How does the body change?

The 4 stages of the menopause

After puberty, the second big hormonal transition that women experience is the menopause. In the time between these two events, a complex system controls the female cycle of menstrual periods. The ovaries produce the hormones oestrogen and progesterone. The pituitary gland synthesises follicle-stimulating hormone (FSH). At the beginning of the menopause, ovulation becomes less frequent. Hormone levels begin to fluctuate more. These fluctuations can cause discomfort.

From about age 45, the body produces less oestrogen. During menopause, eventually the concentration of all sex hormones decreases, including that of testosterone.

This sequence is divided into 4 stages. Pre-menopause is the first. This stage comprises the last 1-2 years before a woman's last menstrual period. Only very few hormonal changes take place during this time. Because egg cells no longer mature as well, strong hormonal fluctuations can occur. Menstruation itself can also be disrupted. Some women report tender breasts and low mood during the second half of their menstrual cycle. The reason for these symptoms is an imbalance of hormones. Menstruation may be stronger or weaker at times, and the time intervals also change. Some women experience these symptoms as early as 10 years before their menopause, others have no discomfort at all. Fertility may be limited. Unexpected ovulations may also occur.

The second stage is called perimenopause. This is the time just before a woman's last ever menstruation. Hormone levels drop at this time (see diagram below). Hormonal fluctuations are very common. They often cause discomfort. Complaints include, for example, abnormal menstruation, very heavy or missing menstrual periods, tenderness in the breasts, mood swings, hot flushes, and sleep disorders. Some women, however, have hardly any symptoms during this stage.

The third 'stage' is more accurately a point in time: the last menstruation. It is called menopause. It is the end of menstrual periods. A menstruation is called menopause if no further menstruation follows it for at least 12 months. At what age the actual menopause occurs varies greatly. Its timing is often similar to that experienced by the woman's own mother. Some women experience a regular menstrual cycle right up to their menopause. For others, menstruation stops only during the colder half of the year. Some women experience a menstrual cycle of 3 to 4 months. This cycle may stay the same for a period of several years. After menopause, no new pregnancy can develop.

The fourth and last stage is called post-menopause. During this time, hormone levels slowly reach their new equilibrium. This means that the potential discomforts can also last up until this point.
The onset of each stage, and the overall duration of menopause can vary a lot. For some women, the entire process lasts 3, for others 10 years. On average, it amounts to 5 to 8 years. In most women, the hormonal situation stabilises after menopause. Some women are glad that they no longer menstruate.

The diagram shows how hormone levels drop permanently. However, each menstrual cycle contains significant changes in hormone concentrations from one day to the next. These are often even more pronounced during perimenopause.

In some exceptional medical circumstances (e.g. when menopause starts very early), gynaecologists can measure hormone levels in the blood. This is how they determine if menopause has started. Normally, hormone tests don't signify anything regarding health complaints or treatment options. Neither do they indicate whether the woman concerned can still become pregnant or not.

Discomforts and physical changes

Menopause is often characterised by physical and psychological changes. However, some of them may be related to normal ageing or to women's status in society. Different cultures have different perspectives on these changes and discomforts.

Not all women experience problems related to menopause. Around one third of women do not notice any discomfort. Another third notice mild discomfort, but are not bothered by it. During pre-menopause, tenderness in the breasts and mood swings occur more frequently before menstruation. Disturbed sleep may add to this during the perimenopause. Hot flushes mainly occur during post-menopause.
Only one third of women report that these symptoms are stressful and limit their quality of life. In these cases, medical interventions can help alleviate the discomfort. However, even medical professionals can't predict when exactly these discomforts will occur and how long they will last. The most frequent physical symptoms during menopause are hot flushes and sweats. A hot flush is a sudden sensation of heat that has nothing to do with the ambient temperature or physical exertion. Sweats often occur during the night, but also during the day. Both these symptoms can put a strain on everyday life. Disturbed sleep can be an additional symptom. Disturbed sleeping patterns lead to tiredness, headaches, reduced performance and other discomforts.