Editing Menopause (section)

== Signs and symptoms ==
[[File:Symptoms of menopause (vector).svg|thumb|303x303px|Symptoms of menopause]]
During early menopause transition, the [[menstrual cycles]] remain regular but the interval between cycles begins to lengthen. Hormone levels begin to fluctuate. Ovulation may not occur with each cycle.<ref name="Hoffman20122">{{cite book |title=Williams Gynecology |vauthors=Hoffman B |publisher=McGraw-Hill Medical |year=2012 |isbn=9780071716727 |location=New York |pages=555–56}}</ref>

The term ''menopause'' refers to a point in time that follows one year after the last [[menstruation]].<ref name="Hoffman20122" /> During the menopausal transition and after menopause, women can experience a wide range of symptoms.<ref name="NIH2013Sym" /> However, for women who enter the menopause transition without having regular menstrual cycles (due to prior surgery, other medical conditions or ongoing hormonal contraception) the menopause cannot be identified by bleeding patterns and is defined as the permanent loss of ovarian function.<ref name="auto2" />

===Vagina, uterus and bladder (urogenital tract)===
[[File:Vaginal_Canal_Normal_vs._Menopause.png|thumb|Size of the [[vaginal canal]] before and after menopause, demonstrating vaginal [[atrophy]]]]
During the transition to menopause, [[Menstrual cycle|menstrual patterns]] can show shorter cycling (by 2–7 days);<ref name="Hoffman20122" /> longer cycles remain possible.<ref name="Hoffman20122" /> There may be [[Irregular menstruation|irregular bleeding]] (lighter, heavier, spotting).<ref name="NIH2013Sym" /><ref name="Hoffman20122" /> [[Dysfunctional uterine bleeding]] is often experienced by women approaching menopause due to the hormonal changes that accompany the menopause transition. Spotting or bleeding may simply be related to vaginal [[atrophy]], a benign sore ([[Polyp (medicine)|polyp]] or lesion), or may be a functional endometrial response. The [[European Menopause and Andropause Society]] has released guidelines for assessment of the [[endometrium]], which is usually the main source of spotting or bleeding.<ref name="pmid236190092">{{cite journal |vauthors=Dreisler E, Poulsen LG, Antonsen SL, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, Pérez-López FR, Simoncini T, Tremollieres F, Rees M, Ulrich LG |date=June 2013 |title=EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women |journal=Maturitas |volume=75 |issue=2 |pages=181–90 |doi=10.1016/j.maturitas.2013.03.011 |pmid=23619009}}</ref>

In post-menopausal women, however, any unscheduled vaginal [[bleeding]] is of concern and requires an appropriate investigation to rule out the possibility of malignant diseases.

Urogenital symptoms may appear during menopause and continue through [[postmenopause]] and include [[Dyspareunia|painful intercourse]], [[vaginal dryness]] and [[atrophic vaginitis]] (thinning of the membranes of the [[vulva]], the [[vagina]], the [[cervix]] and the outer [[urinary tract]]). There may also be considerable shrinking and loss in elasticity of all of the outer and inner genital areas. [[Urinary urgency]] may also occur and [[urinary incontinence]] in some women.<ref name="Hoffman20122" /><ref name=":4">{{Cite journal |last1=Allafi |first1=Ahmad Hasan |last2=Al-Johani |first2=Amal Saleem |last3=Babukur |first3=Raed M. |last4=Fikri |first4=Jehad |last5=Alanazi |first5=Raneem Rashed |last6=Ali |first6=Sara Dafaalla Mohamed Hag |last7=Alkathiry |first7=Abdulrahman |last8=Alfozan |first8=Abdalmelk Mohmed |last9=Mayoof |first9=Kawthar Ishaq Ahmed Ali Husain |last10=Abualhamael |first10=Maya Ahmad |date=2024 |title=The Link Between Menopause and Urinary Incontinence: A Systematic Review |journal=Cureus |volume=16 |issue=10 |pages=e71260 |doi=10.7759/cureus.71260 |doi-access=free |issn=2168-8184 |pmc=11550778 |pmid=39525118}}</ref>

