So You Want to Know About Menopause
If you’ve opened this article because you’re in, going into or post-menopause — including those of you who are young or younger people — it’s pretty obvious why you want to read about menopause. For those of you who aren’t in that group, anywhere near being in that group yet, or are someone who won't ever experience any kind of menopause, you might wonder why we even have an article about it at a site intended for young people.
Why do I think young people might want to know anything about menopause now? Well, for one, I have been listening to menopausal and postmenopausal people bellow, “WHYYYYYYYY DIDN’T ANYBODY TELL ME ABOUT THIS WHEN I WAS YOUNGER, WHEN THEY WERE TALKING TO ME ABOUT PERIODS AND PUBERTY?!?”
They do that because a lot can happen in and around menopause, some of it very disruptive, so being taken by complete surprise can make something often already challenging a whole lot harder (something you may know about yourself if you’ve gone through or have been going through puberty without information about it). Menopause isn’t just about periods stopping and someone no longer being able to reproduce, though those are two big things that are part of menopause for most people. It also isn't just about older people: menopause is something that can sometimes happen to younger people, too.
Menopause, especially in the years leading up to and around a final period, is something that can affect every system of the body, creating or exacerbating things like:
- wonky, unpredictable periods, missed periods, and menstrual “flooding” which is exactly what it sounds like: periods where you might think about building an ark for yourself
- sleep disturbances
- hot flashes (also called “vasomotor symptoms”) and night sweats
- mood changes or new or increased mental illness
- body shape and size changes
- changes in sexual desire, everything from feeling much more to feeling much less
- vulval and vaginal dryness, urinary tract and bladder problems
- skin issues
- cognitive issues, including some extra challenges with ADD or ADHD
- bone and heart health
- chronic pain
- digestive troubles
- not to mention our relationships and how we live the rest of life inside our bodies
As someone who talks to people in their teens and twenties about periods, puberty, and other related things on a daily basis, you can perhaps imagine my horror when I realized that I had been one of those people who had rarely included menopause in these conversations. Mind, like nearly everyone else who hasn’t been through it, I also didn’t know jack about it myself until relatively recently, but that’s no excuse. So, I’m fixing it here with some starter information. Much like you can’t educate someone about all of puberty in just one article, you can’t about menopause, either: for most folks, the whole of the menopause experience is a life phase, not just a moment in time, and the transition alone can span a decade or more with a whole range of things that happen throughout. People who experience menopause can potentially be post-menopause for as long as half their life or more. That’s even longer than most people live with the way their sex hormones are post-puberty.
For a person born with a uterus, menopause is going to happen in some form or fashion. If this isn’t something that can happen to you, personally, it still is something that can happen, will absolutely happen, has happened, or is currently happening for your parents or other relatives, to a friend or a partner, to a teacher, a coach, a therapist, a bus driver, or that poor barista who has to sling steaming coffee all day while already sweating to death at that place you like. Menopause is likely going to be some part of everyone’s life sometime, if it hasn’t been or isn’t already, whether it happens to them, to others in their lives, or both. Just like puberty, periods, or pregnancy can be really big deals to the people experiencing them, and potentially a big part of life, the same goes with menopause. Knowing about it can help you understand what’s going on for those folks, provide better support and keep you from saying something really foolish to them.
So here I am, sweatily reporting for duty.
Words, words, words.
Menopause is a word used two different ways, one that’s very specific and one that’s more general. The specific way means the day when someone who gets menstrual periods has not had a period for 365 days — one year — specifically because the hormones responsible for menstruation and fertility have changed significantly. That’s usually permanent (but not always) and most often occurs to people as a result of the aging process (but not always). 51 is the mean age people are when they reach menopause by way of aging, and that’s been the average age for a long time. For people who didn’t have regular periods to pinpoint when menopause happened (or periods at all), or who came to it by way of things like cancer treatment or hysterectomy, menopause as a specific term instead can instead mean something like “the day my doctor told me I had reached menopause,” “the day I got my hysterectomy,” or “the time I had to go off my estrogen hormone therapy.”
The more general use of the term menopause describes the larger process of menopause: both the time leading up to that one single day or time I just talked about, that single day, and then what’s on the other side of it, too. It’s a lot like the way that lately, “gay” can be used to describe anyone who isn’t straight, rather than just describing homosexual men. The menopause transition is another term used to describe whatever someone experiences as the whole of menopause, not just that one day.
Premenopause is a word for folks who will experience menopause and/or the menopause transition, but have not yet begun any stage of menopause.
