Menopause is often mentioned in passing, like other scary future realities — such as big tax bills or how much money you need to save for retirement. Like much of the nitty-gritty of women’s health, menopause is not commonly discussed, and historically has been stigmatized.

“It is very taboo and not talked about often,” says Dr. Kelly Culwell an OBGYN and former medical officer at the World Health Organization. “Mothers don’t really talk to their daughters about it. Sometimes when women first start going through these things they no have idea what is happening, and think something is very, very wrong. But once these things are ruled out, they realize this is something that is very common, and can go on for years.” Because knowledge, is after all, power, here’s a primer on what to expect.

What is menopause?
Menopause is often presented as a reproductive cliff but it is really more of a slow fade out of the reproductive cycle. “You start to have irregular swings in hormones, which causes irregular bleeding. And if you are not regularly releasing an egg, your bleeding is going to be irregular,” Dr. Culwell explains. As the body stops producing estrogen, women stop having their periods. The average age of menopause is 51, but symptoms can begin in your 40s, and extend into and through your 50s and in some cases early 60s.

What is perimenopause?
Perimenopause is the period of time preceding menopause. Symptoms can begin in your 30s and 40s when the amount of estrogen produced by the ovaries begins to change. Periods may change in length, heaviness, and even frequency. A change in bleeding is normal, but talk to your doctor about any irregular bleeding.

What are the symptoms of menopause?
Many women experience hot flashes, night sweats, insomnia, tiredness, mood swings, vaginal dryness, and urinary tract issues. Starting at the age of 35, women naturally have a certain amount of bone loss, but after menopause women begin to lose bone mass more rapidly due to decreased levels of estrogen. “Mental health issues are common and mood changes ranging from irritability to full clinical depression are very common as well,” Dr. Culwell says. “It is heightened by the fact that sleep becomes more difficult during this time so women have a hard time getting a good night’s sleep whether it is just from the hormonal changes or from the night sweats and hot flashes.”

What is hormone replacement therapy?
The symptoms of menopause and perimenopause are often addressed with hormone therapy, which can mean taking estrogen in the form of pills, patches, gels, sprays, and creams. Systemic estrogen treatment is often the most helpful for the treatment of hot flashes, and vaginal dryness can often be treated locally through creams, rings, and tablets.

Is hormone replacement therapy dangerous?
Certain hormone replacement therapies can increase the risk of uterine cancer, heart attacks, stroke, and deep vein thrombosis, and there is a small increase in the risk of breast cancer. “We used to think every woman needed to be on hormones from the minute she started having menopausal symptoms and stay on them for the rest of her life. Then we learned those hormones could be harmful for some women, so there was a huge reversal. But for most women low-dose hormone therapy can be incredibly helpful for getting through certain menopausal transitions, like hot flashes and mood swings,” Dr. Culwell says.

What other medications are prescribed?
Antidepressants may help with some symptoms such as hot flashes. The anti-seizure medication Gabapentin, and the blood pressure medication Clondine, can also help with symptoms, specifically hot flashes and sleep problems. Some women have found certain plants and herbs such as soy, and black cohosh, are helpful with menopause symptoms, as well. Various over the counter medications can also help with vaginal dryness, and certain lubricants can also help during sex.

What lifestyle changes can help with the symptoms of menopause?
Because menopause can lead to bone loss, it is particularly important that women get regular exercise as well as enough calcium and vitamin D. According to Dr. Culwell, “Regular exercise and being involved in some sort of meditative practices can also be really helpful for mental health and stave off some of the hot flashes and help with sleep.”

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