Our comprehensive no-nonsense guide to symptoms and treatment options, plus stay-well secrets from top docs.

By Sheryl Kraft Illustration Federica Bordoni
Illustration by Julie Houts

Your period. You don’t think much about it—until it goes missing. And then it has your full and undivided attention. Like when you’re about to enter the mysterious Menopause Years and your flow can be as erratic as a teenager’s mood. Here’s what to expect when you’re done expecting.

PART 1: Perimenopause

Every woman experiences it differently; however, the biology of the process is essentially the same. Levels of estrogen and progesterone begin to drop, but rather than a slow and steady decline, it’s more like a roller coaster, says women’s health expert Pamela Peeke, MD, author of Body for Life for Women. This fluctuation usually begins in your mid-to-late 40s, although it can happen as early as your 30s. You can’t predict how long this phase will last (it could be anywhere from two to eight years) or which twists and turns to brace for along the way. But there are five you will almost definitely experience.

1. Your period pulls disappearing acts. Some months your ovaries won’t release an egg at all and you’ll skip a period entirely. Other months your cycle may be longer or shorter than usual. Your flow will vary too: It could be much lighter than normal or so heavy that you have an accident. Be sure to keep your doctor informed of these changes just to rule out other health issues (like fibroids and endometriosis).

2. Your thermostat goes haywire. Now may be a good time to consider dressing in layers or stashing an extra T-shirt by your bed. Up to 75% of perimenopausal women in the U.S. will have day or nighttime hot flashes, which can last from 10 seconds to 10 very long minutes. These surges are most frequent during perimenopause and peak the first two years post menopause. They usually disappear after a few years, but recent research finds they can last longer (although they’re usually milder and less frequent) for some women, particularly if you’re Latina or African American.

3. You’re feeling dry down there. As estrogen levels wane, vaginal tissue becomes thinner and drier, causing painful intercourse and making you more prone to urinary tract infections. Talk to your ob-gyn about finding the best solution for your particular concern. Over-the-counter lubricants (like K-Y jelly) and vaginal moisturizers (like Replens) may be enough, or you might need a prescription low-dose estrogen cream (like Premarin), suppository or vaginal ring.

4. You’re chasing zzz’s. If only those tossing-and-turning nights were just a bad dream, but they’re not: A new study reports that hormonal fluctuations during perimenopause can make falling and staying asleep especially difficult. Another found that sleep troubles can affect 45% of perimenopausal women. Try to reclaim your rest by practicing meditation and deep breathing and listening to soft, relaxing music.

5. Your emotions play Ping-Pong. Depression, anxiety and moodiness: It’s this maelstrom of hormone-driven feelings that makes you question your sanity. And if you’ve suffered with severe PMS in the past, you may be more likely to get depressed now. “These swings are temporary,” says Margery Gass, MD, executive director emeritus of The North American Menopause Society. “About a year after your last period, you’ll find a new plateau of emotional comfort and mental function.” In the meantime, a healthy diet, regular exercise and stress management (such as meditation) can help. But if symptoms are significant, talk to your MD about medication.

PART 2: Menopause

It’s go time. Or rather, it’s stop time. Once your period is a no-show for 12 consecutive months, you can officially say goodbye to PMS, that box of tampons in the closet and ever having to think about birth control again, says Stephanie Faubion, MD, medical editor of Mayo Clinic, The Menopause Solution. “Seeing the positive in this change is valuable,” she stresses. In case you’re wondering, the majority of women go through menopause around age 51. For answers to a few other questions that might be on your mind, read on.

1. Will the scale start to creep up? Not if you’re vigilant. “As we age, we lose muscle mass,” explains Gass. “Since muscle helps burn calories, we’re more prone to weight gain—unless we eat less and exercise more.” Decreasing estrogen levels can also affect how fat is distributed in your body, and it may end up more concentrated around your midsection. So stay on the move—you’ll reap many benefits. Compared with active women, sedentary women have more severe menopause symptoms.

2. Am I at increased risk of heart disease? Women need to be especially proactive about their hearts during menopause, stresses Nieca Goldberg, MD, clinical associate professor at NYU Langone Joan H. Tisch Center for Women’s Health. “Levels of LDL (or “bad”) cholesterol and triglycerides increase around this time, while levels of HDL (“good”) cholesterol stay put or even decrease,” she says. So exercise for the win, again: Anything that gets your heart rate up is a great option. A heart-healthy diet gets points too, especially one that includes foods rich in omega-3s (like salmon and walnuts), which can reduce triglycerides.

3. How can I keep my bones strong? After menopause the breakdown of bone is greater than the building of new bone. Hormone therapy, calcium and vitamin D supplements, and prescription meds like Boniva, Fosamax and Prolia can treat and may even help prevent osteoporosis. And, as if you need another reason to get moving, “exercise is a fabulous antidote to bone loss,” says Mary Jane Minkin, MD, clinical professor of obstetrics and gynecology at Yale School of Medicine. Strength training as well as medium- and high-impact activities, like running, may offset the loss of bone mineral density and prevent osteoporosis.