Perimenopause describes the process leading up to menopause (the single day kind), for those who experience menopause due to aging. “Perimenopause” literally means “around menopause.” Neither a person nor their healthcare provider can say for sure when perimenopause is starting, but it is considered to have started when the patterns of specific hormones — namely estrogen and progesterone — start to get unpredictable, often erratic, and eventually lead to a lowering of both estrogen and progesterone that lead to menopause. How long it lasts can vary a lot among people.
Postmenopause is a term to describe the phase of life and the reproductive system for all of the time after menopause.
Sudden menopause is a way to describe menopause that happens all at once instead of gradually, like when someone has a full (or “radical”, AKA, both their uterus and ovaries) hysterectomy. There is still often a transition here, whether that’s because someone had already started perimenopause, or we’re talking about the body adjusting to this change afterwards, but it tends to be much shorter (like over just a few months to a year) and more dramatic than when someone reaches menopause because of their bodies’ aging alone. Some people will call kinds of menopause like this “surgical”, “medical” or “treatment-induced” menopause.
Why and how does menopause happen?
You already know what happens with periods and fertility from articles here like this and this, and with puberty from pieces like this one. Here’s the long and very variable story of menopause told short, from some parts of the book I wrote on the subject that’s got me knowing about all this stuff.
For those who come to menopause gradually, by way of perimenopause as a result of the aging process, it most typically starts in a person’s 40s. It’s a normal part of aging, outside a person’s control and occurs all by itself. It doesn’t happen because of anything someone did or didn’t do. It also isn’t an illness or disease.
A lot of folks have the idea that what’s happening from perimenopause into menopause is about a steady, gradual decrease of estrogen until there’s none. That’s not what happens.
What’s happening hormonally during perimenopause is more like a rollercoaster than a slide. For some people, the rollercoaster is the short, gentle kind for little kids — some people even manage to sleep through that ride without even knowing they were on it. For others, it’s one of those where you feel sick and terrified just looking at it. Most people will have something in between.
By the time the transition into menopause begins for most folks, the stockpile of oocytes — egg cells in the ovaries — is down to around 10-20,000 from the one or two million usually present at birth. That 10-20,000 might still sound like a lot, but the ones left are the slackers: they just aren’t the ovum most likely to…well, to do anything. That combination — how relatively few ovum are left, and that the ones left are the bottom of the barrel — is what’s generally agreed to kick off perimenopause. The remaining egg cells send weaker, more chaotic signals — signals that previously kept cycles running pretty predictably and smoothly — to the hypothalamus (the part of the brain responsible for regulating many important processes of the body, including those of the reproductive system) than more and better eggs did. As a result, levels of estrogen and progesterone start to become erratic, unpredictable and unbalanced.
This can result in many different felt impacts across all systems of the body. Perimenopause, menopause and the hormonal situation post-menopause can all influence every system of the body, because every system of the body has hormone receptors for the hormones that are changing, and what’s going on in one system of our body also doesn’t tend to happen in a vacuum. These are the things people often call “symptoms” of perimenopause or menopause (I prefer to call them impacts or effects): like hot flashes and night sweats, body shape or size changes, constipation, fatigue or mood swings. Some people experience few or even none of these impacts in early peri. Early perimenopause, however long it may last, is typically more mellow than the second half: for many, while hormonal changes are happening, they don’t cause major or even noticeable impacts.
The idea that perimenopause has started only once people start having longer cycles or missing periods is outdated: that’s not usually what periods are like in early peri. As perimenopause gets started, those who have had fairly regular menstrual cycles will often start to see some changes. Most commonly, that first looks like cycles that are shorter, where you’re having more periods, not fewer. Some people also experience very heavy or long periods during this time. That’s because it’s typical to have high estrogen during this time, not low estrogen.
When someone starts moving into or is in later perimenopause, that’s when those remaining egg cells start to produce less and less estrogen (and also less of the peptide hormone Inhibin B), FSH goes high and starts staying elevated in a way it normally wouldn’t. That FSH elevation is effectively screaming to the entire neighborhood for estrogen to come home for dinner. Estrogen then flies up and down in response like a haunted elevator and then eventually starts going lower, ignoring that call. Progesterone often goes and stays low (clearly ignoring Michelle Obama’s advice). None of this is a recipe for feeling good. Estrogen and progesterone tend to balance each other out and work best in balance. So, if and when either gets too dominant — especially when the combination is very high estrogen and very low progesterone, which is often the case in much of perimenopause— we generally just don’t feel good.
It’s common to have periods of time in all this where you’re doing pretty alright, with what feels like relatively little impact from perimenopause, and then find yourself in a phase of some big impacts, or new impacts you didn’t have before. It’s just often very unpredictable and varies a lot from person to person.
