Menopause

Perimenopause (the transition before menopause)

Perimenopause is the period from when your cycle starts to change until your final period. It lasts 4 years on average; for some women a few months, for others 8–10 years. The STRAW + 10 classification divides it into the early transition (stage −2) and the late transition (stage −1).

In the early transition, cycle length varies by 7 days or more. In the late transition, gaps of 60 days or longer occur. During this time FSH rises and estrogen levels fluctuate. Ovulation may not occur in every cycle.

Common symptoms:

• Longer or shorter cycles, changes in the amount of bleeding
• Hot flashes and night sweats (vasomotor symptoms)
• Difficulty sleeping, waking at night
• Mood changes, irritability, anxiety
• Breast tenderness
• Changes in how often headaches or migraines occur
• Difficulty concentrating

Vasomotor symptoms can start in perimenopause and may continue for an average of 4–7 years after the final period. In the SWAN study, women with frequent vasomotor symptoms had a median total duration of 7.4 years.

Pregnancy is still possible in perimenopause. Contraception should be discussed. Irregular periods can be confused with thyroid disease, polycystic ovaries or endometrial pathology. In healthy women over 45 with vasomotor symptoms and irregular periods, perimenopause can be diagnosed without laboratory tests. However, abnormal bleeding requires an ultrasound and, if needed, endometrial evaluation.

Diagnosing menopause

Menopause is diagnosed when there has been no period for 12 months after the final period. During this time, pregnancy, thyroid disease or medication effects should be ruled out. If menopause is suspected under age 45, measuring FSH can help; at 45 and over, a clinical diagnosis is usually sufficient.

Surgical menopause results from removal of both ovaries. Symptoms can be sudden and severe. Chemotherapy or pelvic radiation can also cause early menopause.

Postmenopause (the period after menopause)

Postmenopause covers all the years after the final period. STRAW + 10 divides it into early postmenopause (+1a, +1b, +1c) and late postmenopause (+2). In early postmenopause, FSH stabilizes at a high level and estradiol at a low level. Late postmenopause continues for many years.

During this period, the protective effect of estrogen decreases. Bone loss speeds up; the fastest loss occurs in the first 4–8 years after menopause. Cardiovascular risk increases; blood pressure, lipid profile and glucose metabolism may change. Vaginal tissue becomes thinner, and dryness and pain during sex (genitourinary syndrome of menopause) may develop. Urinary tract infections may become more frequent.

Points to watch in the long term:

• Bone density measurement (DXA), especially with early menopause, low body mass index, smoking, a family history of fractures or corticosteroid use
• Monitoring of blood pressure, lipids and glucose
• Breast screening (according to the national program and risk assessment)
• Postmenopausal bleeding: any bleeding requires urgent evaluation (endometrial hyperplasia or cancer must be ruled out)
• Pelvic pain, weight loss or urinary complaints in addition to vaginal bleeding

Hot flashes may continue after menopause. Sleep problems, mood changes and joint and muscle pain may also persist. Symptoms decrease over time; in some women they last for years.

Symptoms and when to see a doctor

An evaluation is recommended if hot flashes, night sweats, sleep problems or mood changes affect your daily life. The following situations should be checked without delay:

• Any vaginal bleeding after menopause
• In perimenopause, bleeding that soaks a pad in 1–2 hours, lasts longer than 7 days or contains large clots
• Gaps between periods of more than 60 days together with abnormal bleeding
• Periods stopping before age 40
• Severe vaginal dryness, pain during sex or recurrent urinary tract infections
• Noticeable loss of height, a fracture or severe bone pain
• Cardiovascular warning signs such as chest pain, shortness of breath or jaw and back pain

Thyroid disease, anemia, depression and medication side effects can mimic menopause symptoms. The differential diagnosis is made by examination and basic tests.

Hormone therapy and other options

Menopausal hormone therapy (MHT) is one of the most effective options for vasomotor and genitourinary symptoms. Systemic estrogen (combined with a progestogen if you have a uterus) or low-dose vaginal estrogen is used. ACOG and international guidelines recommend that, in the absence of contraindications, treatment be started before age 60 or within 10 years of the onset of natural menopause. Timing, dose and duration are individual; a risk–benefit assessment is made every year.

In Turkey, the products used and their indications are subject to the regulations of the Turkish Medicines and Medical Devices Agency (TİTCK). Changes to FDA boxed warnings in the US do not automatically change approvals in Turkey. Treatment decisions are based on examination, medical history and current product information.

Contraindications include active breast cancer, unexplained vaginal bleeding, active thromboembolism, severe liver disease and certain cardiovascular conditions. The transdermal route may be preferred over the oral route in women with a high risk of thrombosis.

For women who do not want or cannot use hormone therapy, non-hormonal options (certain antidepressants, gabapentinoids, lifestyle changes) can be discussed. Moisturizers and low-dose local estrogen for vaginal dryness are evaluated separately. Calcium, vitamin D and weight-bearing exercise are fundamental for bone health; if osteoporosis is present, drug treatment is planned.

Our approach at SoftCare

At SoftCare Clinic, menopause and perimenopause are evaluated with a gynecological examination, ultrasound and any necessary tests. We ask about your menstrual history, how often you have hot flashes, sleep, mood, sexual complaints and fracture risk. If there is postmenopausal bleeding, endometrial evaluation is the priority.

If hormone therapy is discussed, contraindications, whether you have a uterus, and your risk of thrombosis and breast cancer are reviewed. If treatment is started, the dose, route and duration are tailored to you, and a follow-up plan is made. When needed, you are referred for bone density, lipid and blood pressure monitoring. Mammography is not performed at the clinic; we refer you to a partner imaging center.

Appointments: +90 212 241 30 10 · softcareclinic.com

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Medically reviewed by Op. Dr. Şükrü Sanus, Obstetrician & Gynecologist · Last medical review: 2 October 2026