Menopause: symptoms, treatments and thriving through the transition

01Understanding menopause: a natural transition#

Menopause is medically defined as the definitive cessation of menstruation consecutive to the progressive depletion of ovarian follicular capital and the drop in female hormones (oestrogens and progesterone). It is a normal physiological event marking the end of reproductive life and which will affect all women during their lifetime. Diagnosis is retrospective: confirmed menopause is reached after 12 consecutive months without periods in a woman in the usual age range, after ruling out other causes of amenorrhoea.

Although it is a natural phenomenon, menopause is accompanied by profound hormonal modifications that can significantly impact the physical, psychological and sexual well-being of women for several years. These changes are linked to the sudden drop in oestrogens, hormones that play numerous roles in the female body beyond simple reproductive function: thermal regulation, skin quality, bone maintenance, cardiovascular protection, psychological balance, urogenital function, cognitive function. This versatility of oestrogens explains the diversity of symptoms felt and the importance of properly accompanying this transition.

In Morocco, according to High Commission for Planning data (2018 Women's Survey), the average age of menopause is between 47 and 49 years, i.e. 2 to 3 years earlier than in European countries (51 years on average). Several factors explain this gap: genetic component specific to Maghreb population, nutritional history, more frequent multi-parity (multiple pregnancies slightly shorten ovarian activity duration), smoking in some (which advances menopause by 1 to 2 years), environmental factors. This relative earliness concerns about 200,000 Moroccan women each year entering this new life phase.

Several particular situations are distinguished. Early menopause, occurring before 40, affects approximately 1% of women and constitutes a particular medical situation requiring specialised consultation to search for a cause (primary ovarian insufficiency, post-chemotherapy, post-surgery, genetic with Turner syndrome). Its consequences are more marked due to the longer duration spent in hypoestrogenism, often justifying hormone replacement therapy until the natural menopause age. Late menopause (after 55) affects approximately 5% of women and is associated with a moderately increased risk of breast and endometrial cancer through prolonged oestrogen exposure.

02Perimenopause, an often neglected transition phase#

Before definitive menopause, a transitional phase called perimenopause generally extends over 4 to 8 years, sometimes up to 10 years. This period, which typically begins between 40 and 45, is characterised by erratic hormonal fluctuations with increasingly irregular ovulatory cycles. Understanding this phase is important as it can be disturbing without the woman making the link with perimenopause.

Perimenopause manifestations are variable and progressive. Menstrual irregularities are almost systematic: cycles that shorten (going from 28 to 24-25 days), then that lengthen (35-45 days), sometimes with skipped cycles. Bleeding may become more abundant or conversely lighter, longer or shorter. The first discreet hot flushes may appear several years before the definitive cessation of periods, sometimes underestimated by the woman and her doctor. Mood fluctuations (increased irritability in the days preceding periods, cyclic mood drop) are frequent. Sleep disturbances often start at this period. Abdominal weight gain begins.

An important point for women in perimenopause: fertility is reduced but not zero. As long as periods occur, even very irregularly, pregnancy remains possible and contraception means must be maintained until 12 months after the last periods. Several late pregnancies occur each year in women who wrongly thought they were already menopausal. The progestin-only pill, IUD, implant can be maintained as long as contraception is necessary; combined pills are sometimes contraindicated in perimenopause depending on risk profile.

03Classic menopause symptoms#

Menopause symptomatology is extraordinarily variable from one woman to another — some go through it almost without symptoms, others suffer significantly for years. This variability is not fate: current management substantially improves the quality of life of all women who need it.

Vasomotor symptoms

Hot flushes (HF) are the emblematic symptom of menopause, affecting approximately 80% of women at one time or another. They manifest as a sudden sensation of heat, typically rising from the chest to the face and neck, accompanied by skin redness (erythema), profuse sweating, sometimes palpitations and a feeling of anxiety. A typical flush lasts 1 to 5 minutes, often followed by a sensation of cold with shivers. Frequency varies considerably: from 1 to 2 flushes per day in some women to 10-20 per day in severe forms, sometimes disabling to the point of needing to change clothes several times.

