Signs & Symptoms of the 10 Stages of Menopause
The menopause transition will happen to half the people on the planet.
Yet, most of us haven’t had a meaningful chat with our healthcare providers about this stage of life. You want to know what to expect and what's really going on throughout the 10 stages of menopause.
I’m here to help! Welcome, I’m Melinda Staehling, an Oregon-based Certified Nutrition Specialist®, empowering my clients to thrive through the menopause transition and beyond.
In this blog post, I’ll cover the specifics of pre-, peri-, and postmenopause so that you understand the big picture of the menopause transition and feel more confident going through it.
While we can generalize menopause stages by looking at the population, your menopause experience is unique to you. You deserve to have a health and wellness plan tailored to your unique life, goals, and health history.
Let’s start with the basics - what is menopause, exactly?
What is Menopause?
Medically, menopause is determined in the rear-view mirror. We arrive at menopause on the one-year anniversary of going without a period [1]. Your uterus doesn’t announce which period is the last, so we figure it out as time goes by.
While the general public tends to refer to “menopause” as the entire menopause transition, from perimenopause up to the point of the final period, “menopause” literally refers to that one single day.
What we tend to be talking about is the whole process, which we can call the menopause transition.
In medical terms, the menopause transition is marked by the loss of oocytes, which are immature eggs.
A decrease in estrogen, along with other hormonal changes, is another medical marker of this stage. (Not to mention, a slew of potential side effects and symptoms, which we’ll get into, along with what we can do to improve your quality of life on this journey.)
Definitions:
Oocyte: A cell in the ovaries that can undergo cell division to form an egg [2].
Ovarian Follicle: A small, fluid-filled sac in the ovary that contains one immature egg [3].
The Menopausal Timeline:
Menopause typically occurs between the ages of 45 to 55.
The average age for menopause is 52 [4].
Menopause - The one-year anniversary of your final period.
Early menopause - The final menstrual period occurs before age 45.
Late Menopause - The final period occurs after age 55.
Perimenopause, menopause transition, climacteric - The time frame “around menopause” marked by cycle changes or other menopause-related symptoms (hot flashes, sleep problems, vaginal dryness).
Postmenopause - The stage of life after the final menstrual period [4].
What Hormones are Shifting in Menopause?
While the decline in estrogen is the Main Character of the menopause transition, there are shifts taking place in other hormones. Here are some names to get familiar with:
Estrogen - A hormone produced mainly by the ovaries. There are estrogen receptors located on almost every cell in the body [6].
There are three types of estrogen:
Estradiol (E2): The primary estrogen during premenopausal years.
Estrone (E1): With much lower levels than estradiol during premenopausal years, estrone is the primary estrogen after menopause.
Estriol (E3): This is produced during pregnancy.
Progesterone - Also produced in the ovaries. In a usual menstrual cycle, progesterone levels rise after ovulation.
Testosterone - Produced primarily in the adrenal glands, then the ovaries, and other related tissues. Testosterone levels tend to decrease more due to chronological age than menopause [7].
Other hormonal players to recognize:
Follicle Stimulating Hormone (FSH) - One marker for menopausal status is FSH. FSH will continue to rise throughout the transition, as estrogen levels decline.
Anti-Müllerian Hormone (AMH) - A hormone produced by the ovarian follicles, which is involved in ovulation. There is research looking at how this hormone might predict menopause.
Inhibin B - Another ovarian follicle hormone, Inhibin B, can act as a marker for the number of ovarian follicles.
Antral Follicle Count (AFC) - This is not a hormone, but it is a test, usually done by ultrasound, to determine the number of egg follicles.
Reminder - Menopause is not a “disease” or a “deficiency state”. The decline in hormone levels is a natural occurrence. However, this language of disease and deficiency is still seen throughout menopause culture, nutrition plans, and products.
The phrase “Hormone Replacement Therapy (HRT)” was updated to the more preferred “Menopausal Hormone Therapy (MHT or MT)” to reflect this shift in thinking about menopause.
What are the 10 Stages of Menopause?
We usually see the stages of menopause described as pre-, peri-, and postmenopause. I think that’s a good start to describe the transition, but there are actually more details for us to fully understand this process.
The following way of looking at the stages of menopause applies regardless of demographics, age, body weight, or lifestyle [4].
An international group, the Stages of Reproductive Aging Workshop (STRAW*), was established in 2001 to study and assess markers of the menopause transition. This global group took a comprehensive look at the best studies on the menopause transition.
They established the STRAW* and later, in 2011, updated their original work to the 10-phase system known as STRAW+10.
The main criterion of menopause, as seen through the lens of STRAW+10, is the menstrual cycle. Next comes hormone levels, and then we look at signs and symptoms.
