Menopause HUB

Welcome to the Menopause Hub, a collaborative online source brought to you by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Menopause Society.

                 

Menopause Definition

Natural menopause is defined as the permanent cessation of menstruation due to the loss of ovarian follicles, resulting in hypoestrogenism and the end of reproductive potential. Menopause is retrospectively diagnosed after 12 consecutive months of amenorrhea in the absence of any other pathological or physiological cause. Individuals who do not menstruate regularly (for reasons such as hysterectomy, anovulation, or medication-induced amenorrhea) also go through menopause when their ovarian reserve declines, but their final menstrual period is not always known. The average age of menopause in Canada is 51 years, however, typically ranges between 45 – 55 years. Menopause can also be induced either surgically (e.g. bilateral oophorectomy) or medically (e.g. chemotherapy, pelvic radiation, gonadotropin modulators) and is often associated with more abrupt and severe menopause symptoms due to rapid decline in estrogen.

Early menopause is defined as menopause before the age of 45 years and premature (also known as premature ovarian insufficiency) before the age of 40 years.

Stages of Menopause

The time leading up to the menopause is called perimenopause and any time after menopause is termed postmenopause. The Stages of Reproductive Aging Workshop (STRAW+10) is the gold standard for characterizing the stages of reproductive aging.1 It uses menstrual cycles and hormone levels to define the different stages. Below is a summary of the different stages captured in the STRAW+10:

    Pre-menopause: The time before any menopausal symptoms begin.

    Perimenopause: The transitional phase leading up to menopause is often associated with menopause symptoms and/or changes in the menstrual cycle. The term menopause transition is also sometimes used interchangeably however, perimenopause also includes up to the 12 months after the final menstrual period when menopause is diagnosed. Perimenopause can occur anywhere from 4 – 8 years before the menopause and in some it can be 10 years or longer. Menopause symptoms can occur even before menstrual cycle changes, and menstrual cycle changes can occur without menopause symptoms. This is a time of hormonal fluctuations which can lead to menopause symptoms and menstrual irregularities. Pregnancy is still possible during this stage therefore contraception may be needed. This stage is defined as early and late stages:

    • Early perimenopause: The start of menstrual cycle variability ( > 7 days variability in cycle length) and/or menopause symptoms
    • Late perimenopause: Skipped cycles of 60 days or greater of amenorrhea

    Menopause: Defined as 12 consecutive months without a menstrual period.*

    Postmenopause: Any time after the menopause.

* Of note, this definition does not apply to individuals who have amenorrhea due to other factors such as hysterectomy, endometrial ablation, or have medication induced amenorrhea (ie progestin-releasing intrauterine device (IUD), hormonal contraception).

 Details of the STRAW+10 can be found here.

Impact of Menopause

Menopause can have a significant impact on a woman’s life. While the experience varies considerably among individuals, the evidence clearly shows that menopause represents a significant life transition with far-reaching consequences. Up to 80% of women experience menopause symptoms, with 25% seeking treatment due to severity. Symptoms can last 7 – 8 years or longer as many of these symptoms start in the perimenopause, affecting quality of life and work productivity. Early menopause or premature ovarian insufficiency raises the risks of osteoporosis, cardiovascular disease, cognitive issues, and early mortality. The impact of menopause symptoms when not adequately managed is staggering. In a survey from the Menopause Foundation of Canada (MFC) in 2022 in Canada, one in two women felt unprepared for menopause and 4 in 10 women felt alone during this time. 2 Many individuals suffer in silence as they are not getting the care they need. Despite evidence supporting menopause hormone therapy (MHT) as the most effective option for vasomotor symptoms, stigma and fear persist, limiting menopausal care access. There is a real need for improved menopause support in Canada.

Summary of impact of menopause:

  • Quality of life: Menopause symptoms can significantly diminish quality of life for women both physically and mentally. 3

  • Work productivity: The effect of symptoms on work productivity is being recognized. Women experiencing menopausal symptoms report higher degrees of work impairment than women not experiencing menopausal symptoms. 3

  • Economic Impact: In Canada a reported $3.5 billion per year proposed loss to the economy from lost productivity, missed days of work and lost income. 3 Up to 10% of women will quit their jobs because of severe symptoms that impact their ability to function.4

  • Long-term health: Women with prolonged and severe vasomotor symptoms have been linked to negative outcomes later in life including cardiovascular disease. 5

Hormonal Changes:

Ovarian aging is a complex interplay of declining ovarian function and compensatory mechanism that creates a unique hormonal profile that varies considerably between individuals. Estrogen levels drop dramatically with menopause, however this decline in estrogen is not linear but rather characterized by significant fluctuations during perimenopause. Estrogen levels may surge to higher levels at times before eventually falling. Progesterone also decreases with menopause and this decline starts during the perimenopause. FSH levels are elevated as a compensatory mechanism to low estrogen levels, as a response to stimulate ovarian function and produce more estrogen. Luteinizing hormone (LH) also increases significantly, though not to the same degree as FSH.