Night sweats are a particularly disturbing variant: the woman wakes up at night sweating, having to change pyjamas and sometimes sheets, with major degradation of sleep quality. Consequences on daytime fatigue, mood and professional performance can be considerable. The average duration of hot flushes is 4 to 7 years after menopause onset, but can extend to 10-15 years in some women — a fact often poorly known explaining why some women wrongly think "it will pass on its own".

Flushes are triggered or worsened by several factors: spicy foods, coffee, alcohol, hot environment, stress, certain emotional situations. Identifying one's own triggers sometimes allows reducing frequency by avoidance.

Urogenital symptoms

Vulvovaginal atrophy through oestrogen drop causes vaginal dryness in approximately 60% of menopausal women. This dryness can be perceived from perimenopause and progressively worsen after menopause. It manifests as a sensation of discomfort, tightness, local irritation, and especially by dyspareunia (pain during sexual intercourse) which can significantly compromise sexual life if not managed. This atrophy is progressive and does not improve spontaneously, contrary to hot flushes — it generally requires specific treatment.

Recurrent urinary infections (cystitis) are more frequent through modification of vaginal flora and trophicity of urethral mucosa. Stress urinary incontinence (leakage during efforts like coughing, laughing, jumping) can worsen after menopause through loss of perineal support tone. Perineal rehabilitation by specialised physiotherapist is effective in the majority of cases.

Neurovegetative and psychological symptoms

Sleep disturbances affect approximately 50% of menopausal women, partly linked to night sweats but also to specific sleep modifications by hormonal drop. Difficulty falling asleep, prolonged nocturnal awakenings, less restorative sleep are frequent. Resulting daytime fatigue worsens other symptoms.

Irritability, anxiety, depression may appear or worsen at this period. Several studies have demonstrated a transient increase in the risk of major depression during perimenopause and the first years of menopause, independently of life context. This is a real biological vulnerability that should not be minimised. Cognitive disorders (concentration difficulties, working memory disorders, "brain fog") are frequently described, generally transient and reversible. Chronic fatigue unexplained by sleep is reported by many women.

Morphological modifications

Weight gain is a frequent challenge: about 5 to 6 kg on average in the years following menopause, mainly with abdominal distribution. This gain is explained by basal metabolism drop (about 200 kcal/day less), physiological loss of muscle mass with age, and hormonal modification favouring abdominal storage. Its prevention requires particular attention to diet (reducing caloric intake by about 10%) and maintaining regular physical activity including muscle strengthening.

On the skin level, oestrogen drop accelerates skin ageing: dryness, loss of elasticity, accentuation of wrinkles, slowed wound healing. On the hair level, progressive density loss (not complete baldness, except in particular cases), hair thinning, sometimes a few facial hairs through modification of oestrogen/androgen ratio.

04Long-term risks: osteoporosis, cardiovascular, cancers#

Beyond immediate symptoms, menopause exposes to several long-term medical risks that justify structured follow-up.

Osteoporosis

Bone loss considerably accelerates in the first years post-menopause, due to loss of oestrogens' protective effect on bone metabolism. Bone density can decrease by 2 to 3% per year in the first 5 years, then 1% per year after. About 30% of menopausal women develop authentic osteoporosis, exposing to fractures (vertebral, femoral neck, wrist) which can be very disabling or even fatal in elderly subjects. Femoral neck fracture has a one-year mortality of 20-30% in elderly women, mainly through immobilisation complications.

Prevention rests on several pillars: adequate intake of calcium (1,200 mg/day ideally, preferably through diet — dairy products, sardines with bones, almonds, green vegetables), adequate intake of vitamin D (800 to 1,000 IU/day, often by supplementation in Morocco where deficiency is frequent despite sunshine), regular physical activity including weight-bearing exercises (walking, moderate running, dancing) which stimulate bone, muscle strengthening which prevents falls. Screening by bone densitometry is recommended from age 60-65, or earlier in case of risk factors (early menopause, family history of fracture, long-term corticosteroid therapy, thinness, smoking). In case of confirmed osteoporosis, several treatments are effective: oral or injectable bisphosphonates, denosumab, teriparatide for severe forms.

