Natural menopause occurs when there is a complete, or near complete, ovarian follicular depletion of a female's ovaries. This results in the end of her menstrual cycle for 12 months, which is retrospectively determined. It occurs at a median age of 51.4 years and menopause before the age of 40 years old is considered abnormal. The months and years leading up to this are called peri-menopause.[1]

Clinical Exam


Symptoms of menopause and peri-menopause:[2][3]

Symptoms Information
Hot flashes
  • A hot flash typically begins a sudden sensation of heat in the upper chest, face, and back, often associated with perspiration[4]
  • Occurs in up to 80% of women[4]
  • Hot flashes can begin in the late reproductive years and symptoms become more common through early menopause, late menopause, and early post menopause period[5]
Vaginal dryness and/or Sexual function
  • Genitourinary syndrome of menopause (GSM) refer to atrophic symptoms women may have in the vulvovaginal and bladder-urethral areas from loss of estrogen that occurs with menopause[6]
  • Epithelial lining of the vagina and urethra are estrogen-dependent tissues, and estrogen deficiency leads to thinning of the vaginal epithelium, resulting in vaginal atrophy, which leads to dryness, itching, and often dyspareunia[7]
  • Estrogen deficiency leads to a decrease in blood flow to the vagina and vulva, which causes decreased vaginal lubrication and sexual dysfunction[8]
  • One of the earliest signs of estrogen insufficiency is noticed when there is a decrease in vaginal lubrication upon sexual arousal
  • vaginal dryness affects up to 85 percent of women over 40 years of age, with an additional 29 to 59 percent reporting dyspareunia and another 26 to 77 percent reporting vaginal itching and irritation
  • There is a significant risk of new-onset depression during menopause[9]
Sleep disturbances
  • This may be secondary to hot flashes
  • Anxiety and depression may have a negative effect on sleep during this time
  • Sleep disturbances can occur in the absence of any other issues listed above[10]
Joint pain
  • Joint pain appears to increase during menopause[11]
  • This may be due to estrogen deficiency, and may be reliefed with either combined estrogen-progestin therapy or unopposed estrogen [12][13]
Cognitive changes
  • Estrogen plays a role in cognitive function, therefore, with estrogen deficiency women may experience memory loss and difficulty concentrating[14]


Stages of Reproductive Aging Workshop (STRAW) staging system was developed from data from multiple longitudinal cohort studies. This system is considered the gold standard and includes criteria for the reproductive years, the menopausal transition, perimenopause, final menstrual period (FMP), and postmenopause based upon bleeding patterns, endocrine findings, and symptoms. The STRAW system is used mainly in research, however, it may be helpful in the clinical setting for patients and clinicians to assess fertility potential, contraceptive needs, and potential need for hormone therapy.[15]

Stage[15] Signs/Symptoms[15]
Late reproductive years May begin to notice changes in her menstrual cycle (ie. a shorter cycle)
Early menopausal transition This is marked by increased variability in menstrual cycle length
Late menopausal transition Marked by the occurrence of amenorrhea of 60 days or longer

Characterized by increased variability in cycle length, and extreme fluctuations in hormonal levels

Early postmenopause period Corresponds to the end of “perimenopause,” a term still in common usage that means the time around menopause
Late postmenopause period Symptoms of vaginal dryness and urogenital atrophy become increasingly prevalent at this time

Longterm effects of menopause

Health Concerns Information
Bone loss
  • The loss cortical bone affected by estrogen deficiency and the  trabecular bone loss is age related[16]
Cardiovascular disease
  • The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines recognize the postmenopausal state as a risk factor for CVD[17]
  • The increased risk may be due to a change in the lipid profile, with an increase in the low density lipids (LDLs) in women going through menopause[18]
Body composition
  • During the postmenopausal period women often gain fat mass and lose lean mass, however, it is not clear as to whether this is directly due to the effects of menopause on the body[19]
  • Estrogen deficiency has been linked with impaired balance in postmenopausal women[20]



It is important as part of the healthcare team, we are aware of the menopausal process and the symptoms that can come along with this period. Many of the symptoms and health concerns discussed can have a negative impact on a women's health and overall quality of life. It can be beneficial to be able to identify patients who are dealing with these symptoms because we can aid through physiotherapy interventions or refer them to a physician.

Sexual Health

Sexual health may be negatively impacted by some of the issues stated above. Simple, non‐hormonal interventions for sexual dysfunction are often overlooked. Several studies show that education on vaginal lubricants, moisturizers, and dilator use (as needed) can have a positive impact on sexual health.[21] Pelvic health physiotherapists are well positioned to assist patients with this.


Physiotherapists are able to assist in providing guidance around exercise in this population. Exercise, with a mix of cardio and resistance is beneficial in preventing fractures, maintaining bone mineral density, and body weight.

A systematic review encompassing only randomized controlled trails, conducted by Howe et al. (2011) examined the effectiveness of exercise interventions in preventing bone loss and fractures in postmenopausal women, and they found that exercise was safe and effective way to prevent bone loss in this population.[22][23]

Additionally, higher levels of participation in physical activity were independently associated with lower weight, waist circumference, and risk of substantial weight gain.[19]

Medical Interventions

Patients should discuss treatment options with their physicians. This may include menopause hormone therapy to aid with the issues listed above. Menopause hormone therapy can include estrogen and/or progestin.