By the time a final period (if someone has had them), and then capital-M menopause, are near, estrogen and progesterone are making their way to the low, stable levels they’ll be for the rest of life. They aren't going to cycle constantly anymore the way they often did from the start of menstruation on. They're chill. The signals to develop ovum have all but stopped and, without those cells developing, so has most of the estrogen that occurs expressly from that process. An estrogen switch starts to happen in the body: it’s moving from getting most of its estrogen from the ovaries (an estrogen called estriadol) to getting it (now as an estrogen called estrone, via a conversion process by the steroid hormone androsteneodione, which also helps create testosterone) primarily from body fat instead.
Once someone's body has started to settle into the new hormonal situation postmenopause, things often tend to get easier than they were during the transition. That's not to say there aren't still some possible and common issues, including some things that started during the transition and don't go away, but by and large, most people feel better postmenopause than they did while their bodies were in the biggest periods of change with this. Some people report that being postmenopause feels better for them than being premenopause did.
But menopause can also happen a few other ways than by way of aging, or can happen earlier than average for a handful of reasons.
People who go through perimenopause and menopause at the expected times can often have a hard enough time, and can often have difficult or challenging feelings around it — even when it’s wanted. But things can be a lot more complicated, and often feel a lot more isolating, if it happens earlier. So much of the talk about menopause is about aging, and by and from aging people: that isn’t about you if it’s happening for you very early, and it often won’t include you. Sometimes it will even willfully exclude you. No matter how you may feel about reproducing, no matter what you have or haven’t wanted with it, it’s also one thing to accept you won’t or can’t (or won’t or can’t anymore) at 50. It’s often something different at 30 or younger.
People who reach menopause -- the on-the-day-kind -- before age 45 are said, in medical parlance, to have experienced early menopause. People who experience menopause before age 40 are often said to have experienced premature menopause, even if experiencing menopause was their intention, like for many folks who have elective hysterectomies.
Menopausal transition or menopause may happen earlier due to:
- smoking, especially heavily or over a long time, including secondhand smoke
- not having any pregnancies or births
- poor nutrition
- high body fat
- autoimmune conditions like diabetes, rheumatoid arthritis, hypothyroidism, or
- medical gender transition
- Fragile X Syndrome
- Turner Syndrome
- hysterectomy and oopherectomy; surgical removal of the uterus, ovaries or ovatestes
- chemotherapy, radiation or other medical treatments
I want to focus on the ways it can happen expressly for young or younger people, since one of these may be why you’re reading this article in the first place.
“Premature” menopause or primary ovarian insufficiency (POI): You may also hear this called “premature ovarian failure” (POF) or, because 5–10% of those with primary ovarian insufficiency can still become pregnant and deliver, “decreased ovarian reserve.” POI is menopause that happens when people reach menopause considerably earlier than expected. If you are or were in perimenopause in your 20s or 30s — it can even happen to some in their teens — or found yourself on the other side of menopause before 40, and haven’t had any kind of surgery or medical treatment that can cause sudden menopause, you’re probably someone experiencing or who has experienced POI. POI is said to occur for anywhere from 1-5% of people with uterine systems, but since diagnosis is rare, that number might be higher.
POI is understood to happen because of medical conditions like chromosomal disorders or certain intersex conditions, thyroid conditions, diabetes, autoimmune disorders, surgeries or medications that have affected the blood supply to the ovaries. It’s sometimes also used to describe menopause due to radiation or chemotherapy treatment when that happens for younger people. It can also be genetic.
- heart disease and stroke
- lower bone density and osteoporosis
- feelings of social isolation (this can particularly happen around pregnancy and childbearing as well as other exclusion from age-normative lifestyles or events)
- autoimmune disorders (or, additional autoimmune disorders for those who already have one or more)
- cognitive function issues
Hormone therapy that includes estrogen is often strongly recommended for those who experience premature menopause, the earlier the more strongly, because of the impact the sudden lack of estrogen can have on overall health, particularly on bones, cognition and mental health, and the cardiovascular system. Topical estrogen can also be prescribed for genital use to treat or guard against genital impacts of menopause, like extreme dryness that can cause discomfort. (This can also be used if you’re in menopause or experiencing genital dryness or inflexibility due to gender transition and using testosterone and it will not impact or undo the effects of the T.)
POI is usually diagnosed by a pattern of missed periods for a few months or more paired with tests of hormone levels over time that show elevated FSH levels. You may also have tests of other hormones, an ultrasound, or genetic testing, as well. POI is not always permanent. It can sometimes be intermittent, which means that you should not assume infertility. POI also doesn’t always cause menopause in the first place.
