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 postmenopuse.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.