Cardiovascular risk

Before menopause, women are relatively protected from cardiovascular diseases by oestrogens. This protection progressively disappears after menopause, and female cardiovascular risk joins that of men in the 10 to 20 years that follow. Menopausal women must therefore benefit from the same level of cardiovascular surveillance as men of the same age: annual blood pressure check, regular cholesterol dosing, diabetes screening, global risk evaluation. Modifiable risk factors (smoking, sedentary lifestyle, overweight, diet) must be actively managed.

Cancer risk

Several cancers deserve increased surveillance at menopause. Breast cancer sees its incidence increase with age, with a peak between 50 and 70. Screening by mammography every 2 years is recommended from age 45 in Morocco (organised screening according to the National Cancer Plan), continued until 74. Monthly self-examination of breasts remains a useful complement. Any unusual sign (lump, mammary discharge, deformation, skin lesion) requires rapid consultation.

Endometrial cancer (uterine body) classically manifests as bleeding occurring after menopause or abnormal bleeding during perimenopause. Any post-menopausal metrorrhagia (bleeding after definitive cessation of periods) is a diagnostic emergency that should lead to a gynaecological consultation without delay for pelvic ultrasound and hysteroscopy if necessary. The earlier the diagnosis, the better the prognosis.

Cervical cancer continues to require screening by Pap smear every 3 years until age 65, or longer depending on history. Colorectal cancer sees its incidence increase with age and screening by FIT test from age 50 is recommended for women as for men.

05Hormone Therapy of Menopause (HTM)#

Hormone therapy of menopause (HTM), sometimes still called hormone replacement therapy (HRT), consists of administering oestrogens (with or without progesterone depending on whether the woman still has her uterus) to compensate for hormonal drop and relieve disabling symptoms. This treatment, long controversial after the 2002 WHI study which had highlighted worrying risks, has been rehabilitated by subsequent analyses and new studies that have allowed better characterisation of its benefit/risk balance.

Indications

HTM is now clearly indicated in several situations. Disabling hot flushes in a woman before age 60 or within the first 10 years of menopause remain the main indication. Osteoporosis prevention in high-risk women who also have climacteric symptoms. Severe genitourinary syndrome with dyspareunia for which local treatment with vaginal oestrogens is very effective and presents an excellent safety profile (without cardiovascular or mammary excess risk). Early menopause (before 40) where HTM is recommended until the usual age of natural menopause (about 50) to compensate for the long period of hypoestrogenism.

Benefits

HTM is extremely effective on climacteric symptoms: over 90% efficacy on hot flushes, considerable improvement of sleep, mood, vaginal dryness, diffuse joint pain previously attributed to "ageing". On the preventive level, it decreases the risk of osteoporotic fractures by 30-40% and probably decreases cardiovascular risk when initiated in young women in early menopause ("window of opportunity" theory).

Risks

WHI studies and subsequent meta-analyses identified several risks to know for an informed decision. Breast cancer: a slight excess risk (multiplied by approximately 1.2 to 1.3) after 5 years of combined oestrogen-progestin treatment, more marked for certain combinations. This excess risk is reduced or absent with oestrogen-only treatment (reserved for hysterectomised women). Deep vein thrombosis: risk multiplied by 2 to 3 with oestrogens taken orally, but not increased with transdermal route (patches or gels), which should be preferred in the majority of women for this reason. Stroke: slight excess risk in women over 60 at initiation, low before 60.

Balance and practical modalities

HTM is recommended at the minimum effective dose, by transdermal route preferably (Climara, Œstrodose, Œstrogel patches), in association with micronised natural progesterone (Utrogestan) in women still having their uterus, for the duration necessary for symptom control with annual reassessment. Absolute contraindications are active or recent breast cancer, history of deep vein thrombosis or pulmonary embolism, stroke, severe hepatopathy, unexplained vaginal bleeding.

In Morocco, HTM is widely available, prescribed by gynaecologists. Medications are reimbursed at 50-80% depending on funds and complementary insurance. Annual gynaecological consultation allows reassessment of indication and tolerance.

06Alternatives to hormone therapy#

For women who cannot or do not want to take HTM, several alternatives exist with varying levels of efficacy.