Menstrual cycle
Hormone levels
Signs & Symptoms
Keep in mind that STRAW+10 was established to examine the biological phases of menopause.
There are many other changes taking place during this transition that this tool doesn't capture. For example, STRAW+10 doesn’t look at shifts and changes in nutrition status or signs of mental health.
We’re going to include some of those other signs and changes below, but they aren’t part of the STRAW+10 criteria.
Side note: If you experienced irregular periods throughout the premenopause years, for example, you have PCOS, had ovaries removed, or are going through early menopause, the STRAW+10 criteria don’t apply. These are unique situations and require personalized treatment with your healthcare practitioners.
What are the Stages of Premenopause?
(STRAW+10: Stages -5 through -3A)
Premenopause lasts from the start of the first period up until the beginning of perimenopause.
STRAW+10 refers to the entire window, from the onset of the menstrual cycle up until the beginning of perimenopause, as the “reproductive phase.”
But … I don’t love that language, as not all of us spend that time of our lives focused on reproduction. The STRAW* group didn’t ask my opinion when they were writing up their guidelines.
For our work, I’m going to rename that “reproductive phase” to a more inclusive “premenopause” here. Premenopause is pretty standard in both medical terms and in our general menopause culture.
Premenopause takes place from the first menstrual period to the beginning of the signs of perimenopause.
Signs of Premenopause (According to the STRAW+10 Guidelines)
STRAW+10 Stages -
Stage -5 - This is the onset of menstruation, and the menstrual cycle can be variable for a few years before it becomes regular.
Stage -4 - The menstrual cycle typically occurs every 21-35 days throughout this phase.
Stage -3b - Here, the hormone FSH is normal, but AMH and Inhibin B are low, and the AFC will start to decrease.
Stage -3a - This phase is marked by the first potentially noticeable yet small changes in both the flow and length of the menstrual cycle. FSH levels can vary, and AMH, Inhibin B, and AFC are all low.
What are the Symptoms of Premenopause?
As for symptoms, this premenopause phase is still marked by what we typically think of as the signs and symptoms of the menstrual cycle, including usual PMS or menstrual cycle symptoms for you.
Some people will experience a heightened and more severe form of PMS during premenopause, known as premenstrual dysphoric disorder, or PMDD.
PREMENOPAUSE NUTRITION:Premenopause might last for 30 years or more, and nutrition during this phase can be a time of growth in developing our relationship with food.
From a 10,000-foot view, practicing the basics of eating regularly throughout the day, developing our taste and preferences, and exploring different cultural foods can all be important factors here.
If you’re someone more prone to disordered eating behaviors or body image distress, or have chronic health conditions, developing a support network for your nutrition is a much-needed step during premenopause.
What are the Stages of Perimenopause? (Stages -2 through -1)
Perimenopause lasts, on average, 4 years. However, it can last as short as 6 months, or up to 8 years.
When I used to think about menopause, probably up until the point where I started going through perimenopause myself, I thought that periods just got farther apart, and then stopped.
Oh my. How wrong I was.
Early perimenopause looks different for most people. This is backed up by the STRAW+10 data.
In the STRAW+10 framework, perimenopause is divided into two distinct stages: early and late perimenopause.
A reminder: STRAW+10 uses the menstrual cycle as the primary measurement.
Despite what any hormone testing company tells you, the best way to determine a perimenopausal stage for most of us is by looking at the menstrual cycle. There aren’t specific hormone markers or tests for “perimenopause.”
There can be so much hormone fluctuation from day to day in perimenopause, especially with hormones like estrogen and FSH. Taking blood levels of these hormones doesn’t usually help to predict exact perimenopause stages or typically guide hormone therapy treatment.
However, your practitioners might have specific reasons for testing based on your unique situation.
Perimenopause can look a little different if you have PCOS; you might experience your first regular cycles ever. Perimenopause can also have a different profile for those who haven’t had a consistent cycle for other reasons over the premenopausal phase.
Signs of Perimenopause
Early Perimenopause (STRAW+10 - Phase -2)
For this first perimenopausal phase, the menstrual cycle typically gets shorter and more unpredictable. We're said to be in early perimenopause (Stage -2) when there is a ≥ 7-day difference between cycles, and this happens once within 10 cycles [4].
Because of the changes in cycle length, spending more time in the luteal phase of the cycle can lead to an increase in PMS-like symptoms. Symptoms like mood and mental health changes, increase in migraine, and the onset of hot flashes and night sweats are some of the changes in early perimenopause.
Increasingly in peri, some menstrual cycles don’t lead to ovulation, and these cycles can produce more irregular bleeding patterns. The ovulatory cycles are typically more predictable.
Late Perimenopause (STRAW+10 - Phase -1)
As we move into later perimenopause, your cycles are typically spaced farther apart. We’re talking twice as long, with greater than 60 days between cycles as the marker for this phase.