Long Term Health Consequences

Menopause is associated with a range of long-term health consequences, primarily due to the decline in ovarian hormone production, especially estradiol.

  • Metabolic syndrome: A marked increase in the incidence of metabolic syndrome is seen with menopause including increased central abdominal fat, hypertension, and insulin resistance. This increased rate of metabolic syndrome does not subside with time. 5,6
  • Cardiovascular Disease: Menopause accelerates adverse changes in cardiovascular risk factors. The menopause transition is associated with an increase in low-density lipoprotein cholesterol (LDL-C) and a less favorable lipid profile. Additionally, impaired endothelial function and changes in arterial elasticity are seen.5
  • Bone health: Bone mineral density declines with the loss of estrogen. Bone loss starts during the perimenopause and this loss accelerates sharply during the late perimenopause. Though the greatest loss is the first 10 years after the final menstrual period, bone loss accelerates sharply during the late perimenopause and the first 1 – 2 years after the final menstrual period.5
  • Cognition: Cognitive function, particularly verbal memory, may worsen during the transition but generally stabilizes or improves after menopause, then follows an age-related decline.5

It is important to recognize that many of these changes begin during the menopause transition. As such, perimenopause presents a critical time to initiate screening for long term disease risks and to implement evidence based preventive health strategies.

Menopause Symptoms

Validated symptoms of menopause extend beyond vasomotor symptoms, encompassing a range of physical, psychological, and genitourinary symptoms. Understanding these symptoms allows healthcare providers to better evaluate and address women's health concerns during menopause.

A description of common symptom classifications is included below. Access the link in each box to find further details about each symptom classification.

Vasomotor Symptoms

Vasomotor symptoms (VMS)—primarily hot flashes and night sweats—are the most common symptoms experienced during menopause, affecting up to 80% of women, with about 20 - 25% reporting symptoms severe enough to disrupt daily life.7 Hot flashes and night sweats can cause significant discomfort and, in some women, may be accompanied by heart palpitations and anxiety. Night sweats can cause sleep disturbances. Vasomotor symptoms last an average of 7.4 years as they often start during the perimenopause, but for some, symptoms can persist for more than a decade.8 VMS typically persist 4.5 years after the final menstrual period.8

Recent advances have identified the underlying mechanism behind vasomotor symptoms. Kisspeptin, neurokinin B, dynorphin (KNDy) neurons located in the hypothalamus play an important role as regulators of thermoregulation. Estrogen withdrawal results in hypertrophy and hyperactivity of the KNDy neurons which drives activation of the heat dissipation pathways causing skin vasodilation and vasomotor symptoms. New agents targeting the neurokinin receptors antagonizes the action of KNDy neurons and leads to improvement in vasomotor symptoms. This new class is called neurokinin (NK) receptor antagonists, with fezolinetant, an NK3-receptor antagonist, the first of its kind approved in Canada.

Sleep Disturbances

Sleep disturbances are among the most common symptoms during the menopausal transition, affecting 40–60% of peri- and post-menopausal women. The most frequent complaint is sleep fragmentation and difficulty maintaining sleep, though problems with falling asleep and early morning awakenings are also common.9 Sleep disturbances can be multifactorial during the menopause, often linked to frequent night sweats, however women without VMS can also be affected.10 Mood issues such as depression or anxiety can also lead to disrupted sleep. The prevalence of sleep apnea also increases in postmenopause and should be ruled out when assessing patients with sleep disturbances.11 Sleep issues can significantly impact quality of life and work productivity, as well are associated with long-term health risks such as cardiovascular disease, diabetes, obesity, and increased risk of cognitive decline.9

Mood Disorders

The menopause transition is a period of increased vulnerability for new and worsening mood disorders due to the changes in hormone levels during this phase.10 These include anxiety, irritability, mood swings and depressive symptoms significantly affecting quality of life and well-being. These are especially prevalent during the perimenopause, while pre-existing mental health concerns can be exacerbated during this time. Depressive symptoms are more common compared to a major depressive disorder (MDD) – either new onset or recurring – however, studies suggest a 2 – 4 fold increase risk of MDD during the perimenopause.10,12

Concentration/Cognition/Brain Fog

Cognitive changes during the perimenopause are often reported with about 40 – 60% of women reporting issues with memory, difficulty concentrating, and forgetfulness.12 Brain fog is often a term that is used to describe these effects.10 These symptoms can be quite bothersome and significantly impact a woman’s daily function. Women should be reassured that these symptoms tend to stabilize and improve after menopause.

