and minerals. But will eating three ounces of beans every day for twelve weeks have significant benefits for bone and cardiovascular health? Edralin Lucas, PhD, at Oklahoma State University, is recruiting healthy postmenopausal women who will be asked to eat three ounces of lentils, pinto beans, peas, chickpeas, or kidney beans every day for three months. Stool and blood samples will be used to determine the effects on gut bacteria, blood cholesterol, and blood sugar. Changes in bone density will also be measured.

Nitroglycerin for Hot Flashes

Alison Huang, MD, MPhil, of the University of California, San Francisco, has published preliminary research suggesting that nitroglycerin patches may reduce the number of hot flashes that women experience (Huang et al., 2016). Huang is following up this research with a randomized, blinded trial in which women will receive placebo patches or transdermal patches that deliver nitroglycerin. Women who are menopausal or late in the transition and who have an average of at least seven hot flashes daily may be eligible for this study.

Temperature-Regulating Sleepwear

Is there a type of pajama fabric that can help you sleep better? Paul Glovinsky, PhD, at St. Peter’s Sleep Center in Albany, New York, was recruiting menopausal women who don’t sleep well to evaluate unique sleepwear with “lateralized thermal characteristics.” This means that depending on the side you are sleeping on, the sleepwear will either keep you warm or help cool you down. You have to be able to sleep on either side for this to work. The right side of the sleepwear is made with insulating fabric, so if you are lying with your right side up, the insulating fabric will help keep you warm. The left side is made with conductive fabric to help disperse heat and keep you cool. If you’re hot and you turn to lie on your right side, the conductive fabric will be facing up—facing the air—and will be able to help cool you. The hope is that you learn to turn automatically as needed without waking up. Unfortunately this study has been halted, so you won’t be able to participate, but perhaps in the future we’ll hear more about conductive sleepwear and whether it improves sleep quality.

Cooling Mattress Pad

Cooling mattress pads are commercially available, but do they help people sleep through hot flashes and night sweats? Nancy Avis, MD, at Wake Forest University Health Sciences, is recruiting perimenopausal and menopausal women who would like to try out a cooling mattress pad at home for eight weeks. Questionnaires will be used to quantify the benefits.

Hyaluronic Acid Moisturizer

Revaree, a vaginal moisturizer containing hyaluronic acid, will be compared to Estrace (estradiol) cream for vaginal and vulval symptoms of GSM. Lila Nachtigall, MD, at New York University Langone Health, will oversee the trial in collaboration with JDS Therapeutics, the maker of Revaree. After eight weeks of use, people will be surveyed using a vulvovaginal questionnaire that asks about symptoms and about their impact on quality of life. A pelvic exam will be done in order to assess tissue health and to measure vaginal pH. Revaree is a commercially available vaginal suppository containing five milligrams of hyaluronic acid.

DHEA for Urinary Tract Infections

Prasterone is a synthetic version of the steroid DHEA that is used for the treatment of painful intercourse due to GSM. Olivia Cardenas-Trowers, MD, at the University of Louisville, in collaboration with AMAG Pharmaceuticals, Inc., will be recruiting postmenopausal women with a history of recurring urinary tract infections (UTIs) to see if this steroid can also reduce the number and severity of UTIs and other symptoms of GSM. This will be a double-blind study comparing twenty-four weeks of nightly vaginal Prasterone inserts to a placebo treatment.

A Balloon for Incontinence

In stress urinary incontinence, “stress” doesn’t refer to mental stress; it refers to physical stress—pressure on the urinary bladder when you cough or exercise or sneeze that causes urine to leak out. If the bladder has lost elasticity and can’t expand, then when there is pressure on the bladder, that pressure pushes open the urethra. Solace Therapeutics, Inc. is recruiting postmenopausal women with stress urinary incontinence who have at least one leak every day to test a balloon device, the Vesair Bladder Control System. It’s a lightweight balloon about the size of a quarter that floats in the urinary bladder. The balloon is designed to be compressed under pressure. Air can be compressed, so the question is whether an air-filled balloon can help buffer pressure enough to reduce urine leakage.