Find more information on POI:
Sudden menopause: Menopause can occur due to radical hysterectomy (removal of both the uterus and ovaries) or bilateral oopherectomy (removal of both ovaries), as a result of some treatments for illness, or anything that damages the ovaries. Some medical treatments, such as chemotherapy, pelvic radiation, or medications like Tamoxifen, Leuprolide or Zoladex, can result in permanent or temporary menopause.
Where gradual menopause — like going through perimenopause — is like riding a rollercoaster, sudden menopause tends to be like that ride where you shoot all the way up and are then quickly dropped all the way down: it’s faster and usually way more intense. Some people’s gradual menopause is so gradual and so mild when it comes to physical and mental impacts that they seem to barely notice it’s happening: that’s not at all likely to be the case with surgical menopause.
How sudden it is and feels depends on how someone got there, and if a person is using hormone therapy to ease that transition and make it more gradual. Menopause due to chemotherapy or other medical treatment often occurs over months; menopause that happens due to surgical removal of both ovaries happens instantly. But just as the case can be with some who come to menopause gradually, a minority of those who come to it suddenly can experience some menopause impacts, like hot flashes or fatigue, for a long time.
Those who experience sudden menopause, especially those who aren’t already in or very near perimenopause, can have a harder time with it — particularly if they lack proper medical support following — than those who experience menopause with a gradual transition. Most people who experience sudden menopause will need ongoing medical care and treatment, often including hormone therapy.
People who have only a hysterectomy, without removal of or damage to the ovaries, will typically still come to menopause via perimenopause, as they would have had they retained their uterus. It can occur earlier than it would have otherwise sometimes, though, because of the lack of hormonal feedback from the uterus to the ovaries. If, as it does about half the time, hysterectomy includes bilateral oophorectomy (“radical” or “total” hysterectomy”), the removal of one or both ovaries or the removal of ovatestes, when those are present, very sudden menopause will occur as a result. If only one ovary has been removed and another remains, it’s a hybrid gradual/sudden menopause experience, but menopause does often happen earlier.
Temporary menopause: Sometimes people call what turns out to be an impermanent stall-out of the reproductive system temporary or medical menopause. That can happen sometimes with some medical treatments. With treatments that can bring about either temporary or permanent menopause, menopause is more likely to be permanent the closer a person is to the time of life they’d start to experience menopause due to aging, and more likely to be temporary the further away from that time someone is. This term is also sometimes applied to people who stop ovulating and menstruating for other reasons, including long term use of hormonal birth control methods, or because of eating disorders or very high levels of exercise. Trans women who temporarily go off estrogen and then go back on may also use this term to describe that experience.
People who experience temporary menopause can experience menopause twice, because they can still go through menopause as a result of aging. You can also experience temporary menopause more than once.
Testosterone use: If you’ve been using testosterone at levels typical for gender affirmation for at least six months, your body has basically started a gradual menopause transition. If you’ve been on it for a couple years or more, even without radical hysterectomy, you’re probably in menopause. The menopause that can happen with testosterone therapy will usually be similar to a gradual perimenopause in the late stages, but also a pretty quick menopausal transition. Setting aside the range of effects testosterone brings to the table itself, when it comes to menopause, the erratic estrogen and progesterone fluctuations common in early perimenopause probably won’t happen, because of increasing testosterone dominance from the HT. Some of the emotional volatility many people feel when they start T is because of T, but some of it is also because of the change in hormone balance that results in dropping, and then eventually, minimal, estrogen levels. So, in some ways, it may feel like sudden menopause.
Systemic estrogen withdrawal: Suddenly or gradually withdrawing from estrogen hormone therapy, either by choice, because of surgeries or health conditions, or due to lack of access, can be similar to suddenly or gradually going through menopause, regardless of one’s gonads or assigned sex at birth. Similar physical impacts can occur — like hot flashes, sleep disturbances and genital dryness — and there are similar possible psychological impacts as well, like anxiety, depression or dysphoria, particularly for transgender women.
However someone goes through or arrives at menopause, what happens to a person — to their body and how it feels, how it looks, how they feel in it, including in their mind, and to their whole lives — varies so much from person to person. There is no universal experience of menopause, just like there isn't of periods or pregnancy. The impacts menopause has on us has a lot to do with all the conditions of our lives and bodies and the whole of their histories AND our life conditions and our bodies and their current state now. What happens isn’t just about hormones or reproductive systems in the moment. Someone who, for instance, has a lot of trauma history, a chronic illness, and is a marginalized person in the world living with all the stresses and burdens of that who also has limited access to healthcare is likely to have a very different experience than someone who has lived or is living without any of those challenges. Not everyone will experience all of the impacts there can be with menopause, or experience them the same ways. Even someone who does experience all of them won’t usually have all of them happening at the same time, but instead, is more likely to experience different things over many years.