As far as symptoms, late perimenopause can look dramatically different depending on the person.
Later perimenopause is when hot flashes and night sweats might become more pronounced. Unfortunately, these vasomotor symptoms can last well into postmenopause.
An increase in vulvovaginal changes like vaginal dryness and pain with sex can also show up during this time.
What are the Symptoms of Perimenopause?
Do we have all day?
I joke, but there are a lot of signs and symptoms.
Keep in mind that some of the body signs and symptoms are due to chronological aging, not just the timing of perimenopause.
Personally, I fell off the cliff with night sweats, sleep issues, mental health decline, and migraine. I was hit by the proverbial peri truck. Ouch.
Sleeplessness, hot flashes and night sweats, and increased mental health concerns like perimenopausal anxiety and depression can all occur during peri. Then, there are the less common but still annoying symptoms like burning mouth and itchy ears.
Weight redistribution is a hallmark concern in pop culture posts and conversations about perimenopause. However, research suggests that weight gain during the menopause transition happens more due to aging and lifestyle changes than the hormone shifts associated with menopause [8].
Body image distress and increased risk of disordered eating and eating disorders are heightened during perimenopause [9].
PERIMENOPAUSE NUTRITION:Due to the hormonal shifts taking place, perimenopause is a time when taking a more individualized approach to nutrition might make sense for you.
At perimenopause, some people experience shifts in digestion, like more bloating and constipation. Others see an increase in markers like blood sugar and cholesterol.
You deserve personalized, evidence-based perimenopause care that takes into account your unique relationship to food and body image.
What are the Stages of Postmenopause?
Postmenopause lasts from one year after the final menstrual period, or menopause, for the remaining lifespan.
Most women and AFAB folks will spend up to ⅓ or more of their lives in postmenopause.
Quick reminder: “menopause” is officially declared after you’ve gone one year without a period.
The first few years of postmenopause are broken into year 1 and year 2 within the STRAW+10 system because the leveling out of hormones and dynamic symptoms at this time warrants separate stages.
Signs of Postmenopause
Early Postmenopause (STRAW+10 - Stages +1a, +1b, +1c)
STRAW+10 Stages +1a, +1b - In their system, STRAW +1a is the first 12 months after the final menstrual period. Estrogen levels continue to decrease this year, while FSH levels rise. Phase +1b is the second year of postmenopause, where the hormone changes start to level off.
These first two years of post tend to be the most symptomatic for hot flashes and night sweats.
STRAW+10 - Stage +1c - After the first 2 years of early postmenopause, phase +1c begins, and lasts for the next 3-6 years. Here’s when the high FSH and low estrogen levels stabilize.
Late Postmenopause
STRAW+10 - Stage +2 - Within 5-8 years after the final menstrual period, once hormones are stabilized, there are fewer hormonal changes. FSH levels tend to remain high, and while estrogen levels decrease, estrone levels are higher.
This time is when an increase in genitourinary symptoms like vaginal dryness happens for many. Any postmenopausal bleeding should be evaluated by your healthcare professional.
Common Symptoms During Postmenopause:
After the final menstrual period, it’s typical for hot flashes and night sweats to continue for a few years; this usually tapers off as hormones stabilize, but for some, can continue for many years following the final period.
The postmenopausal stage is characterized by another annoying collection of symptoms, the increase in Genitourinary Syndrome of Menopause. In one study, 48% of women experienced vaginal discomfort in menopause, with the most common reported symptoms being vaginal dryness (85%), and pain with sex (52%) [10].
This stage comes with an increase in vulvovaginal tissue changes due to the loss of estrogen. This can result in feelings like burning or pain and other pelvic floor issues. Appropriate treatment is critical for maintaining a good quality of life.
POSTMENOPAUSE NUTRITION:As we enter postmenopause, we may naturally need more care and attention with our nutrition. Maintaining a balanced approach to meet our nutritional needs (eating protein, healthy fats, carbs, and fiber) and monitoring nutrient deficiencies as we age can help us remain vibrant and flourish beyond midlife.
Let’s Recap: The 10 Stages of Menopause
The menopause transition can be marked for some by distinct characteristics of the menstrual cycle and hormonal changes.
Others will find that surgical menopause or premature menopause leads to a different experience.
For many, the menopause transition is a multi-year process of physical and emotional health and body image change. It can also be a time of personal transformation and self-discovery.
I hope that by exploring the specifics of the menopause phases through the framework of STRAW+10, you'll gain a better understanding of the changes that occur during the menopause transition.
Regardless of which phase of the menopause transition you’re in, you deserve evidence-based care and accurate information.
Ready to move away from the usual, toward a more neurodivergent-affirming and weight-inclusive menopause?
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