Menopause is the permanent end of menstruation caused by loss of ovarian follicular activity. It is diagnosed retrospectively after 12 consecutive months without menses with no other cause (pregnancy, thyroid disease, hyperprolactinemia, medications). The average age is about 51 years.

Hormonal changes — follicle depletion lowers estrogen (and inhibin), so FSH rises. Progesterone falls because ovulation stops. The ovaries and adrenal glands continue to make androgens, so androgen effects become relatively stronger.

Effects of estrogen loss

• Vasomotor symptoms (hot flashes, night sweats) from a narrowed thermoregulatory zone in the hypothalamus; neurokinin B–kisspeptin neurons are involved (the target of newer nonhormonal drugs)
• Genitourinary syndrome of menopause (GSM): thin, dry vaginal and urethral tissue → dryness, burning, dyspareunia, urgency, frequency, recurrent urinary tract infections, stress or urge incontinence
• Bone loss — rapid in the first years after menopause → osteoporosis and fracture
• Cardiovascular risk rises — loss of estrogen's favorable effects on blood vessels and lipids (LDL and triglycerides rise, HDL falls); central fat and insulin resistance increase
• Sleep disturbance, mood changes, brain fog, joint aches, skin thinning, weight redistribution

Subjective

• Irregular then absent periods; hot flashes, night sweats, palpitations during flushes
• Insomnia, irritability, low mood, anxiety, difficulty concentrating
• Vaginal dryness, itching, painful intercourse, decreased libido
• Urinary urgency, frequency, leakage, recurrent UTIs

Objective

• Pale, thin, less elastic vaginal mucosa with loss of rugae; vaginal pH above 4.5
• Height loss or kyphosis (vertebral fractures)
• Weight gain around the abdomen, elevated blood pressure or lipids

History to obtain

• Last menstrual period and bleeding pattern — any bleeding after 12 months of amenorrhea is abnormal
• Personal and family history: breast cancer, VTE, stroke, heart disease, liver disease, osteoporosis; smoking; mother's age at menopause (POI can be familial; also consider Turner syndrome or autoimmune disease)

• Diagnosis in women over 45 is clinical — based on age and 12 months of amenorrhea; routine FSH testing is not needed
• POI in women under 40: FSH above 25 IU/L (a repeat test 4–6 weeks later is often done) with low estradiol and 4 or more months of oligomenorrhea or amenorrhea; rule out pregnancy, thyroid disease, and hyperprolactinemia
• Postmenopausal bleeding → transvaginal ultrasound (endometrial thickness ≤ 4 mm makes cancer unlikely) and/or endometrial biopsy
• Bone density (DXA): USPSTF (2025) — screen all women 65 and older and postmenopausal women under 65 at increased fracture risk; T-score ≤ −2.5 = osteoporosis, −1.0 to −2.5 = low bone mass
• Cardiovascular risk: blood pressure, lipid profile, glucose/A1C, weight
• Age-appropriate cancer screening: mammography, cervical screening through age 65 (then stop only if prior screening was adequate and negative), colorectal screening from age 45
• Before systemic hormone therapy: history, blood pressure, breast exam and up-to-date mammography; evaluate any abnormal bleeding first

Menopausal hormone therapy (MHT) — the most effective treatment for vasomotor symptoms and GSM, and it prevents bone loss.

Risks of systemic MHT — VTE, stroke, gallbladder disease; breast cancer risk with estrogen plus progestogen that rises with longer use; endometrial cancer with unopposed estrogen.

Contraindications — undiagnosed vaginal bleeding, known or suspected breast cancer or estrogen-dependent cancer, active or past VTE, stroke, or MI, active liver disease, pregnancy.

Labeling change (US, 2025): In November 2025 the FDA announced removal of the boxed warnings on cardiovascular disease, breast cancer, and probable dementia from menopausal hormone therapy labels, adding age-based guidance (start before 60 or within 10 years of menopause). The boxed warning about endometrial cancer for systemic estrogen-alone products remains, and the risks above still appear in labeling — they still guide nursing assessment and teaching.

Local (vaginal) estrogen — low-dose cream, tablet, or ring for GSM; minimal systemic absorption; progestogen generally not needed; still report any vaginal bleeding. Other GSM options: vaginal moisturizers and lubricants, vaginal DHEA (prasterone), oral ospemifene.