Fatigue

Fatigue is a very common yet often underrecognized symptom during the menopause. Several contributors to fatigue include sleep disruption, mood issues and musculoskeletal pain. Women who have heavy, irregular bleeding during the perimenopause are especially vulnerable to fatigue from iron deficiency anemia.13

Genitourinary Syndrome of Menopause

Genitourinary Syndrome of Menopause (GSM) is a term that encompasses a range of symptoms and physical changes affecting the vulva, vagina, and lower urinary tract. GSM is very common in close to 80% of menopausal women affected and is a chronic progressive condition persisting indefinitely into the postmenopause.14,15 Unfortunately many women do not seek treatment, often due to lack of awareness or hesitancy to discuss symptoms.14

Hormone receptors to estrogen and androgen exist throughout the female genitourinary system. Estrogen depletion during menopause causes effects in the vagina, vulva, urethra, and bladder resulting in vaginal epithelial thinning, collagen degradation and decreased blood flow to the area. This leads to several structural changes, including a vaginal wall which becomes narrower, shorter and less elastic, along with increased vaginal dryness. The loss of glycogen-rich epithelial cells results in a reduced substrate for lactobacilli, raising the vaginal pH. This loss of acidic environment in the vagina increases susceptibility to infections, therefore increased risk of urinary tract infections.

Symptoms of genitourinary syndrome of menopause include:

  • Vaginal: vaginal dryness, dyspareunia, itching, bleeding
  • Urinary: frequency, urgency, stress incontinence, frequent urinary tract infections
  • Sexual: reduced lubrication, arousal and libido due to vaginal pain and sensitivity

Musculoskeletal

There is increased awareness on the effects on the musculoskeletal system with menopause. This cluster of symptoms is now being referred to as “Musculoskeletal Syndrome of Menopause” by some clinicians.16 It is reported that over 70% of women experience these symptoms, with about 25% facing severe or disabling effects.16 The fall in estrogen levels may impact bone, muscle, tendon, cartilage, ligament, and adipose tissue, leading to the cluster of symptoms. Types of features include joint pain, joint discomfort/stiffness and frozen shoulder. The loss of lean muscle mass is also seen leading to risk of sarcopenia. Loss of bone mineral density is seen increasing the risk of osteoporosis and fractures. 16

Other

There are several other menopause symptoms reported by women which do not fall into the specific classifications highlighted in this section. Other menopausal symptoms include migraines/headaches, bloating, tingling extremities, burning mouth/tongue, skin and hair changes and dry eyes. Migraines/headaches and bloating tend to be more common during the perimenopause.

Diagnosis and Management

Diagnosis

Menopause diagnosis is primarily clinical based on age, menstrual history and symptoms, while hormonal testing only in specific situations.6

Menopause:

For women aged 45 years and older, menopause is diagnosed if there has been no menstruation for more than 12 months, with or without symptoms.6 In women with a uterus, the cessation of periods is the primary clinical marker. For women who have had a hysterectomy, endometrial ablation, or are using progestin IUD, diagnosis relies on symptoms rather than bleeding patterns.

A thorough medical history that documents the frequency, severity, and impact of menopause symptoms, as well as menstrual history provides valuable diagnostic information. Several symptom assessment tools are available for use by patients.

Laboratory testing such as with hormonal measurements with FSH and estradiol may be required for the following situations:6

  • Women younger than 45 years who become amenorrheic.
  • Women under 40 with suspected premature ovarian insufficiency (POI). For POI diagnosis, FSH should be elevated on at least two separate occasions about 4 – 6 weeks apart.17 Estradiol level is not completely necessary for POI diagnosis but a low estrogen level with high FSH provides additional support for the diagnosis.17

Other laboratory testing to rule out other causes of amenorrhea if diagnosis is uncertain (i.e. hyperprolactinemia, thyroid, pregnancy).

