The first signs of menopause: how to recognize them

Menopause is a natural biological process that begins with the menopausal transition and ends with menopause, which is confirmed retrospectively after 12 months of absence of menstruation. Current guidelines emphasize that diagnosis is based primarily on symptoms and changes in the menstrual cycle, rather than on single laboratory tests. This avoids unnecessary testing and focuses on maintaining quality of life. [1]

The STRAW plus 10 system of stages of reproductive aging is used to describe the timing and sequence of changes. The early stage of transition is defined by a persistent difference in cycle length of 7 days or more between adjacent cycles, while the late stage is defined by menstrual-free intervals of 60 days or more. These criteria help distinguish physiological fluctuations from pathological conditions. [2]

The earliest signs often include irregular menstruation and hot flashes, often accompanied by night sweats, sleep disturbances, and mood swings. Some people complain of "brain fog," decreased concentration, and forgetfulness, which are associated with both hormonal fluctuations and sleep disturbances. [3]

The duration and severity of symptoms vary. In large cohort studies, the average total duration of severe vasomotor symptoms approaches 7 years, with some individuals experiencing hot flashes for longer and more intense periods. This is important to consider when planning treatment strategies and choosing therapy. [4]

How to recognize the first symptoms

Early symptoms can be roughly divided into four groups: vasomotor, sleep disturbances, emotional-cognitive, and urogenital. Vasomotor manifestations include a sudden sensation of heat followed by sweating and palpitations, which intensify at night and disrupt sleep. Their appearance often serves as a "marker" for the onset of transition, even if menstruation continues. [5]

Sleep disturbances manifest as difficulty maintaining sleep at night, frequent awakenings, and a feeling of inadequate rest. Research shows that sleep continuity is more often impaired during the transition than the speed of falling asleep, and nighttime hot flashes can increase awakenings and daytime fatigue. [6]

Emotional and cognitive changes include mood swings, anxiety, decreased motivation, and subjective complaints about memory and attention. Systematic reviews indicate a moderate decline in verbal memory and information processing speed during the transition, with the severity fluctuating and dependent on associated factors, including sleep disturbance. [7]

Urogenital symptoms form the so-called genitourinary syndrome of menopause: vaginal dryness and discomfort, painful intercourse, frequent urination, and recurrent urinary tract infections. In the early stages, these complaints may be episodic, but without treatment, they tend to escalate. [8]

Table 1. Early symptoms of menopause: what is most common at the beginning of the transition

Group of symptoms	Specific manifestations	Why do they arise?	What is important to remember
Vasomotor	Hot flashes, night sweats, palpitations	Estradiol oscillations and hypothalamic neural networks	Often the first noticeable signal
Dream	Frequent night awakenings, feeling of shallow sleep	Relationship with hot flashes and changes in thermoregulation	Impairs attention and mood during the day
Emotions and cognitions	Anxiety, mood swings, forgetfulness	Hormonal fluctuations and lack of sleep	Usually reversible and undulating
Urogenital	Dryness, discomfort, frequent urge to urinate	Estrogen deficiency in the tissues of the urogenital tract	Tend to progress without treatment
Source: modern reviews and guides. [9]

What is considered normal: chronology and variability

Normally, the frequency and severity of symptoms vary among individuals and within the same individual over different months. According to large observational programs, approximately 50-80% of people experiencing vasomotor symptoms experience vasomotor symptoms, while the severity and duration depend on ethnicity, body mass index, smoking, and stress. [10]

Sleep disturbances often go hand in hand with hot flashes: the more hot flashes you have at night, the higher the risk of awakenings and daytime fatigue. While falling asleep may remain relatively quick, the main problem is frequent awakenings and prolonged wakefulness during the night. [11]

Cognitive complaints are generally moderate and transient: verbal memory and processing speed are most often impaired, while general intelligence remains stable. Improving sleep hygiene and treating vasomotor symptoms often reduce the severity of cognitive complaints. [12]