Nonhormonal drugs for vasomotor symptoms

Cognitive behavioral therapy and clinical hypnosis are evidence-based nonhormonal options. Over-the-counter supplements (black cohosh, soy isoflavones) have limited or inconsistent evidence — ask about their use.

Osteoporosis prevention and treatment — calcium, vitamin D, weight-bearing exercise; bisphosphonates, denosumab, and other agents for osteoporosis (see bone disorders).

Listed in priority order.

1. Investigate postmenopausal bleeding promptly — it is endometrial cancer until proven otherwise; arrange evaluation rather than reassurance
2. Screen for contraindications before hormone therapy — VTE, stroke, MI, breast cancer, liver disease, smoking, blood pressure
3. Monitor clients on MHT for thrombosis and stroke: sudden severe headache, visual changes, speech difficulty, weakness, chest pain, dyspnea, unilateral leg swelling or pain; breast changes; vaginal bleeding
4. Fall and fracture prevention — assess gait, vision, home hazards, medications causing dizziness (gabapentin, sedatives)
5. Symptom management — cool environment, layered clothing, fans; sleep hygiene
6. Cardiovascular risk reduction — blood pressure, lipids, glucose, smoking status, activity counseling
7. Psychosocial support — menopause is a normal life transition, not a disease; screen for depression; include sexual health in the assessment; for POI, address infertility grief

• Hot flashes: dress in layers, keep the bedroom cool, use fans; identify and avoid triggers — hot drinks, caffeine, alcohol, spicy foods, hot baths or saunas, smoking, stress; slow paced breathing
• Exercise: regular aerobic activity (about 150 minutes per week) plus weight-bearing and muscle-strengthening exercise at least 2 days per week; balance exercises reduce falls
• Bone health
  • Calcium about 1,200 mg/day for women over 50, preferably from food; take calcium carbonate with meals (calcium citrate can be taken anytime); split doses of 500 mg or less
  • Vitamin D 600 IU/day to age 70, 800 IU/day after 70 (more if deficient)
  • Limit salt and alcohol, stop smoking — all increase bone loss
• Diet: reduce saturated fat, emphasize vegetables, fruits, whole grains, legumes, and soy foods; maintain healthy weight; adequate fluids
• Sleep: consistent bedtime and wake time, short naps only, relaxation before bed; avoid alcohol and heavy exercise close to bedtime; do not use sleeping pills without a prescription
• Genitourinary symptoms: use vaginal moisturizers regularly and lubricants during intercourse; do not douche; regular sexual activity helps maintain vaginal health; local estrogen is safe and effective for most women
• Contraception: continue until 12 months without a period after age 50 (or 24 months if under 50) — pregnancy is still possible in perimenopause; menopause does not protect against STIs
• Hormone therapy: understand the individual benefits and risks; take the progestogen as prescribed if you have a uterus; keep yearly reviews, mammograms, and blood pressure checks
• Report immediately: any vaginal bleeding after menopause, breast lump, calf pain or swelling, chest pain, sudden severe headache, vision or speech changes

• Menopause = 12 months of amenorrhea; average age about 51; POI before 40
• Estrogen falls, FSH rises; relative androgen excess
• Estrogen loss → hot flashes, GSM, bone loss, increased cardiovascular risk
• Postmenopausal bleeding = evaluate for endometrial cancer
• MHT is most effective for vasomotor symptoms; favorable when under 60 or within 10 years of menopause
• Intact uterus → add a progestogen to estrogen
• MHT contraindications: undiagnosed bleeding, breast cancer, VTE/stroke/MI, liver disease
• Teach MHT warning signs: severe headache, vision change, chest pain, leg swelling
• GSM: moisturizers and lubricants for mild symptoms; low-dose vaginal estrogen is the most effective treatment for moderate to severe symptoms; do not douche
• Nonhormonal: SSRIs/SNRIs, gabapentin, fezolinetant (monitor liver), elinzanetant
• Bone: calcium 1,200 mg/day, vitamin D 600–800 IU, weight-bearing exercise, limit salt and alcohol; DXA at 65 or earlier with risk
• Contraception until 12 months without menses (after 50)