What are the stages of menopause?

Menopause, perimenopause, postmenopause, menopause transition, climacteric… All these terms can get confusing

In day-to-day conversation, menopause is when a woman’s reproductive life comes to an end, and she can no longer become pregnant. A time during which she will probably experience a variety of symptoms, many of which can be pretty grim. In daily life, we all understand this, and it serves us well. 

However, once we delve into how doctors talk about menopause and try to understand research papers or online articles, we have to get to grips with a whole new level of terminology. In the medical realm, menopause is a series of stages, transitions, and milestones. It can quickly become confusing. 

Have you ever found yourself lost in the jargon – perimenopause, postmenopause, climacteric? You’re not alone. Online articles can’t even agree if there are three stages, or two, or four!

By the end of this read, you’ll not only be clear about the stages of menopause but might just be the go-to person for insights on the topic!

The progress of a woman’s reproductive life

Let’s start with the view from 30,000ft.

Before she’s even welcomed into the world, a woman’s reproductive journey has already begun. Before a girl is born, all the eggs she will ever have form in the ovaries. There will never be any more. They lie dormant until, under the influence of hormones from the pituitary gland in the brain, the ovaries mature, and periods start. At first, they are often irregular, but then they usually settle into a regular cycle, and so it goes on for many years. As menopause appears over the horizon, subtle changes in the periods begin, and they become more and more irregular. As they do so, the symptoms of menopause – hot flashes, night sweats, mood swings, brain fog and all the rest – begin and become more troublesome. Next, some periods will be skipped altogether.

Finally, the periods stop, and gradually, most of the symptoms of menopause fade away.

Creating a standard definition – the STRAW classification

Just as we use milestones to chart our life’s journey – first steps, graduations, and anniversaries – scientists felt the need for landmarks in the complex narrative of a woman’s reproductive life. 

Doctors and scientists needed a way to be sure they were talking about the same stages of reproductive life when they were doing research, writing papers or sharing information on their patients. So, they developed the STRAW classification (Stages of Reproductive Ageing Workshop). It divides a woman’s life from the first period (menarche) onwards into ten stages, but for our purposes, we can simplify it a little to seven stages, as shown in Figure 1.

At first, the diagram may look a little complicated, but it’s really not. As you read on, all will become clear.

Perimenopause (‘peri’) – the first signs of menopause

Picture this: Sarah, like many women approaching their late 40s, begins to notice that her usually punctual periods are starting to keep their own unpredictable schedule.

Towards the end of a woman’s reproductive life, her periods start to become a little irregular in both timing and flow. It’s usually subtle to begin with and easily overlooked, but over time, it becomes more apparent. It’s like standing at the doorway of a place you’ve never seen before, and taking the first hesitant steps.

Once the variation in cycle length is seven or more days between periods, she has officially entered perimenopause. Perimenopause runs until one year after the final period. It’s usually when menopausal symptoms are at their worst.

Perimenopause is the stage when symptoms such as hot flashes, mood swings, and brain fog are typically at their worst.

Early and late perimenopause

Perimenopause is divided into early and late stages.

We’ve seen that early perimenopause starts when the time between periods varies by seven days or more. Over time, they become more irregular and then start skipping. Once a woman has gone sixty days or more without a period, she has entered late perimenopause.

Late perimenopause runs until one year after the final menstrual period.

Menopause

Eventually, she will have her final menstrual period (often abbreviated as FMP). This last period marks her menopause.

You might’ve thought of menopause as a long phase, but in medical terms, it’s a pinpointed event – that last menstrual period.

Of course, since her periods will have been irregular and unpredictable for a while, she won’t know this is her final period for some time. By the definition of menopause, she will have to wait 12 consecutive months of absent periods to be sure she won’t have another. So, she can’t be certain she’s experienced menopause until one year after the event.

It’s an odd concept that even though it is, in some ways, a momentous event, you’re oblivious to the fact that it’s happened – only able to recognise it in retrospect a year later.

This point, one year after the final menstrual period, also marks the end of perimenopause.

Postmenopause

Think of postmenopause as the long, winding road after crossing a significant bridge – it’s the journey that continues after that last menstrual period. It never ends.

Most symptoms of menopause, the hot flashes, brain fog, mood swings and the like, tend to slowly fade after menopause, though they can drag on for years. A few symptoms, however, notably the genitourinary symptoms, such as vaginal dryness and discomfort with sex, tend to start in postmenopause and progressively worsen.

Estrogen is as vital to our bodies as oil is to our cars. Low hormone levels of both estrogen and progesterone after menopause lead to the longer-term consequences of menopause – dementia, osteoporosis and heart disease, strokes and other health conditions.