Urogenital complaints may worsen over time due to decreased estrogen levels in the vaginal tissues and lower urinary tract. Early treatment allows for the selection of local therapy and the prevention of chronic discomfort. [13]

Table 2. Frequency of key symptoms in the menopausal transition

Symptom	Estimated prevalence in the transition	Commentary on sources
Hot flashes and night sweats	50-80%	Data from large surveys and the SWAN program
Sleep disorders	High, intensifies with night tides	Sleep continuity is often affected
Subjective cognitive complaints	44-62%	Memory and attention are most often affected.
Vaginal dryness and discomfort	From episodic to persistent, with a tendency to increase after menopause	Require early discussion and treatment
Sources: SWAN and contemporary reviews. [14]

When the first symptoms require investigation: red flags

Any bleeding after 12 months of no menstruation is considered postmenopausal and requires an endometrial assessment, as a small proportion of cases are associated with precancerous changes and cancer. Transvaginal ultrasound with endometrial thickness measurement helps select individuals for biopsy. [15]

In women aged 45 years and older, it is recommended to exclude endometrial hyperplasia in cases of abnormal uterine bleeding, even during the menopausal transition. This rule reduces the risk of late diagnosis of clinically significant conditions. [16]

Other warning signs include sudden, intense lower abdominal pain, persistent fever, severe weakness with signs of anemia, and new neurological symptoms. Any delay in conception, even if fertility is preserved, should lead to pregnancy being ruled out before treating symptoms. [17]

The decision regarding additional examinations is made on an individual basis, taking into account risk factors and associated symptoms. If there is any doubt regarding endometrial thickness, a threshold of approximately 4 mm is used in people with postmenopausal bleeding, which is supported by modern research. [18]

Table 3. Situations when the first symptoms require an in-person assessment

Situation	Why is it important?	The first step
Bleeding after 12 months without menstruation	Risk of endometrial pathology	Transvaginal ultrasound
Abnormal bleeding in 45 years of age and older	Exclusion of hyperplasia and cancer	Consider endometrial biopsy
Severe pain, fever, signs of anemia	Possible acute conditions	Urgent Care
Any delay when there is a risk of pregnancy	The danger of missing a pregnancy	Human chorionic gonadotropin test
Sources: clinical guidelines. [19]

Differential diagnosis: not everything can be explained by menopause

Early symptoms often overlap with those of thyroid disease. Hypothyroidism can cause fatigue, weight gain, dry skin, and menstrual irregularities; hyperthyroidism can cause palpitations, sweating, and anxiety. If typical symptoms are present, thyroid-stimulating hormone screening is warranted. [20]

Periods of irregular cycles and missed periods require excluding pregnancy until menopause is confirmed retrospectively. This rule applies to everyone in transition, even with infrequent menstruation and decreased fertility. [21]

Anxiety, depressive symptoms, and sleep disturbances can be both components of menopause and independent disorders. The approach includes assessing the duration, impact on daily life, and possible triggers, prioritizing non-pharmacological approaches and, if necessary, referring to a specialist. [22]

Urogenital complaints should be distinguished from urinary tract infections and dermatological conditions of the external genitalia. Examination and, if indicated, laboratory tests help to clarify the cause and select the optimal therapy. [23]

Table 4. Differential diagnosis of early symptoms

Symptom	Possible alternative causes	What helps to distinguish
Hot flashes and sweating	Hyperthyroidism, drug effects, anxiety	Pulse, thyroid-stimulating hormone, drug history
Fatigue and drowsiness	Sleep apnea, depression, anemia	Sleep screening, complete blood count, mood assessment
Irregular cycles	Pregnancy, hyperprolactinemia, thyroid disorders	Pregnancy test, prolactin, thyroid-stimulating hormone
Urogenital complaints	Infections, dermatological diseases	Examination, microscopy and culture as indicated
Sources: modern manuals and reviews. [24]