Vaginal estrogens[24]

  • low dosage for the management of vaginal atrophy (also known as GSM)
  • high dosage can be used to treat vasomotor symptoms (ie. hot flashes)

Bone mineral density

  • Physicians or a Registered Dietician/Nutritionist can advise on diet, Vitamin D and Calcium


American College of Obstetricians and Gynecologists: Menopause Resource Overview

For further information on managing menopause, please refer to this presentation by Dr. Kathryn Macaulay


  1. The American College of Obstetricians and Gynecologists. Menopause: Resource Overview. Available from
  2. Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause international. 2011 Dec;17(4):153-4.
  3. Burger HG, Hale GE, Dennerstein L, Robertson DM. Cycle and hormone changes during perimenopause: the key role of ovarian function. Menopause. 2008 Jul 1;15(4):603-12.
  4. 4.0 4.1 Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women's Health across the Nation. Obstetrics and Gynecology Clinics. 2011 Sep 1;38(3):489-501.
  5. Randolph JF, Sowers M, Bondarenko IV, Gold EB, Greendale GA. The relationship of longitudinal change in reproductive hormones and vasomotor symptoms across the menopausal transition. Fertility and Sterility. 2004 Sep 1;82:S65.
  6. Portman DJ, Gass ML, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Climacteric. 2014 Oct 1;17(5):557-63.
  7. Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, Khan SA. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. American journal of obstetrics and gynecology. 2016 Dec 1;215(6):704-11.
  8. Sarrel PM. Ovarian hormones and vaginal blood flow: using laser Doppler velocimetry to measure effects in a clinical trial of post-menopausal women. International journal of impotence research. 1998 May;10:S91-3.
  9. Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL. Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles. Archives of general psychiatry. 2006 Apr 1;63(4):385-90.
  10. Kravitz HM, Ganz PA, Bromberger J, Powell LH, Sutton-Tyrrell K, Meyer PM. Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause. 2003 Jan 1;10(1):19-28.
  11. Dugan SA, Powell LH, Kravitz HM, Rose SA, Karavolos K, Luborsky J. Musculoskeletal pain and menopausal status. The Clinical journal of pain. 2006 May 1;22(4):325-31.
  12. Barnabei VM, Cochrane BB, Aragaki AK, Nygaard I, Williams RS, McGovern PG, Young RL, Wells EC, O'sullivan MJ, Chen B, Schenken R. Menopausal symptoms and treatment-related effects of estrogen and progestin in the Women's Health Initiative. Obstetrics & Gynecology. 2005 May 1;105(5):1063-73.
  13. Chlebowski RT, Cirillo DJ, Eaton CB, Stefanick ML, Pettinger M, Carbone LD, Johnson KC, Simon MS, Woods NF, Wactawski-Wende J. Estrogen alone and joint symptoms in the Women’s Health Initiative randomized trial. Menopause (New York, NY). 2013 Jun;20(6).
  14. Weber MT, Rubin LH, Maki PM. Cognition in perimenopause: the effect of transition stage. Menopause (New York, NY). 2013 May;20(5).
  15. 15.0 15.1 15.2 Harlow S, Gass M, Hall J, Lobo R, Maki P, Rebar R, Sherman S, Sluss P, de Villiers T. Executive summary of the stages of reproductive aging workshop+ 10. Menopause. 2012 Apr 1;19(4):387-95.
  16. Khosla S, Melton III LJ, Riggs BL. The unitary model for estrogen deficiency and the pathogenesis of osteoporosis: is a revision needed?. Journal of Bone and Mineral Research. 2011 Mar;26(3):441-51.
  17. Stone NJ, Robinson JG, Lichtenstein AH, Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014 Jul 1;63(25 Part B):2889-934.
  18. Derby CA, Crawford SL, Pasternak RC, Sowers M, Sternfeld B, Matthews KA. Lipid changes during the menopause transition in relation to age and weight: the Study of Women's Health Across the Nation. American journal of epidemiology. 2009 Apr 8;169(11):1352-61.
  19. 19.0 19.1 Sternfeld B, Wang H, Quesenberry Jr CP, Abrams B, Everson-Rose SA, Greendale GA, Matthews KA, Torrens JI, Sowers M. Physical activity and changes in weight and waist circumference in midlife women: findings from the Study of Women’s Health Across the Nation. American journal of epidemiology. 2004 Nov 1;160(9):912-22.
  20. Ekblad S, Bergendahl A, Enler P, Ledin T, Möllen C, Hammar M. Disturbances in postural balance are common in postmenopausal women with vasomotor symptoms. Climacteric. 2000 Jan 1;3(3):192-8.
  21. Carter J, Goldfrank D, Schover LR. Simple strategies for vaginal health promotion in cancer survivors. The journal of sexual medicine. 2011 Feb 1;8(2):549-59.
  22. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US preventive services task force. Jama. 2018 Apr 24;319(16):1705-16.
  23. Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane database of systematic reviews. 2011(7).
  24. Speroff L, Group US. Efficacy and tolerability of a novel estradiol vaginal ring for relief of menopausal symptoms. Obstetrics & Gynecology. 2003 Oct 1;102(4):823-34.