In previous clinical trials, use of the balloon led to improvements in incontinence in some women, but was also associated with adverse effects such as UTIs. This six-month study will continue to evaluate the best uses of the Vesair balloon. Participants will need to come into one of twenty-one centers in the US at least five times over a year. After six months, they will be surveyed about quality of life related to incontinence, and the amount of leakage will be assessed (McCammon et al., 2018; Winkler et al., 2018).

A Neurosteroid for Depression

Neurosteroids are steroids that can enter the brain and affect brain function. Pregnenolone is a neurosteroid with antidepressant effects, and it is also a precursor for the production of estrogen and other hormones. Pregnenolone has been used as a medication and is sold as a dietary supplement. Sherwood Brown, MD, PhD, at the University of Texas Southwestern Medical Center, and Marlene Freeman, MD, at Massachusetts General Hospital are recruiting peri- and postmenopausal women with depression for a sixteen-week trial comparing pregnenolone to a placebo. Questionnaires will be used to determine benefits for mood and quality of life.

Heart Health Program for Latinas

The risk of cardiovascular diseases goes up at perimenopause, and these risks vary among ethnic and racial groups. Yamnia Cortes, PhD, at the University of North Carolina, Chapel Hill, is recruiting perimenopausal Latina women ages forty to fifty-five for a program of lifestyle interventions to reduce risk factors for heart disease. There will be exercise classes, stress-management sessions, and education on other lifestyle factors. Classes will be weekly for three months, then monthly for three months. The investigators will assess blood cholesterol and other physiological parameters, as well as behavioral changes.

Resources

Online

1. • HealthyWomen’s mission is education enabling women ages thirty-five to sixty-four to make informed health choices. It is a good source of evidence-based articles on a wide range of menopause-related topics, including sex after menopause, the experiences of transgender women, brain fog, and much more.

2. • The Office on Women’s Health—a service of the US Department of Health and Human Services—provides comprehensive information on menopause and other topics of particular interest to women. It operates a helpline at 800.994.9662, Monday through Friday, 9 a.m. to 6 p.m. Eastern Time.

3. • The North American Menopause Society site includes a searchable database of clinicians who wish to treat those in perimenopause and menopause, including the society’s own certified menopause practitioners.

4. • The National Institute on Aging is a good source for basic information on all aspects of menopause.

5. • The National Library of Medicine’s MedlinePlus provides links to reliable sources of information on menopausal symptoms and treatments.

6. • The Endocrine Society can help you find an endocrinologist to address concerns about hormones.

7. • Red Hot Mamas provides support groups and education around all aspects of menopause and women’s midlife health.

Books

1. • Natural Menopause by Myra Hunter, PhD, Sabrina Zeif, Paul Harter, Anita Ralph, MSc, and Louise Robinson.

2. • Before the Change: Taking Charge of Your Perimenopause by Ann Louise Gittleman, PhD, CNS

3. • New Menopausal Years, Volume 3: Alternative Approaches for Women 30–90 by Susan S. Weed

4. • Herbal Healing for Women by Rosemary Gladstar

Online Q&A’s with Practitioners

1. • “When Menopause Comes Early” with gynecologist Sherry Ross, MD

2. • “A Beginner’s Guide to Hot Flashes” with ob-gyn Caitlin Fiss, MD

3. • “Don’t Call It Menopause: Embracing the Change” with Dominique Fradin-Read, MD, MPH

4. • “A Plastic Surgeon on Bioidentical Hormone Therapy” with Ronald Moy, MD

5. • “GP & Sara Gottfried, MD, on Perimenopause, Menopause & Hormone Resets”

Other Content

1. • Information about pelvic floor health: “Ask Gerda: When Do I Need to Start Doing Kegels—and How?”

2. • About soy in the diet: “Ask Gerda: Is Soy Good for You or Not?”

3. • “An Author on Going Through Menopause at 37” by Isabel Gilles

Episodes of The goop Podcast

1. • “How to Balance Your Hormones” with Dominique Fradin-Read, MD, MPH

2. • “Resetting Hormones, Weight & the Conversation around Women’s Health” with Sara Gottlieb, MD

References