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]

Types of Menopause

Physiological Menopause

Also known as spontaneous progressive decline of menstrual cycle due to decline of ovarian function, the average age is between 40-51 years of age.

Pathological Menopause

Premature menopause: cessation of ovarian function before the age of 40.[2]

  • Artificial or surgical menopause; permanent cessation of ovarian of ovarian function due to surgical intervention, or medical treatment like chemotherapy, pelvic radiation therapy.[3]
  • Delayed menopause: cessation of ovarian function after the age of 51.

Females who experience premature menopause have a greater probability of developing early mortality and morbidity rates.[4][5]

Clinical Exam


Symptoms of menopause and peri-menopause:[6]

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[7]
  • Occurs in up to 85% of women.
  • Hot flashes can begin in the late reproductive years and symptoms become more common through early menopause, late menopause, and early post menopause period.[8]
Vaginal dryness and/or Sexual function
  • Genitourinary syndrome of menopause (GSM) refer to atrophic symptoms that, women may have in the vulvovaginal and bladder-urethral areas from loss of estrogen that occurs with menopause.
  • 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.[8]
  • 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 when compared with pre-menopausal women.[9]
Sleep disturbances
  • Women with menopause report increase sleep difficulties more than women perimenopause such as, difficulty falling asleep,night time awakening. This may be secondary to hot flashes, mood changes
  • Anxiety and depression may have a negative effect on sleep during this time
  • Treatment of sleep disturbance depend on clinical presentation.[8]
Joint pain/ arthritis Musculoskeletal pain/arthralgia
  • Joint pain appears to increase during menopause, may be due to esrtogen deficiency.
  • Analgesic drug such as oral NSAID, or intra-articular injection.
  • HRT(hormonal replacement therapy) doesn't show improve for joint pain still under study.
  • Musculoskeletal pain increase in both pre and post menopause. How estrogen causes musculoskeletal pain is still not clear.
  • Weight control and regular exercise will be the better choice for musculoskeletal pain.[10]
Cognitive changes
  • Estrogen plays a role in cognitive function, therefore, with estrogen deficiency women may experience memory loss and difficulty concentrating.[8]


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.[12]

Stage[12] Signs/Symptoms[12]
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[13]
Cardiovascular disease
  • The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines recognize the postmenopausal state as a risk factor for CVD[14]
  • 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 , [15]
Body composition
  • During the postmenopausal period women often gain fat mass,central abdominal fats and loose lean mass,
  • Spontaneous decrease of activities, decrease energy expenditure, decrease metabolic rate.
  • decrease estrogen level with increase level of follicle stimulating hormone. [16]
  • Estrogen deficiency has been linked with impaired balance behavior in postmenopausal women.[17]


Physical Therapy Intervention

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.[18] Pelvic health physiotherapists are well positioned to assist patients with this.


Classified into:

1.Weight bearing exercise:

Low impact weight bearing for example (walking, Tai Chi)

High impact weight bearing for example ( jogging, vibration platform)

2.resistance and strength exercise(weight lifting, swimming, cycling).[19]

Exercises show to have a positive impact on;

Osteoporosis and Bone Density

Studies show that physiotherapists are able to assist in providing guidance around exercise in this population, but not all exercises have same osteogenic effect. Resistance exercise has stronger osteogenic effect, and for exercise to be effective it's mechanical load should exceed that of activities of daily life.

To obtain best result a combination of exercises that include (resistance and weight bearing exercises) is best choice to obtain the effect of both as resistance exercise affect on muscular loading, weight bearing has a mechanical loading effect on bone.

How exercise affect virtually on bone density still not clear but articles stated that exercise increase activity of osteoblast and inhibit osteoclast activity. Enhance bone strength as it increase cross sectional area due to mechanical loading in turn increase resistance of bone[19] . 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.[20][21]

Additionally, higher levels of participation in physical activity were independently associated with lower weight, waist circumference, and risk of substantial weight gain.[16]

Cardiovascular Disease (CVD),

Regular, gradual aerobic exercise program improve cardio-respiratory endurance and decrease risk of (CVD),some articles agree that exercise increase level of HDL, decrease LDL and TAG, control hypertension that in turn improve cardiovascular.[23]


Exercise therapy has an effect to relief symptoms in people with depression when compared to participants without clinical depression symptoms.[24]

It show an increase in level of Brain -derived neurotrophic factor (BDNF) in depressed population but that didn't show improvement in depression symptoms and mechanism of how it affect depression not clear.[25]


Regular exercise program show to increase metabolic rate and energy expenditure, promote loss of abdominal fats.

Aquatic Therapy

It provide water medium where stress on joints and muscles will be reduced.For women who would prefer to do exercise without feeling muscle soreness, fatigue after exercise and without applying stress on joint will be effective.

Benefits of Aquatic Therapy

Has bouncy effect that protect joint from stress of exercise that in turn relief joint pain as arthritis.

Improve general blood circulation and reduce swelling.

Provide strengthening exercise program for muscles without feeling soreness.

Improve cardio respiratory capacity and endurance.[26]

Help with balance problems.



Physicians or a Registered Dietitian/Nutritionist can advise on diet,.Diet rich in fibers, fruits and vegetables . Vitamin D and calcium supplements may be with benefit.

Low caloric diet (calculated according to each individual's total calorie intake) with exercise show to be most effective for weight loss and loss of abdominal fats, In the study exercise program was 4 H/week , 60 minute /day exercise vary between resistance and endurance exercise,[28]


Medical Interventions

Patients should discuss treatment options with their physicians. This may include menopause hormone replacement therapy[30] to aid with the issues listed above. Hormonal replacement therapy (HRT) may be a support it can include estrogen with progestin for example;

  • Resveratrol (phytoestrogen), has positive effect to improve cognitive decline and cerebrovascular function.[31]

Psychological Intervention

Talking with other women with menopause will be with benefit.

Quick summary video

About symptoms and how to control it.



American College of Obstetricians and Gynecologists: Menopause Resource Overview

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

How menopause affect on Lipid metabolism in menopausal women.[15]

Myoclinic ready to get in on the aquatic fitness movement

Physio Aqua menopause aquatic therapy can help


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