Perimenopause:

Perimenopause is diagnosed based on patient history with symptoms and changes in menstrual cycles. Women may experience irregular menstrual cycles that may include skipped periods, shorter cycles, or unusually heavy or light bleeding. Menstrual cycles may be irregular which may include changes in frequency (skipped periods or shorter cycles), or unusual changes in flow (heavy or light bleeding). Of note, menopause symptoms can happen even before menstrual cycle changes occur. Hormone levels, including FSH and estradiol, are not reliable during the perimenopause because of fluctuating hormones during this time.

Management of Menopausal Symptoms

Decision making about menopause management include consideration for most bothersome symptoms, degree of severity of symptoms, menopause stage, presence of uterus, comorbidities and need for perimenopausal contraception/bleeding control.18 Patient’s personal preference about treatment should also be considered as should affordability.

Options for management of menopause symptoms include menopausal hormone therapy (MHT), non-hormonal prescription medications, lifestyle modifications and complementary therapy. A brief description for each is below.

  • Menopausal hormone therapy (MHT): MHT is the most effective treatment for vasomotor symptoms.19 MHT can also help with sleep, mood issues, GSM and prevent bone loss.10,15,20 MHT involves the use of estrogen and progestogen therapy (EPT) for individuals with a uterus or estrogen alone (ET) for those without a uterus. Current guidelines recommend that MHT can safely be initiated in women who are less than 60 years of age or less than 10 years since menopause and have no MHT contraindications.19 Estrogen products available in Canada include oral, transdermal gels and patches, and local vaginal estrogen therapy. Vaginal estrogen therapy provides primarily a local effect for GSM symptoms. Progestogen products include oral, transdermal patch (combined with estrogen) and off label use of progestin intrauterine system (levonorgestrel intrauterine system).

  • Other MHT options which do not require additional progestogen include the use of a tissue selective estrogen complex (TSEC) which combines conjugated estrogen with bazedoxifene (a SERM) and tibolone. Tibolone is converted in the body to three active metabolites with estrogenic, progestogenic and androgenic activities.

  • Non-hormonal prescription medications: Non-hormonal prescription medications are viable options for women who have contraindications to MHT, experience adverse effects or prefer not to use MHT. Non-hormonal prescription medications include SSRI/SNRI antidepressants, gabapentin, oxybutynin and fezolinetant.19 Most of these agents are used off label in Canada, except for fezolinetant and clonidine which have been approved by Health Canada for the treatment of VMS. According to the 2023 clinical practice guidelines from The Menopause Society, clonidine is not recommended due to insufficient supporting evidence and an unfavorable side effect profile.21 The newest agent, fezolinetant is a NK3-receptor antagonist is the first medication of its class to have been approved in Canada for the treatment of VMS. It is the first of the NK-receptor antagonists to be approved in Canada (see additional details about KNDy neurons under vasomotor symptoms).

  • Lifestyle measures: Though lifestyle measures have mixed evidence for their benefit, they are practical approaches for VMS symptoms with many other health benefits. Lifestyle measures include cooling techniques, avoiding triggers, exercise, yoga and maintaining a healthy weight.19,21 Though the evidence is limited, weight loss may be used to help with VMS.21

  • Complementary Therapies: Complementary therapies with the most evidence to support their use to help with menopause symptoms include cognitive behavioural therapy and clinical hypnosis.21 Phytoestrogen such as soy and acupuncture have mixed evidence for menopause symptoms.19 Many natural health products have limited evidence of their benefit.19

For more detailed information on management options for menopause please refer to the SOGC guidelines or to the following review in CMAJ.22

Options for Genitourinary Syndrome of Menopause:

There are several options for managing GSM. These provide primarily local effect for GSM symptoms:

  • Lubricants/moisturizers
  • Vaginal estrogen therapy (vaginal tablets/ovules, vaginal cream, vaginal ring)
  • Prasterone (intravaginal DHEA ovules)
  • Ospemifene (oral tablet)

For more detailed information on management options for GSM please refer to the SOGC guidelines or to the following review in CMAJ.22

General Comments about Menopause Management:

Patients have the right to make informed decisions about their care. It is important to provide comprehensive information on management options, including their advantages and disadvantages. Decisions can be influenced by perceived benefits, harms, affordability, beliefs, values, and availability. Respecting patient choices is important, ensuring they are empowered to make decisions on the most appropriate option for them.

