Menopause: what changes, and what to protect

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Menopause is a natural stage, not an illness, and it is defined by a single thing: twelve months with no period. Everything else people call menopause is either the run-up or the years after.

Most articles lead with the symptoms. This one gives them their share and then spends its length on the part that matters longer: what changes in your bones and your heart, and what actually protects them. For the symptoms themselves in depth, our guides to hot flashes, night sweats and perimenopause go further than this page does.

What menopause is

Menopause is the point when you have gone 12 months without a period. The NHS puts it usually between 45 and 55, though it can happen earlier (NHS), and the average is around 51. The years of fluctuating hormones before it are perimenopause, and that is when most symptoms actually begin.

Early and premature menopause

Menopause before 45 is called early menopause, and before 40 it is premature menopause, sometimes named premature ovarian insufficiency. It can happen on its own, or follow surgery to remove the ovaries, chemotherapy or radiotherapy.

If your periods stop well before your mid-40s, see your doctor rather than waiting to see whether they return. The reason is the section further down: an earlier loss of estrogen means more years without it, and the bone and heart consequences scale with that. This is why treatment such as HRT is usually recommended in early menopause, often continued until around the average age of natural menopause, and why it is a different conversation from HRT started at 52.

The three stages

People use "menopause" loosely, but it helps to separate the stages, because they call for different things.

Stage	What it means	Your periods
Perimenopause	Hormones fluctuate in the run-up	Irregular, eventually further apart
Menopause	12 months with no period	Have stopped
Postmenopause	All the years after that point	None; any bleeding needs checking

The symptoms

Vasomotor symptoms, the term covering hot flashes and night sweats, affect 60 to 80% of women during or after the transition (Am J Physiol Heart Circ Physiol, 2022). Alongside those, common symptoms include:

• Broken sleep
• Mood changes, low mood or anxiety
• Brain fog and memory lapses
• Vaginal dryness and lower libido
• Joint aches and weight gain, often around the middle

Symptoms last an average of about four years, though for some women they run much longer.

What actually changes, beyond the symptoms

Hot flashes end. The changes in this section do not, and they are the reason menopause is worth taking seriously even if your symptoms are mild.

Bone loss has a window, and it is narrower than people think

Bone does not drift down gently from midlife. It falls fastest in a short phase around your final period.

Research on the transition puts that rapid phase at about three years, starting roughly one year before the final period, with the lumbar spine losing about 2.5% a year and the femoral neck about 1.8% a year in white women. The rate differs by ethnicity: Black women lost less at both sites, while Japanese and Chinese women lost more at the hip (Obstet Gynecol Clin North Am, 2018).

Two things follow, and both are practical. The window is short, so what you do in your late 40s counts for more than what you do at 60. And because the loss is quiet, nothing tells you it is happening. Our guides to protecting your bones and osteoporosis cover what works.

The heart picture shifts slowly

Estrogen has a protective role in the blood vessels, so its fall changes cardiovascular risk over years rather than overnight. That slowness is exactly why it goes unattended while the attention goes to flashes.

Muscle is the part you can most directly defend

Muscle is easier to lose and harder to build from this decade on, and it carries strength, balance and metabolic health with it. Strength training twice a week plus enough protein is the combination with the best evidence behind it, and the two only work together: protein without the training does very little. The protein calculator turns your weight and activity into a daily figure, which is more useful than being told to eat more of it.

Postmenopause: what the years after actually look like

The word gets used as though it were an ending. It is the longest stage of the three.

• Symptoms do not all stop at the line. In the SWAN cohort, women with frequent flashes had a median of 4.5 years of them after the final period. Our perimenopause guide has the full timeline.
• Some symptoms arrive rather than leave. Vaginal dryness and urinary symptoms tend to persist or worsen without treatment, unlike flashes, which usually fade. They also respond well to treatment, which is why they are worth raising rather than absorbing.
• Any bleeding needs checking. Once you have gone twelve months without a period, bleeding after that point is not a late period. It is its own reason to be seen, and it is the single most important line in this guide.

What helps

• HRT is the most effective treatment for hot flashes and night sweats for many women. Our HRT guide walks through the benefits and risks.
• Non-hormonal prescription medicines include some antidepressants and medicines aimed specifically at hot flashes. In the US, the FDA-approved neurokinin options are fezolinetant (Veozah) and elinzanetant (Lynkuet). Both treat moderate to severe hot flashes rather than menopause as a whole. Their current labels require liver tests before treatment; Veozah also carries a boxed liver-injury warning and requires repeat testing during treatment. These are prescription choices to discuss with a clinician, not supplements to try on your own.
• Vaginal dryness has simple, effective treatments that make a real difference to comfort and intimacy.
• Lifestyle matters: regular exercise, good sleep, stress management and a balanced diet all ease symptoms and protect long-term health.
• Supplements are mostly a disappointment, and it is worth knowing which claims collapsed under testing before you spend on them. Our guide to menopause supplements covers what the trials found for black cohosh, red clover and soy.

When to see a doctor

See your doctor if:

• Symptoms are affecting your daily life
• You have any bleeding after menopause, which always needs checking
• You want to talk through treatment options

Menopause is very manageable, and you have real options.

Frequently asked questions

What is menopause, exactly?

One thing: twelve months with no period. Everything before that line is perimenopause, everything after is postmenopause. It usually falls between 45 and 55, with an average around 51. The definition matters practically, because once you have crossed it, any bleeding at all needs checking.

What are the main symptoms of menopause?

Hot flashes and night sweats are the most common, affecting 60 to 80% of women during or after the transition. Alongside those come broken sleep, mood changes, brain fog, vaginal dryness, lower libido, joint aches and weight settling around the middle.

What happens to your bones at menopause?

Bone loss speeds up for a few years around the final period. Research puts the rapid phase at about three years, beginning roughly a year before the final period, with the spine losing about 2.5% a year and the hip about 1.8% a year in white women. Rates differ by ethnicity. This is why the bone conversation belongs in your 40s rather than your 60s.

Why does menopause affect heart health?

Estrogen has a protective role in the blood vessels, so the fall changes the cardiovascular picture over time rather than overnight. It is a slow shift, which is exactly why it goes unnoticed while the attention goes to hot flashes.

What is early or premature menopause?

Menopause before 45 is early, and before 40 it is premature, sometimes called premature ovarian insufficiency. It can happen on its own or follow surgery to remove the ovaries, chemotherapy or radiotherapy. Losing estrogen early raises the long-term risk to bones and heart, so treatment is usually recommended, often until around the average age of menopause.

What treatments help menopause symptoms?

HRT is the most effective option for hot flashes and night sweats for many women. Non-hormonal prescription options include some antidepressants and the FDA-approved hot-flash medicines fezolinetant (Veozah) and elinzanetant (Lynkuet). Vaginal dryness has separate local treatments. The right choice depends on your symptoms and medical history; the two neurokinin medicines require liver testing before treatment, and Veozah requires repeat monitoring.

References

1. Menopause basics · Office on Women's Health
2. Menopause and perimenopause · NHS
3. Symptoms of menopause and perimenopause · NHS
4. Bone health during the menopause transition and beyond · Obstetrics and Gynecology Clinics of North America, 2018
5. Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease · American Journal of Physiology, 2022