Diagnostics: What's Really Needed at the Start

Current recommendations agree that in people 45 years and older, menopause is diagnosed clinically. Routine measurements of follicle-stimulating hormone and anti-Müllerian hormone are not required to confirm perimenopause, as their values fluctuate from cycle to cycle and rarely change management. [25]

The basic minimum includes a thorough interview with an emphasis on the cycle calendar and symptom diary, ruling out pregnancy at each missed period, and targeted testing as clinically indicated, primarily thyroid-stimulating hormone and prolactin. This approach conserves resources and prevents overdiagnosis. [26]

Instrumental methods are used in cases of alarming symptoms or atypical progression. Transvaginal ultrasound and, when indicated, endometrial biopsy remain key tools for excluding pathology of the uterine mucosa. [27]

Regular reassessment of symptoms and risk factors helps adjust the treatment strategy, combining non-pharmacological and pharmacological measures. Interventions are selected based on priorities: sleep, hot flash control, intimate comfort, and psycho-emotional well-being. [28]

Table 5. Diagnostic algorithm for the first symptoms of menopause

Step	For whom	What are we doing?	For what
Detailed questionnaire and symptom diary	To everyone with complaints	Record cycles, hot flashes, sleep, mood	Understand the dynamics
Exclusion of pregnancy during delays	With preserved fertility	Human chorionic gonadotropin test	Safety
Spot tests	According to the readings	Thyroid-stimulating hormone, prolactin	Rule out reversible causes
Instrumental assessment	At the red flags	Transvaginal ultrasound, biopsy	Don't miss pathology
Sources: clinical guidelines. [29]

What helps without medication: evidence-based self-help strategies

Sleep hygiene is fundamental. Regular bedtimes and wake-up times, a cool bedroom, layered clothing, and limiting evening caffeine and alcohol are recommended. Managing hot flashes reduces the number of awakenings and improves daytime performance. [30]

Aerobic and strength training support cardiovascular and bone health, reduce anxiety, and improve sleep. Adequate calcium and vitamin D intake, smoking cessation, and weight management complement this strategy. These steps are important for everyone, regardless of therapy choice. [31]

For intimate comfort, regular daily vaginal moisturizers and lubricants are helpful. These are the first line of treatment for mild urogenital symptoms and the basis for further treatment if needed. [32]

Psychoeducation and stress management techniques reduce the perception of symptoms and improve quality of life. For persistent emotional complaints, evidence-based psychological approaches are discussed individually and in groups. [33]

Table 6. Non-drug measures and expected effect

Direction	Concrete actions	Expected benefits
Dream	Cool bedroom, stable routine, limit stimulants	Fewer night awakenings
Activity and nutrition	Aerobic and strength training, calcium, vitamin D	Support of bones and blood vessels
Urogenital comfort	Daily moisturizers, lubricants	Reducing dryness and pain
Psycho-emotional support	Training, stress prevention techniques	Reduced anxiety and improved quality of life
Sources: modern manuals and reviews. [34]

Medication approaches for early symptoms

Hormone replacement therapy remains the most effective method for relieving vasomotor symptoms. The best balance of benefits and risks is observed when therapy is initiated near the last menstrual period in healthy individuals without contraindications. Prescription is always individualized based on age, type of medication, dose, and route of administration. [35]

For those for whom hormones are unsuitable or undesirable, non-hormonal medications have demonstrated proven efficacy. Clinical guidelines recommend selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), gabapentin-like agents, and the neurokinin-3 receptor antagonist fezolinetant. The choice is based on the patient's symptom profile and associated conditions. [36]

Genitourinary tract infection (GTU) in menopause, when moisturizers are ineffective, is effectively treated with topical estrogens in minimal doses. These estrogens reduce dryness, pain during intercourse, and recurrent urinary tract infections, acting primarily locally. The decision on the duration and type of therapy is made by the physician in consultation with the patient. [37]

It's important to remember that hormone replacement therapy is not a method of contraception. Occasional ovulation continues during menopause, so reliable methods of birth control should be used until menopause is confirmed. The approach is chosen based on the effect on bleeding and symptoms. [38]