For many of you reading this, this is all ten to twenty years away. Even if that's the case, there are still some very good reasons to learn a little about it now.
Even when perimenopause starts at an “average” time, that average time tends to be earlier than people expect. You might be thinking that time is in your fifties, maybe in your late forties. But more realistically, perimenopause often begins in the 40s, sometimes even in the 30s. It also doesn’t start or end at an average time for everyone. For some people, like those with POI or treatment-based menopause, it just happens much earlier. This is especially important to know for people who:
- want to conceive/are planning to conceive so they can plan accordingly.
- are having “mystery” reproductive issues that they or healthcare providers can’t find any other cause for, despite investigating other common causes.
- are thinking about medically and/or surgically transitioning their gender, particularly with testosterone and/or via hysterectomy and/or oopherectomy so they better know what to expect.
Because menopause and the menopausal transition can be very challenging for some people, learning a little about it so you can better support those people in your life -- or at least avoid being flatly unsupportive or ignorant -- is a great thing to do. It's fairly common for parents to be going through it around or at the same time their kids are also going through puberty, so you may even be able to connect around both these big transition in ways you wouldn't have thought of if you didn't know you were in sometimes similar states of being. As you probably know for yourself from puberty, in these kinds of times, a little patience and understanding for what we're going through can go a very, very long way.
There are a few more things about menopause I think it’s good to know way in advance:
- Smoking makes the experience of any kind of menopause worse. It also gets harder to quit smoking the longer you do it, so if you smoke, quitting sooner rather than later would be the way to go for this as well as many other reasons.
- Before you start getting fewer periods or skipping periods in perimenopause, you usually get MORE periods, and by more, I mean both more often, closer together and MORE period, as in, more flow. You won’t be dying, but you might think you are if you don’t know this can happen.
- It is a fact and not at all a myth or hyperbole that your cycles and hormones and all the things that have always happened with them, and will happen with them, can have a big impact on your moods and mental health. Sexism and misogyny have taught many of us to deny this and to act like this isn’t the case, but the truth is, they have always had an impact, and come perimenopause and menopause, they often especially will. In fact, they can have really serious mental health impacts for quite a lot of people, especially those who have a history of mental health or mood upsets linked with cycles or the hormones involved, like PMS, PMDD, and postpartum depression. So, if you find yourself feeling — or people are observing in you — an uptick in rough mental health
, particularly if you’re in your thirties or nearing or in your 40s, it helps to know it may be influenced by menopause or perimenopause. (The good news about that is that it is most common for mental health to improve postmenopause.)
If we have the idea, as we often will,
Who can you talk to about menopause to find out more?
Us: You can come into any of our direct services and ask us about it.
A healthcare provider: Unfortunately, a majority of healthcare providers don’t have any menopause training or much education about it. But OB/GYNs, especially those who don’t focus mostly on obstetrics (on childbirth), endocrinologists and trans health specialists are often a best bet. You can always just ask a healthcare provider what their background is with any kind or part of menopause.
Family members (blood relatives, chosen family or both) who have gone through it, or other people who have experienced it: You can ask people in your life about this. Just be aware that some people have a lot of shame around menopause -- much like many people do around periods or sex -- so be gentle in your asks, and respect anyone who says no or seems really uncomfortable about it.
A therapist: Menopause isn’t just about physical changes, it often involves feelings and mental health too, as well as things that are the purview of a therapist, like social and family life. If you’re someone going through or reaching menopause long before you expected to, especially if you also don’t want it, it can be extra tough, and a therapist can give good support.
Books and other web resources: Like I said, I wrote a book about this: What Fresh Hell is This? Perimenopause, Menopause, Other Indignities and You. If you’re coming to this by way of surgery, Surgical Menopause: Not Your Typical Menopause, edited by Helen Kemp is a good book to start with. If POI is your issue, The Complete Guide to POI and Early Menopause by Hannah Short and Mandy Leonhardt is coming out soon. Online, Women Living Better has excellent and clear information. This page from GenderGP has some good basic information about menopause for trans people. Do be aware that unlike my own book or that page from GenderGP, most past and current menopause information and even healthcare isn’t inclusive, in terms of gender, sexual identity, and often with other issues too, like race, fat, disability and economic class.