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Midlife and Menopause

Signs of the Menopause Transition

Problems that some women associate with changing hormones include hot flashes and night sweats; depressed mood; sleep disruption; sexual concerns; changes in cognition (thinking and judgment); vaginal dryness; urinary incontinence; and bodily aches and pain. Only a few of these become much more prevalent as women progress through the transition to menopause. Hot flashes, night sweats, vaginal dryness, and sleep disruption increase in prevalence, especially as women begin the late menopausal transition stage marked by skipping periods.21 How long these problems persist during the postmenopause is uncertain because most studies have not followed women for more than two or three years after their final menstrual period.


Nearly four in ten women are bothered by hot flashes during the late menopausal transition stage and postmenopause.22 About 26 percent of women have severe hot flashes, according to one large study; 23 according to another study, 15 percent of women experience hot flashes on more than fifteen days per month and 9 percent experience them every day.24 (For more information about hot flashes, see Chapter 5, “Hot Flashes, Night Sweats and Sleep Disturbances.”)

One woman with severe hot flashes says,

Your invitation to share my story came just as I was experiencing the fourth hot flash of the day. I was, as usual, dripping with sweat and wiping my brow, under my breasts, the back of my neck, and my hands so I could continue working at the keyboard. Fortunately, I work at home, so I can strip down when necessary. Occasionally, though, I do media work, and it can be quite inconvenient to sweat away the makeup that someone has just carefully applied! Anyway, this has been going on for more than two years now but I can definitely say some days are worse than others. It’s worst of all at night, and in the first year I sometimes was awakened every hour with the intensity of it. I actually get hot enough to steam up my own glasses—something that evokes unfailing sympathy from my husband, who keeps saying he can’t imagine how I can cope with it. I tell him I’m not alone, there are millions of baby boomer women out there going through the same thing.


Sleep problems seem to increase steadily across the early and late menopausal transition stages and into postmenopause, with an estimated 30 percent of women without signs of the menopausal transition reporting sleep disturbances and 45 percent reporting them three years after menopause.25 This pattern suggests that sleep problems may worsen with progression through the menopausal transition and perhaps be related to other signs, such as night sweats. However, sleep problems increase in both women and men with age and have also been associated with the stress of poverty (for example, worry about paying for basic needs).26 (For more information about sleep problems, see page 82.)


Vaginal dryness becomes more prevalent during the early postmenopause, as do other sexual changes. Nearly 50 percent of women report bothersome vaginal dryness three years after menopause.27 Some of the sexual problems women report, such as pain with intercourse, may be related to vaginal dryness.

Other changes, such as lower sexual interest and responsivity, increased in prevalence as women made the transition to menopause. Lower estrogen levels, but not lower testosterone levels, were associated with sexual problems in a large longitudinal study of women during the menopausal transition in Australia; recent reports from the SWAN study indicate that testosterone levels have minimal influence on sexual desire, a finding corroborated by another study of Australian women.28 Our prior sexual experiences and factors related to our partners, our relationships, and other aspects of our lives influence our sexuality as well as the biological changes associated with menopause. (For more information about sexuality, see Chapter 9, “Sexuality.” For more information about vaginal dryness, see Chapter 6, “Vulvovaginal Changes.” For more information about testosterone and low sexual desire, see page 110.)


It is unclear if problems with depressed mood, urinary control, cognitive functioning, and joint and muscle aches and pains change because of the menopause transition. Depressed mood is common in women across the lifespan, with about 30 percent of women of all ages in a recent study noticing symptoms.29 Women with depressed mood may have slightly lower estradiol levels, but research has found that having severe hot flashes and disrupted sleep is more frequently associated with depression than low estradiol is.30 In addition, women who experience depressed mood during the menopause transition are more likely to have been depressed earlier in the lifespan and to have faced major stressors such as abuse.31 (For more information, see Chapter 15, “Memory and Mood.”)


Many women going through the menopause transition and after menopause describe problems with memory, such as difficulty recalling names, but few women rate these as serious. Women attribute memory problems to increased responsibilities and stress, advancing age, physical health problems, inadequate concentration, and emotional changes.32 To date only one study has tracked changes in cognitive function across the menopause transition; it found there was no change in the prevalence of memory problems. In that study, memory actually improved as women progressed to the early menopausal transition stage. The only memory change noted was a modest decrease in perceptual speed after women became postmenopausal, a change usually associated with age in both women and men.33 (For more information, see Chapter 15, “Memory and Mood.”)