4. How can I save my sex life? Although many women report a slight decrease in their libido, you can have a fulfilling sex life after menopause, says Donnica Moore, MD, founder and president of Sapphire Women’s Health Group. “The symptom most likely to interfere with a woman’s sexual satisfaction is vaginal dryness, due to a lack of estrogen. It may cause vulvar and vaginal atrophy,” she explains. In addition to discussing lubricants, you can talk to your doctor about estrogen therapy or Osphena, a non-hormonal oral therapy that improves vaginal tissue and relieves pain during intercourse.

5. Are there natural or herbal supplements for hot flashes? If you can’t—or don’t want to—turn to hormonal meds (like Estrace or Prempro) for relief, there are still a few options. Some studies suggest that acupuncture and hypnosis can work to minimize hot flashes. Research has found that some drugs prescribed for depression may be effective for reducing hot flashes, although the only FDA-approved non-hormonal option is Brisdelle, a low-dose antidepressant. Celexa, Effexor, Lexapro, Paxil, Pristiq and Prozac are sometimes prescribed off-label. While soy, black cohosh and Chinese herbal remedies have been researched as natural treatments for menopause symptoms, there isn’t enough evidence of their safety and effectiveness.

Know Your Hormone Options

Hormone therapy has long been lauded as the gold standard for treating moderate to severe hot flashes and vaginal dryness. But many women abandoned it out of confusion and fear following the 2002 news that linked hormone therapy to serious health concerns like breast cancer and heart disease. Since then, many experts have agreed that the studies were flawed, but hormone therapy does carry small risks for women with a history of breast or endometrial cancer, stroke, heart attack or liver disease. Bottom line: If you’re considering hormone therapy, consult your health care provider to come up with an individualized plan that’s right for you—and review it periodically.

Have You Outgrown Your Doc?

Although all ob-gyns are trained to provide comprehensive health care for women, it’s possible to find an MD who concentrates more on the unique issues of midlife women’s health. (And a doctor who has taken the OB out of her title won’t bump your appointment for an emergency delivery.) The North American Menopause Society sets standards for practitioners to care for women during perimenopause and beyond. Look for the initials NCMP (NAMS certified menopause practitioner) after a medical professional’s name and degree. To locate an NCMP in your area, go to www.menopause.org/for-women/find-a-menopause-practitioner.

Top Docs Spill Their Stay-Well Secrets

→  “I’m on a continuous low-dose birth control pill that helps with the hot flashes, night sweats, brain fog and fatigue of perimenopause. I’ll switch over to hormone therapy when I’m 55.” —Tara Allmen, MD, author of Menopause Confidential

→  “I practice guided imagery for 30 minutes every day. I close my eyes and take myself on a journey to a relaxing place, like my childhood yard blooming with beautiful pink flowers. Those images improve my stress, hot flashes and sleeplessness.” —Felice Gersh, MD, ob-gyn and medical director of the Integrative Medical Group of Irvine in Irvine, CA

→  “Since I don’t have any risk factors for cancer or heart disease, I started using the Vivelle-Dot estrogen patch when my perimenopausal symptoms began. I reassess my health status and needs every year.” —Pamela Peeke, MD, author of Body for Life for Women

→  “I work out twice a week with a personal trainer and cross-train two to three times a week on my own. I also eat lots of fruits and veggies, and supplement my diet with calcium and Vitamin D.” —Donnica Moore, MD, founder and president of Sapphire Women’s Health Group

→  “Weekly acupuncture gives me some relief from hot flashes. I also avoid triggers like spicy foods and limit my alcohol intake to a two-glass maximum—on the weekend.” —Sherry Ross, MD, ob-gyn and Women’s Health Expert at Providence Saint John’s Health Center in Santa Monica, CA

Anatomy of a Hot Flash

That sweater you needed because it was chilly this morning? Now you want to yank it off . . . and stick your head in the freezer. Scientists aren’t certain, but they suspect dropping estrogen levels mess with your body’s thermostat to cause these personal heat waves. We’ve mapped out what happens, from your head on down.

  • Your brain (specifically, the hypothalamus, which helps control body temperature) notices hormonal dips in your blood. It thinks you’re overheating.
  • The upper third of your body—head, face and chest—suddenly feels intensely warm and can get red and blotchy.
  • Although your core body temperature doesn’t rise above its normal 98.6 degrees, you’d swear you were running a very high fever as you radiate extreme heat.
  • You may become dizzy and anxious and even experience heart palpitations as things heat up.
  • Your body tries to reduce its temperature by making your sweat glands gear up to pump out perspiration. Sweating can last a few minutes.
  • As skin temperature climbs, your blood vessels dilate to try to cool you off.
  • While the flash flames out, blood vessels begin to constrict, sweat evaporates and soon you may feel chilly and depleted.

Good to Know: If your waistline is expanding (a belly bulge some call the “menopot”), consider some new hues. A recent study published in The BMJ found that a diet high in colorful fruits and veggies like berries, peaches and peppers could help with your middle management.