There are two more terms you may come across, but they’re less important to commit to memory – the menopause transition and the climacteric.

The menopause transition

Have you ever stumbled upon the term “menopause transition” and wondered how it fits amidst all the other terms?

The term menopause transition is less frequently used than others we’ve described here. The menopause transition starts at the same time as perimenopause: when the variation in cycle length is seven or more days. It runs from this point up until the final menstrual period (aka menopause). That makes it one year shorter than perimenopause.

The climacteric

You may also come across the term climacteric.

It’s an older and somewhat vague term that we use much less now. The climacteric is the time from when the ovaries begin to fail until after they have ceased functioning. That means it includes some of the late reproductive phase, perimenopause and part of postmenopause.

It’s too broad a time to be very useful, though of all the terms, it’s probably closest to what we refer to in everyday language as menopause.

When does natural menopause happen?

The average age of menopause (the final menstrual period) in Western countries is 51.

Of course, women experience menopause at a wide range of ages, as this graph shows. The graph comes from the age at menopause for more than 13,000 Australian women. With even larger numbers, the graph would lose its ‘bumpiness’ but retain a similar shape.

Of course, the menopause symptoms that women experience begin long before and finish after this final period. For example, hot flashes can start four years before the final period and continue for a decade afterwards. Read this post for more on how long your hot flashes might last.

Of course, the description so far presupposes a natural progression through the stages of menopause, which isn’t always the case.

Early, premature and surgical menopause

The age at which a woman enters perimenopause varies widely, but if menopause occurs before the age of 40, it is considered sufficiently outside of the normal range to be regarded as a medical condition, called premature ovarian insufficiency or premature menopause. Menopause occurring between ages 40 and 45 is called early menopause. As we’ve said, the majority of women experience menopause around the age of 51.

Of course, the description so far presupposes a natural progression through the menopause transition, but that’s not always the case. Many women don’t have natural menopause; instead, it may be brought on surgically – by hysterectomy (removal of the womb/uterus) with or without removal of the ovaries, or chemically through chemotherapy or hormone-blocking medicines for breast and other cancers. This is sometimes called induced menopause.

Staging menopause when periods are unhelpful

Deciding the stage of menopause is based on periods. Mostly, this makes it easy to assess the stage of menopause as there’s no need for any tests. However, sometimes it’s trickier. 

Some women may have longstanding irregular periods, so noticing the progression to perimenopause may not be as straightforward as for others. 

In these cases, determining the stage of the menopause transition may be more challenging. For example, if someone has had their uterus removed, it is no longer possible to use the regularity of periods to decide the phase. In such cases, the symptoms, the hot flashes and night sweats, for example, are used as markers. Sometimes, we can use blood levels of certain hormones.

We’ll look at these variations of menopause in another article.

How will I know if I have started menopause?

The progression from reproductive life to menopause, which, remember, is defined as the final menstrual period, is a gradual one.

As the number of eggs in the ovaries becomes very low, subtle changes in the length of the menstrual cycle and flow begin to develop. Perhaps your period starts a few days early or late and may be heavier or lighter than usual. How regular your cycles have been up to that point will decide how noticeable this change is.

Eventually, the time between cycles starts to vary by a week or more. This is the ‘official’ start of the menopause transition and of perimenopause. Researchers needed a definition they could all agree upon, and they chose this definition.

So, once your periods start to arrive a week or more early or late, you are in perimenopause. More specifically, you are in early perimenopause. How long until your final period occurs will depend on several factors, but the age at which you start perimenopause is particularly important. Typically, it will be somewhere between four and eight years.

Around this time, you may also notice the signs of your body reacting to lower estrogen levels. So you may experience hot flashes, mood changes, brain fog, disturbed sleep, dry skin or vaginal dryness and itching.

How will I know if I have completed menopause?

As the number of eggs in your ovaries gets lower and lower, your menstrual cycles will become more and more irregular. At some point, you’ll start skipping periods. Once you start going sixty days or more between periods, you have entered late perimenopause, and it’s just a matter of time before your periods stop altogether.

Understanding menopause isn’t just about recognising its stages. It’s about gaining insight into a transformative period of life, embracing change, and seeking ways to make the journey smoother. Now that you understand the stages of menopause, what’s next for you? Will you dive deeper into understanding treatments or lifestyle changes, or perhaps share your newfound insight with someone on the brink of their menopause journey? Whatever your next step, remember that knowledge is empowering. Stay informed, stay connected, and remember you’re never alone in this.