=== Other physical effects ===
[[File:Menopause - Osteoporosis -- Smart-Servier (cropped).jpg|thumb|Bone mineral density, especially of the vertebrae, decreases with menopause.]]
The most common physical symptoms of menopause are heavy [[night sweat]]s, and [[hot flash]]es (also known as vasomotor symptoms).<ref>{{cite journal | vauthors = Crandall CJ, Mehta JM, Manson JE | title = Management of Menopausal Symptoms: A Review | journal = JAMA | volume = 329 | issue = 5 | pages = 405–420 | date = February 2023 | pmid = 36749328 | doi = 10.1001/jama.2022.24140 | s2cid = 256628900 }}</ref> Sleeping problems and [[insomnia]] are also common.<ref>{{cite journal | vauthors = Santoro N, Epperson CN, Mathews SB | title = Menopausal Symptoms and Their Management | journal = Endocrinology and Metabolism Clinics of North America | volume = 44 | issue = 3 | pages = 497–515 | date = September 2015 | pmid = 26316239 | pmc = 4890704 | doi = 10.1016/j.ecl.2015.05.001 }}</ref> Other physical symptoms may be reported that are not specific to menopause but may be exacerbated by it, such as [[Fatigue (medical)|lack of energy]], [[Arthralgia|joint soreness]], [[Joint stiffness|stiffness]], [[back pain]], breast enlargement, [[Mastodynia|breast pain]], [[heart palpitation]]s, [[headache]], [[dizziness]], [[Xeroderma|dry]], [[itch]]y skin, thinning, [[Paresthesia|tingling]] skin, [[rosacea]], [[Obesity|weight gain]].<ref name="Hoffman20122" /><ref>{{Cite web |date=27 June 2017 |title=Red in the Face |url=https://newsinhealth.nih.gov/2012/08/red-face |access-date=31 March 2021 |website=NIH News in Health |language=en}}</ref>

=== Mood and memory effects ===
Psychological symptoms are often reported but they are not specific to menopause and can be caused by other factors.<ref name=":2">{{Cite journal |last1=Hogervorst |first1=Eef |last2=Craig |first2=Jen |last3=O'Donnell |first3=Emma |date=2022-05-01 |title=Cognition and mental health in menopause: A review |url=https://www.sciencedirect.com/science/article/pii/S1521693421001644 |journal=Best Practice & Research Clinical Obstetrics & Gynaecology |series=Menopause Management |language=en |volume=81 |pages=69–84 |doi=10.1016/j.bpobgyn.2021.10.009 |issn=1521-6934 |pmid=34969617|s2cid=244805452 }}</ref><ref name=":1">{{Cite journal |last1=Kilpi |first1=Fanny |last2=Soares |first2=Ana Luiza G. |last3=Fraser |first3=Abigail |last4=Nelson |first4=Scott M. |last5=Sattar |first5=Naveed |last6=Fallon |first6=Sean James |last7=Tilling |first7=Kate |last8=Lawlor |first8=Deborah A. |date=14 August 2020 |title=Changes in six domains of cognitive function with reproductive and chronological ageing and sex hormones: a longitudinal study in 2411 UK mid-life women |journal=BMC Women's Health |language=en |volume=20 |issue=1 |page=177 |doi=10.1186/s12905-020-01040-3 |issn=1472-6874 |pmc=7427852 |pmid=32795281 |doi-access=free }}</ref> They include [[anxiety]], poor memory, inability to concentrate, depressive mood, [[irritability]], [[mood swing]]s, and less [[Libido|interest in sexual activity]].<ref name="Hoffman20122" /><ref name="Llaneza2">{{cite journal |vauthors=Llaneza P, García-Portilla MP, Llaneza-Suárez D, Armott B, Pérez-López FR |date=February 2012 |title=Depressive disorders and the menopause transition |journal=Maturitas |volume=71 |issue=2 |pages=120–30 |doi=10.1016/j.maturitas.2011.11.017 |pmid=22196311}}</ref><ref name="NIH2013Sym" />