Patient Resources:

Education and Training

Key Reports

The Silence and the Stigma: Menopause in Canada
Menopause Foundation of Canada, 2022

TÉLÉCHARGER

Menopause and Work in Canada
Menopause Foundation of Canada, 2023

TÉLÉCHARGER

HER BC: Health and Economic Research on Midlife Women in British Columbia
Women’s Health Research Institute, 2024

TÉLÉCHARGER

The Health and Economic Impacts of Menopause
FP Analytics with Bayer, 2025

TÉLÉCHARGER

Blueprint to Close the Women’s Health Gap: How to Improve Lives and Economies for All
World Economic Forum / McKinsey, 2025

TÉLÉCHARGER

The M Factor: Global Impact Report 2025
Women in the Room Productions / The M Factor Film, 2025

TÉLÉCHARGER

Quality Standards: Menopause Care for Women and Gender-Diverse People
Ontario Health, 2025

TÉLÉCHARGER

Guide To Menopause
Women & Diversity Health , 2025

TÉLÉCHARGER

Printable Resources and Posters

The SOGC has developed new perimenopause and menopause posters (11X16) for health care providers to display in their clinics, helping raise awareness and support informed conversations with patients.

Perimenopause

TÉLÉCHARGER

Menopause

TÉLÉCHARGER

References:

1. Harlow SD et al. STRAW 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012 Apr;19(4):387-95

2. Menopause Foundation of Canada. https://menopausefoundationcanada.ca/menopause-in-canada-report/

3. Whiteley J, DiBonaventura M, Wagner JS, Alvir J, Shah S. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. J Womens Health Nov 2013;22(11):983-90.

4. Menopause Foundation of Canada. Menopause and Work in Canada 2023. https://menopausefoundationcanada.ca/pdf_files/Menopause_Work_Canada_2023EN.pdf

5. Santoro N. Understanding the menopause journey. Climacteric 2025:1-5.

6. Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner's Toolkit for Managing Menopause. Climacteric 2023;26(6):517-536.

7. Archer DF, Sturdee DW, Baber R, et al. Menopausal hot flushes and night sweats: where are we now? Climacteric 2011;14(5):515-28.

8. Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-9.

9. Schaedel Z, Holloway D, Bruce D, Rymer J. Management of sleep disorders in the menopausal transition. Post Reprod Health. 2021;27(4):209-214.

10. Shea AK, Wolfman W, Fortier M, Soares CN. Guideline No. 422c: Menopause: Mood, Sleep, and Cognition. J Obstet Gynaecol Can. 2021;43(11):1316-1323 e1. doi:10.1016/j.jogc.2021.08.009

11. Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 Pt 1):608-13.

12. Horst K, Cirino N, Adams KE. Menopause and mental health. Current opinion in obstetrics & gynecology. Apr 1 2025;37(2):102-110.

13. Harlow SD, Gold EB, Hood MM, Mukwege AA, Randolph JF, Greendale GA. Abnormal uterine bleeding is associated with fatigue during the menopause transition. Menopause. Mar 11 2025;doi:10.1097/GME.0000000000002525

14. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA 2023;329(5):405-420.

15. Johnston S, Bouchard C, Fortier M, Wolfman W. Guideline No. 422b: Menopause and Genitourinary Health. J Obstet Gynaecol Can. Nov 2021;43(11):1301-1307 e1.

16. Wright VJ, Schwartzman JD, Itinoche R, Wittstein J. The musculoskeletal syndrome of menopause. Climacteric 2024;27(5):466-472.

17. ESHRE Guideline on Premature Ovarian Insufficiency 2024. https://www.imsociety.org/education/updated-eshre-premature-ovarian-insufficiency-clinical-guideline/?v=5435c69ed3bc

18. Duralde ER, Sobel TH, Manson JE. Management of perimenopausal and menopausal symptoms. BMJ 2023;382:e072612.

19. Yuksel N, Evaniuk D, Huang L, et al. Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. J Obstet Gynaecol Can 2021;43(10):1188-1204 e1.

20. Khan AA, Alrob HA, Ali DS, Dandurand K, Wolfman W, Fortier M. Guideline No. 422g: Menopause and Osteoporosis. J Obstet Gynaecol Can. May 2022;44(5):527-536 e5.

21. The Nonhormone Therapy Position Statement of The North American Menopause Society" Advisory P. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause 2023;30(6):573-590.

22. Lega IC, Fine A, Antoniades ML, Jacobson M. A pragmatic approach to the management of menopause. CMAJ May 15 2023;195(19):E677-E672.


This project is supported by a financial contribution from the Government of Canada. The views expressed herein do not necessarily represent the views of the Government of Canada.