Urinary problems, such as leaking urine, are prevalent in women during midlife, with about half of women reporting varying levels of severity of leakage. These symptoms do not seem to change with the progression to menopause. They are more prevalent in heavier women.34 (For more information, see Chapter 14, “Uterine and Bladder Health.”) Likewise, 40 to 60 percent of women across the menopausal transition experience stiffness or soreness in our joints, neck, or shoulders, but this pain does not change significantly with the transition to menopause.35

Severity of problems such as hot flashes, night sweats, vaginal dryness, and sleep problems increases during the late menopausal transition stage and postmenopause. There are not enough follow-up data to know how long problems persist during the postmenopause.

End of excerpt
Excerpted from Chapter 3: What's Happening to Our Bodies in Our Bodies, Ourselves: Menopause  © 2006 Boston Women's Health Book Collective


21. N. Woods and E. Mitchell, "Symptoms during the Perimenopause: Prevalence, Severity, Trajectory, and Significance in Women's Lives" (submitted). [back to text]

22. L. Dennerstein, E. Dudley, J. Hopper, J. Guthrie, and H. Burger, "A Prospective Population-Bases Study of Menopausal Symptoms," Obstetrics and Gynecology 96 (2000):351-58. [back to text]

23. E. B. Gold, B. Sternfeld, et al., "Relation of Demographic and Lifestyle Factors to Symptoms in a Multi-Racial/Ethnic Population of Women 40-55 Years of Age," American Journal of Epidemiology 152, no. 5 (2000):463-73. [back to text]

24. E. W. Freeman, J. A. Grisso, J. Berlin, et al., "Symptom Reports from a Cohort of African American and White Women in the Late Reproductive Years,"  Menopause 8, no. 1 (2001):33-42. [back to text]

25. Dennerstein et al., " A Prospective Population-Based Study." [back to text]

26. Gold et al. [back to text]

27. Dennerstein et al., "A Prospective Population-Based Study." [back to text]

28. Dennerstein et al., "Hormones, Mood"; N. Santoro, J. Torren, S. Crawford, J. Allsworth, J. Finkelstein, E. Gold, S. Korenman, W. Lasley, J. Luborsky, D. McConnell, M.J. Sowers, and G. Weiss, "Correlates of Circulating Androgens in Mid-Life Women: the Study of Women's Health Across the Nation (SWAN)," Journal of Clinical Epidemiology and Metabolism 90, no. 8 (2005):4836-45; Davis et al. [back to text]

29. L. Dennerstein, J.R. Guthrie, M. Clark, et al., "A Population-Based Study of Depressed Mood in Middle-Aged, Australian-Born Women," Menopause 11, no. 5 (2004):563-8. [back to text]

30. N. Avis, S. Crawford, R. Stellato, and C. Longcope, "Longitudinal Study of Hormone Levels and Depression among Women Transitioning through Menopause," Climacteric 4 (2001):243-49. [back to text]

31. N. Woods, A, Mariella, and E> Mitchell, "Patterns of Depressed Mood across the Menopausal Transition: Approaches to Studying Patterns in Longitudinal Data," Acta Obstetrica Gynecologica Scandnavica 81 (2002):623-32. [back to text]

32. E.S. Mitchell, N.F. Woods, "Midlife Women's Attributions about Perceived Memory Changes: Observations from the Seattle Midlife Women's Health Study," Journal of Women's Health and Gender-Based Medicine 10, no. 4 (2001):351-62; N.F. Woods, E.S. Mitchell, et al., "Memory Functioning among Midlife Women: Observations from the Seattle Midlife Women's Health Study," Menopause 7, no. 4 (2000): 257-65. [back to text]

33. P.M. Meyers, L.H. Powell, R.S. Wilson, et al., "A Population-Based Longitudinal Study of Cognitive Functioning in the Menopausal Transition," Neurology 61 (2003):801-6. [back to text]

34. C.M. Sampselle, D.S. Harlow, J. Skurnick, et al., " Urinary Incontinence Predictors and Life Impact in Ethnically Diverse Perimenopausal Women," Obstetrics and Gynocology 100, no. 6 (2002):1230-38. [back to text]

35. Gold et al.  [back to text]

Excerpted from Our Bodies, Ourselves: Menopause, © 2006, Boston Women's Health Book Collective.

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