[[Postmenopausal confusion|Menopause-related cognitive impairment]] can be confused with the [[mild cognitive impairment]] that precedes [[dementia]].<ref>{{Cite book |title=Managing the Menopause: 21st Century Solutions |vauthors=Panay N, Briggs P, Kovacs G |date=20 August 2015 |publisher=Cambridge University Press |isbn=9781316352717 |chapter=Memory and Mood in the Menopause |chapter-url=https://books.google.com/books?id=UZ9rCgAAQBAJ&pg=PA91}}</ref> There is evidence of small decreases in verbal memory, on average, which may be caused by the effects of declining estrogen levels on the brain,<ref name=":02">{{Cite book |url=https://books.google.com/books?id=JtBJDwAAQBAJ&pg=PA38 |title=Pre-Menopause, Menopause and Beyond: Volume 5: Frontiers in Gynecological Endocrinology |vauthors=Birkhaeuser M, Genazzani AR |date=30 January 2018 |publisher=Springer |isbn=9783319635408 |pages=38–39}}</ref> or perhaps by reduced blood flow to the brain during [[hot flash]]es.<ref>{{Cite book |url=https://books.google.com/books?id=xTExDwAAQBAJ |title=Current Medical Diagnosis and Treatment 2018, 57th Edition |vauthors=Papadakis MA, McPhee SJ, Rabow MW |date=11 September 2017 |publisher=McGraw Hill Professional |isbn=9781259861499 |pages=1212}}</ref> However, these tend to resolve for most women during the postmenopause. Subjective reports of memory and concentration problems are associated with several factors, such as lack of sleep, and stress.<ref name=":1" /><ref name=":2" />

=== Long-term effects ===
==== Cardiovascular health ====
Exposure to endogenous [[estrogen]] during reproductive years provides women with protection against [[cardiovascular disease]], which is lost around 10 years after the onset of menopause. The menopausal transition is associated with an increase in [[fat mass]] (predominantly in [[visceral fat]]), an increase in [[insulin resistance]], [[Dyslipidemia|dyslipidaemia]], and [[endothelial dysfunction]].<ref>{{cite journal |vauthors=Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T |date=June 2022 |title=Menopause: a cardiometabolic transition |journal=The Lancet. Diabetes & Endocrinology |language=English |volume=10 |issue=6 |pages=442–456 |doi=10.1016/S2213-8587(22)00076-6 |pmid=35525259 |s2cid=248561432}}</ref>  Women with [[vasomotor symptoms]] during menopause seem to have an especially unfavorable cardiometabolic profile,<ref>{{cite journal |vauthors=Thurston RC |date=April 2018 |title=Vasomotor symptoms: natural history, physiology, and links with cardiovascular health |journal=Climacteric |volume=21 |issue=2 |pages=96–100 |doi=10.1080/13697137.2018.1430131 |pmc=5902802 |pmid=29390899}}</ref> as well as women with premature onset of menopause (before 45 years of age).<ref>{{cite journal |vauthors=Stevenson JC, Collins P, Hamoda H, Lambrinoudaki I, Maas AH, Maclaran K, Panay N |date=October 2021 |title=Cardiometabolic health in premature ovarian insufficiency |journal=Climacteric |volume=24 |issue=5 |pages=474–480 |doi=10.1080/13697137.2021.1910232 |pmid=34169795 |s2cid=235634591 |doi-access=free|hdl=2066/238753 |hdl-access=free }}</ref> These risks can be reduced by managing risk factors, such as tobacco smoking, [[hypertension]], increased [[blood lipid]]s and body weight.<ref name="Souza20132">{{cite journal |vauthors=Souza HC, Tezini GC |date=September 2013 |title=Autonomic Cardiovascular Damage during Post-menopause: the Role of Physical Training |journal=Aging and Disease |volume=4 |issue=6 |pages=320–328 |doi=10.14336/AD.2013.0400320 |pmc=3843649 |pmid=24307965}}</ref><ref name="ESHRE20112">{{cite journal |author1=ESHRE Capri Workshop Group |year=2011 |title=Perimenopausal risk factors and future health |journal=Human Reproduction Update |volume=17 |issue=5 |pages=706–717 |doi=10.1093/humupd/dmr020 |pmid=21565809}}</ref>

==== Bone health ====
The annual rates of [[Bone density|bone mineral density]] loss are highest starting one year before the final menstrual period and continuing through the two years after it.<ref>{{cite journal |vauthors=Warming L, Hassager C, Christiansen C |date=2002-02-01 |title=Changes in bone mineral density with age in men and women: a longitudinal study |journal=Osteoporosis International |volume=13 |issue=2 |pages=105–112 |doi=10.1007/s001980200001 |pmid=11905520 |s2cid=618576}}</ref> Thus, post menopausal women are at increased risk of [[osteopenia]], [[osteoporosis]] and [[fracture]]s.