Table 7. Choice of therapy at the first symptoms of menopause

Target	First line	Alternatives and additions	Security Comments
Hot flashes and night sweats	Hormone replacement therapy in the absence of contraindications	Non-hormonal drugs, including fezolinetant	Individualize the dose and route of administration
Sleep disorders	Hot flash control, sleep hygiene	Treatment of concomitant sleep disorders	Improved sleep often follows hot flash control.
Urogenital symptoms	Local estrogens at the minimum effective dose	Moisturizers and lubricants	The duration is discussed individually.
Contraception in transition	Levonorgestrel intrauterine system, progestogen-only methods	Combined methods with low dose estrogen in the absence of contraindications	Cycle comfort and bleeding control
Sources: positions of professional societies. [39]

Contraception and cycle control during transition

Even with infrequent periods, pregnancy is possible before confirmed menopause. Practical solutions include the levonorgestrel intrauterine system (IUS) and progestogen-only methods, which combine contraception with reduced blood loss and cycle stabilization. The choice of method is discussed based on risk factors and preferences. [40]

Professional societies support the extended use of levonorgestrel-releasing intrauterine systems inserted after age 45, up to age 55, provided safety guidelines are met. This reduces the number of interventions and ensures stable bleeding control. [41]

Combination low-dose estrogen methods can simultaneously reduce bleeding and dysmenorrhea, but require an assessment of the individual risk of thrombosis and cardiovascular events. If contraindications are present, progestogen-only and non-pharmacological alternatives are selected. [42]

Regular reassessment of the tolerability and effectiveness of the method allows for timely changes in strategy and a move towards long-term solutions as menopause approaches. [43]

Table 8. Contraception during the menopausal transition: advantages and features

Method	Advantages	Possible limitations
Levonorgestrel intrauterine system	High efficiency, reduced blood loss, long-lasting effect	Installation and control are required
Progestogen-only pills	Suitable for those with contraindications to estrogens	Irregular spotting may occur.
Low-dose combination therapies	Cycle and symptom control	Thrombosis risk assessment is mandatory
Barrier methods	No systemic impact	Less effective under typical use
Sources: modern reviews on contraception. [44]

Common mistakes and how to avoid them

A common mistake is relying on one-time measurements of follicle-stimulating hormone or anti-Müllerian hormone to "confirm" menopause in people 45 years and older. Hormonal fluctuations during menopause make such measurements uninformative for everyday practice. [45]

Another mistake is delaying seeking medical attention due to embarrassment about discussing sexual and urogenital discomfort. Early initiation of topical estrogen therapy and daily moisturizers prevents chronic complaints and improves quality of life. [46]

For some people with severe hot flashes and sleep disturbances, abandoning effective therapy due to myths and conflicting information is unjustified. Current professional societies emphasize that decisions about hormone therapy are made individually, based on the balance of benefits and risks. [47]

Finally, contraception is often forgotten due to infrequent menstruation. Until 12 months without a period have passed, reliable protection should be continued, especially if cycles are irregular. [48]

Summary: What to do at the first symptoms of menopause

The first step is to monitor your cycle and symptoms, recording your menstrual dates, hot flashes, sleep quality, and urogenital complaints. This will help differentiate normal fluctuations from conditions requiring investigation, and a personalized care plan will be developed. [49]

If warning signs are present, including bleeding after 12 months of missed periods, an in-person endometrial assessment is required. In other cases, the strategy is based on symptom management, sleep hygiene, activity, and, if necessary, modern drug therapy. [50]

Hormone replacement therapy remains the most effective way to relieve vasomotor symptoms, and hormone-free options offer expanded options for those for whom hormones are not appropriate. Urogenital complaints are effectively treated with topical agents. Decisions are made in consultation with a physician based on evidence and individual risk factors. [51]

Contraception during the transition is mandatory until menopause is confirmed. Long-acting methods and progestogen-only options are often convenient and reduce blood loss. Regular reassessment helps maintain quality of life throughout the transition. [52]