Non-medication approaches

Cognitive-behavioural therapy (CBT) specific to menopause has demonstrated significant efficacy on hot flushes (30-40% reduction) and on associated psychological disorders. Hypnosis, acupuncture and yoga have encouraging data in some studies. Stress management techniques (meditation, cardiac coherence, sophrology) can attenuate stress-triggered flushes.

On the environmental level, several simple measures help: maintain a cool bedroom (17-19°C), wear natural fibre clothing (cotton, silk) in several easily removable layers, avoid identified triggers (spicy foods, coffee, alcohol, hot environments), use a portable fan for daytime flushes.

Phytotherapy

Several plants have modest but real efficacy in menopause. Black cohosh (Cimicifuga racemosa) has been the subject of several studies with modest reduction of hot flushes (20-30%). Soy isoflavones (soy-based supplements) have a weak oestrogenic action useful in some women (20-30% reduction in flushes), but their use remains debated in women at risk of breast cancer. Evening primrose and borage oil (rich in omega-6) are sometimes proposed with a modest effect but good tolerance. Beware of drug interactions: phytoestrogens can interact with certain treatments (anticoagulants, tamoxifen, antidepressants) and their use should be discussed with a professional.

Non-hormonal medications

For women unable to take HTM with disabling hot flushes, several drugs have validated efficacy. Low-dose paroxetine (10 mg/day, off-label in this indication in France but validated in USA), an SSRI antidepressant, reduces flushes by 60-70%. Other SSRIs (sertraline, venlafaxine) have similar but lower efficacy. Gabapentin (300 to 900 mg/day, off-label) is useful particularly for night sweats. Clonidine, an antihypertensive, has a modest effect on flushes. Beta-alanine (Abufène), specifically marketed for menopause, has modest efficacy but good tolerance.

More recent drugs (NK3 receptor antagonists like fezolinetant) are starting to arrive on the market with efficacy comparable to HTM on flushes without hormonal effects — an ongoing therapeutic revolution for women unable to take hormones.

07Lifestyle: an essential pillar#

Beyond medication treatments, lifestyle plays a considerable role in living well through menopause and preventing long-term complications.

Diet

The Mediterranean diet is particularly suited to this period: rich in vegetables, fruits, whole grains, legumes, fish, olive oil, it brings essential nutrients and has a beneficial anti-inflammatory effect. Calcium intake should be reinforced (1,200 mg/day ideally) through dairy products, canned sardines, almonds, green vegetables. Vitamin D often insufficient in Morocco despite sunshine (covering clothing, indoor life) benefits from supplementation after dosing. Dietary phytoestrogens (soy, flaxseeds, chickpeas, lentils) may bring modest benefit on symptoms. Reduction of coffee, alcohol and spicy dishes identified as personal triggers is useful.

Physical activity

Regular physical activity is probably the most powerful non-medication measure. The 150 minutes minimum of moderate aerobic activity per week recommended by WHO must be supplemented by 2 weekly muscle strengthening sessions essential to prevent osteoporosis and sarcopenia. Daily walking for 30 to 45 minutes, swimming, cycling, dancing are excellent options. Yoga and Pilates additionally bring benefits on flexibility, balance and stress management. For beginner women, progressively increase activity over several months to avoid injuries and abandonment.

Sleep

Optimising sleep is crucial given its frequent disturbance. Maintain a cool bedroom (17-19°C), use light and breathable bed linen (cotton, silk), avoid screens 1 hour before bed, limit nap to 20 minutes maximum before 3 PM, maintain regular schedules including weekends. If night sweats disturb sleep despite these measures, HTM is particularly effective.

Psychological and social well-being

Menopause is also a psychological passage that deserves attention. Psychotherapy is useful in case of marked depression or anxiety. Specific menopause talking groups (in-person or online) allow breaking isolation and sharing experiences. Communication with partner about experienced changes (sexuality, mood, energy) prevents marital tensions linked to misunderstanding. Maintaining and developing creative, social, voluntary activities combats isolation and brings meaning to this new life phase. Menopause may be lived as liberation (end of contraception, end of periods, energy redeployed to other projects) rather than as an end — it is largely a question of representation and accompaniment.