The Stages of Menopause

Last week I wrote about the STRAW guidelines and STRAW + 10, an update based on the review of research done in the 10 years since the original guidelines were published. Because not all of us have reached menopause, defined as one year without menstruating, some of us are interested in what we can learn from the detailed phases!

For context, remember that STRAW draws three large phases: reproductive, menopausal transition, and post-menopausal. The recent review and enhancement of the model outlined four specific stages within that “menopausal transition” that has many of us looking for answers.

During Late Reproductive Years, your ability to have a child is declining. Your menstrual cycles may be shorter and either lighter or heavier. During the first week of your cycle, the follicle-stimulating hormone may rise more than before as your body works to continue reproduction. The length of this stage varies a lot, but it could be as much as nine years.

Perimenopause officially begins with the second stage, Early Menopausal Transition. During this stage, you’ll see more unpredictability in your menstrual cycle—you may even think it’s not predictable at all! And because your body is producing more estrogen but less progesterone, you may see an increase in PMS symptoms like irritability and bloating. This stage can last four years or longer.

Late Menopausal Transition is the second “half” of perimenopause (I put “half” in quote marks because it’s probably shorter than the first stage—a year up to a couple of years). This is when you’re likely to experience the “typical” symptoms associated with menopause: hot flashes, difficulty sleeping, and mood changes. You may not have a period for a couple of months. At this point, the big trend line for hormones is a decline, but both estrogen and progesterone production can vary wildly from day to day.

Finally, you reach Early Postmenopause. Again, this is marked by a full year without a period. If you haven’t already experienced hot flashes and other menopausal symptoms, you may now, or they may be worse for a while. Because estrogen and progesterone levels are very low, this is when other symptoms become apparent, like vaginal dryness or thinning of vaginal tissues.

As I’ve said before, there’s no clear roadmap that’s infallible for every one of us. I understand, though, the desire to understand what’s happening and to try to predict what lies ahead. I have a friend who’s 56 and still, by the STRAW + 10 stage definition, in “late reproductive years”; by the guidelines, she could be 69 before she reaches menopause. Can that be true? My medical equipment doesn’t include a crystal ball!

But not having a precise roadmap doesn’t change my recommendation to all of us: Learn about what lies ahead, whether it happens fast or slow, early or late. Do what you can to compensate for or manage the changes in your body as you’re aware of them, just as you pick up your reading glasses more often when the menus are hard to read. And, because it’s true that as hormones decline, we “use it or lose it,” stay as sexually active as you choose to be. It’s good for your health, it’s good for your relationship, and it’s good for your self-image.

Tracking Menopause: More Detailed Guidelines for Docs

About ten years ago, a group of medical professionals put their heads together to create a set of guidelines that would chart the course of normal menopause in a more systematic way. They came up with a series of three stages that were each divided into several phases that women normally experience during menopause. These were the reproductive stage, which contained three phases; the menopausal transition, which contained two phases; the postmenopausal stage, which contained two phases.

The stages were determined by the changes that normally occur in a woman’s menstrual cycle and by follicle-stimulating hormone (FSH) levels. (Read this MiddlesexMD blog post for more information about FSH.)

Each phase was given a number, from -5 for the early reproductive phase, in which a woman has regular menses but increasing FSH levels, to +2 for late postmenopausal phase, in which menstruation has completely stopped.

This diagnostic system is called the Stages of Reproductive Aging Workshop, or STRAW, and it’s been a widely used tool for further research. But clinicians have also found it useful as a roadmap for normal menopause—to determine where a woman is in the transition and to predict the course ahead.

Physicians felt that some sort of system was important because menopause marks such a significant change in a woman’s health and quality of life. Some of these changes are temporary (sleep disturbances, hot flashes), and others, such as changes in bone density and urogenital symptoms, are permanent. Given the importance of this transition, some guideline that outlines a normal course through menopause might help in making healthcare decisions about issues like contraception and hormone replacement.

“When women have an awareness of their progress during the shifting manifestations of natural aging, it can be very reassuring,” says Dr. Cynthia Steunkel at the University of California, San Diego, for an article in Menopause.

While helpful for “normal” menopause, however, the original STRAW guidelines specifically exclude women who smoke, are obese, engage in strenuous exercise, have had a hysterectomy, have a significant illness, such as AIDS or cancer, or who have chronic menstrual irregularities. It also fails to address possible differences due to ethnicity, age, and lifestyle.

In 2011, ten years after the first conference, the group reconvened to update the guidelines to take into account the significant body of new research that has emerged and to broaden the subgroups of women for whom the guidelines would apply. The updated guidelines that resulted from this latest review of the research is called STRAW + 10.

Specifically, the updated staging system includes new measures of specific hormones and other “biomarkers” that help to determine the stages of menopause. It added three new subphases that further define the late reproductive and postmenopausal stages. And it can be applied to “most women,” regardless of lifestyle and ethnic diversity, although some exceptions still apply for issues like ovarian failure and chronic illness.

Despite all the fancy testing and technology, however, the most dependable indicator of the stage of menopause is, still, a woman’s menstrual cycle. “...The menstrual cycle remains the single best way to estimate where a woman is along the reproductive path,” said Dr. Margery Gass, one of the coauthors of the new criteria and the executive director of the North American Menopause Society.

In fact, all those other tests for biomarkers are considered “supportive,” and because of the expense of testing and the need for additional research, they aren’t normally called for. I don’t recommend testing for FSH or other biomarkers, either. The tests just aren’t helpful enough.

The new STRAW + 10 guidelines fills in some gaps left by the original system and gives us all a clearer roadmap (which I'll detail in another blog post), but since it relies mainly on the menstrual cycle to determine the course of menopause, your best bet, as I said before, is to tune into your body and work to make peace with the changes you’re experiencing. You're not alone! We're here to help.