Perimenopause and Menopause: Common Questions and Answers

Menopause and the years leading up to menopause (perimenopause) can be turbulent. In addition to hot flashes and insomnia, women can battle night sweats, mental fogginess, fatigue, lower sex drive, weight gain, bone loss and irritability. 

We recently sat down with board-certified gynecologist Brenda Price, MD, and certified nurse-midwife Paige Swales, CNM, MSN, to review evidence-based, research-grounded answers to common perimenopause and menopause questions. 

Left to right: Paige Swales, CNM, MSN, and Brenda Price, MD

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Watch "Menopause and Perimenopause: Common Questions and Answers"

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BCH: What is perimenopause, when does it begin, and how long will it last?

SWALES: Perimenopause is the natural transition leading to menopause. It lasts two to 12 months. During this time hormones begin to fluctuate, and women often experience irregular menstrual cycles. 

BCH: What is menopause, when does it start and how long will it last?

SWALES:  Menopause officially begins 12 months after our periods have ended. Typically, menopause begins between the ages of 48 and 55. Menopause can last seven to 10 years, including perimenopause. But variations may be experienced based on ethnicity. It’s important to find a patient-centered health care provider to guide you in a healthy way.

BCH: What causes menopausal changes, hot flashes and chills?

SWALES: Menopausal changes result from a change in our estrogen levels. These changes send a signal to our brain that we are too warm. Our bodies respond by sweating, which causes our bodies to cool down.

BCH: What are the symptoms of perimenopause and menopause?

SWALES: The seven most common symptoms of perimenopause and menopause include:

1. Vasomotor symptoms (VMS)

VMS is associated with changes in temperature and can include hot flashes, night sweats, chills, and heart palpitations. These symptoms are often felt in the torso, neck, and face and typically last two to 10 minutes. For some VMS is more than a nuisance; it can lead to an increased risk of cardiovascular disease and depression.

2. Sleep disturbances

Sleep disturbances, such as insomnia, can result from fluctuating estrogen levels, as well as from the discomfort associated with hot flashes and night sweats. This disruption of sleep cycles can also lead to depression.

3. Mood disorders

Falling estrogen and progesterone levels can trigger mood swings that make us less able to cope with things we’d normally let roll off our backs.

4. Menstrual irregularities with periods

Our periods are heavier and more spaced out during perimenopause.

5. Vaginal symptoms

Vaginal symptoms are experienced by 70% of women. They are uncomfortable, and progressive, but they need not be permanent. The thinning of the vaginal skin causes a drying effect, which can create discomfort and affect the vagina, urethra, vulva and clitoris.

6. Urinary symptoms

Urinary symptoms can result in increased urinary frequency and incontinence.

7. Weight changes

Some women experience weight gain and muscle loss often in the abdomen. However, when women reach 60 or 70, they may lose this extra weight.

BCH: What percentage of women experience symptoms?

SWALES:

• 80 % will experience VMS, 
• 30 % report frequent or severe symptoms,
• 22 to 68 % of premenopausal women report hot flashes and these increase as they move into menopause.

BCH: Why is sex painful?

SWALES:  The changes occurring with the vaginal skin, urethra, vulva and clitoris is called the “genital urinary syndrome of menopause.” It can lead to reduced libido, arousal and responsiveness and can cause intercourse to become painful. 

BCH: What can be done about vaginal dryness?

PRICE: There are safe-to-use vaginal lubricants, moisturizers and low-dose vaginal estrogen therapy (most effective) available. 

BCH: What is hormone therapy (HT)?

PRICE: Hormone therapy is used to relieve common menopausal symptoms. It usually involves estrogen or estrogen plus progestin (a synthetic hormone with effects similar to those of progesterone) treatments. 

BCH: Does hormone therapy increase the risk of breast cancer?

PRICE: The risk of HT causing breast cancer is minimal. With hormone therapy your risk of breast cancer increases from 12 to 12.8%. This is the same increase in risk you would see if you had two alcoholic beverages a day.  

BCH: What are the benefits of hormone therapy, and is it safe?

PRICE: Hormone therapy has many benefits, even beyond reducing hot flashes. We no longer think of HT as a replacement, but as a supplement. HT is safe and effective for women under 60, if used for less than 10 years. You should talk to your health care professional to understand what is best for you.

Benefits of HT include: 

• If treatments are started earlier than age 60, HT decreases the rate of colon cancer and risk of cardiovascular disease. 
• For those with high blood pressure and high cholesterol, HT can help reduce the increase in LDL (bad) cholesterol that results from menopause. 
• There are no reports of harm when HT is used by those with autoimmune diseases. 
• HT may decrease menopausal weight gain. 
• HT significantly reduces the diagnosis of new onset type 2 diabetes. 
• HT can help with treating depression and mood swings during menopause (but not after). 
• HT is the most important medication available to preserve bone density and reduce risk of bone fractures. However, once you discontinue HT, you may notice rapid bone loss.

BCH: Do you recommend compounded hormone therapy?

PRICE: I do not recommend compounded hormone therapy. These hormones are made by compounding pharmacies that are not well regulated and dosing is often inconsistent. 

BCH: What are bioidentical hormones, and are they safe?

PRICE: Bioidentical hormones are those that are chemically identical to the hormones your body produces naturally, and certainly can be safe and effective. They come in many forms, from oral tablets to skin patches, gels, creams and sprays. Treatments in an estradiol form treat hot flashes, while others in a progesterone form protect the endometrium (thinning of the uterine lining). 

BCH: Who is not a candidate for hormone therapy?

PRICE: Women who are not good candidates for HT include those with:

• Cardiovascular disease, including heart disease, stroke, or deep vein thrombosis (DVT), and pulmonary embolism (PE)
• Breast cancer
• Endometrial cancer
• Undiagnosed vaginal bleeding

However, these women are still able to treat vaginal issues with local vaginal estrogen. For hot flashes antidepressants, Venlafaxine, Gabapentin, Pregabalin and Clonidine can be used. 

BCH: Are there any non-hormonal treatments for hot flashes?

PRICE: The FDA approved in May 2023 Veozah (fezolinetant), a non-hormonal oral medication for the treatment of moderate-to-severe hot flashes caused by menopause.This new medication for treating menopausal hot flashes provides an additional safe and effective treatment option.

BCH: Are there non-medical treatments available?

PRICE: Non-medical options such as exercise, herbal remedies and cognitive behavior therapy result in a limited reduction of hot flashes but are certainly something to discuss with your health care provider.

There’s a company called Bonafide with studies around non-hormonal therapy. Its Reverie product has been shown to relieve vaginal dryness and reduce painful intercourse. Relizen, also by Bonafide, is a Swedish flower extract that has been shown to reduce night sweats.

BCH: Should I have my hormones tested?

PRICE: Hormone testing is unreliable and not helpful. I prefer to talk with my patients and consider their symptoms rather than making a recommendation based on lab tests.

Resources:

mymenoplan.org helps patients walk through their symptoms, talks about treatment options, provides studies and does not support any specific product. 

Schedule an Appointment

Call 303-441-0587 to schedule an appointment with Brenda Price, MD, of Boulder Women's Care.

Call 303-415-4045 to schedule an appointment with Paige Swales, CNM, MSN, of Foothills Community Midwives.

Click here to view/download a PDF of slides shown during our lecture on Menopause and Perimenopause: Common Questions and Answers.

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