Evidence-Based, Personalized, and Holistic Approach During Menopause and Perimenopause

Summary

With the significant increase in women’s average life expectancy, menopause is no longer merely a biological threshold marking the end of the menstrual cycle; it is considered a comprehensive and long-term health phase that affects many body systems—from cardiovascular health to bone density, from cognitive functions to sexual life.

Nearly one-third of a modern woman’s life is spent in the postmenopausal period. Therefore, menopause should be addressed not as a temporary hormone deficiency but as a physiological yet multidimensional transformation requiring conscious monitoring, personalized approaches, and holistic support. The menopausal process generally begins during the perimenopausal transition characterized by fluctuations in hormone levels and, over time, creates marked effects on the nervous system, immune responses, gastrointestinal structure, musculoskeletal system, skin and mucosa, and urogenital functions.

This article examines the definition of menopause, its clinical stages, the scope of hormone therapy, pharmacological and non-hormonal interventions, supportive applications, and personalized lifestyle strategies from a holistic health perspective.

1. The Meaning of Menopause as Life Expectancy Increases

Life expectancy for women has increased markedly over the last century. According to World Health Organization (WHO) data, global average life expectancy rose from 66.8 years in 2000 to 73.1 years in 2019. Healthy Life Expectancy (HALE) increased from 58.1 to 63.5 years in the same period. In Turkey, based on 2021–2023 data, average life expectancy was 80 years for women and 74.7 years for men. Women live on average 5.3 years longer.

As a result of this demographic shift, more than one-third of women’s lives are spent in the postmenopausal period. However, in society, menopause is often defined merely as the “end of menstruation,” and a lack of awareness is observed regarding the accompanying changes.

Yet menopause is not only a period in which reproductive capacity ends, but also a process in which genitourinary syndrome, heart diseases, bone loss (osteoporosis), metabolic issues, and cognitive changes come to the forefront. Therefore, it should be understood not as something to fear, but as a period to be managed consciously.

2. Three Main Stages of Menopause in the Female Life Cycle

Women’s reproductive health is generally examined in three main stages: pre-menopause, perimenopause, and menopause.

Confusion Between the Terms Premenopause and Perimenopause in Turkish

In Turkish medical and popular health sources, the terms “premenopause” and “perimenopause” are frequently confused.

According to international standards (e.g., the International Menopause Society (IMS) and STRAW+10 Workshop criteria), premenopause refers to the reproductive years (from menarche, the first period, to the asymptomatic period before perimenopause), while perimenopause is defined as the transition to menopause (the stage in which menstrual irregularities and symptoms begin).

However, in many Turkish sources, in everyday language, and on some health websites, the term premenopause is mistakenly used for the early phase of perimenopause. This confusion stems from direct translation of English terms and non-standard usage in popular media. Using the correct terminology is important as it facilitates clinical follow-up and patient education.

Premenopause (Reproductive Period)

Premenopause encompasses women’s fertile years and includes the asymptomatic period from menarche (first period) to perimenopause. In this stage, menstrual cycles are generally regular, hormonal fluctuations are minimal, and menopause-specific symptoms (e.g., hot flashes, mood changes) are not observed. According to STRAW+10, this is classified as the “reproductive stage” (Stage -5, -4, -3).

Perimenopause (Early Stage)

Perimenopause is the transition period before menopause and generally begins in the early 40s, about 4–8 years prior to menopause. In this stage, hormone levels (especially estrogen) begin to fluctuate, and menstrual patterns change. In some women, cycle intervals shorten or lengthen, and sudden bleeding may occur. Mild hot flashes, headaches, mood variability, and mild sleep problems may be seen. This is the early perimenopause stage in which the body prepares for menopause (STRAW+10 Stage -2).

Perimenopause (Late Stage)

In the more advanced stage of perimenopause—the period that continues a few years before menopause and sometimes beyond—symptoms are felt more intensely. Estrogen levels decrease markedly and symptoms become more frequent. Hot flashes (sudden upper-body heat), night sweats, fatigue, weight gain, decreased sexual desire, impaired sleep quality, brain fog (concentration difficulty), and mood fluctuations are common. Perimenopause may last on average 3–7 years, and the possibility of pregnancy still exists during this period.

Menopause and Postmenopause

Menopause is the natural physiological period in which the ovaries permanently stop producing estrogen and progesterone, ending the menstrual cycle. For diagnosis, there must be no menstruation for 12 months after the last period. The most common symptoms include hot flashes, night sweats, sleep problems, vaginal dryness, mood changes, and bone weakening. Due to the significant decline in estrogen, the risks of cardiovascular disease and osteoporosis also increase. In Turkey, the age of menopause is generally 47–49.

The period after menopause is called postmenopause and encompasses all the years following menopause. Some symptoms may ease over time; however, long-term health risks such as cardiovascular diseases, cognitive decline, and bone loss continue and require careful monitoring. Symptoms such as vaginal dryness and urogenital atrophy may become permanent if not treated.

Early and Premature Menopause and Primary Ovarian Insufficiency (POI)

Menopause is a natural life stage in which menstrual cycles permanently cease. However, in some women this process may begin earlier than expected.

Early menopause is typically defined as the permanent cessation of periods before age 45, but after 40.

Premature menopause, on the other hand, occurs in women under age 40 and is associated with more serious causes. Genetic factors, autoimmune diseases, chemotherapy, radiotherapy, or surgery and other environmental and medical causes can trigger premature menopause.

One of the most important causes of these two conditions is Primary Ovarian Insufficiency (POI).

Primary Ovarian Insufficiency (POI) is a condition that occurs due to a decrease or complete loss of ovarian function before the age of 40. Insufficient egg reserve in the ovaries, rapid loss of follicles, or inadequate response to hormones can lead to this picture. It is seen in approximately 1% of women.

In POI, periods may either never have started (primary amenorrhea) or may have stopped after previously being regular (secondary amenorrhea). Due to estrogen deficiency, symptoms such as hot flashes, sleep disorders, mood changes, vaginal dryness, and decreased sexual desire may occur. These complaints may sometimes go unnoticed and diagnosis may be delayed. Diagnosis is made by detecting high FSH and low estrogen levels in two measurements taken one month apart.

The causes of POI are varied. Genetic problems (especially X-chromosome abnormalities), autoimmune diseases, chemotherapy or ovarian surgeries, some metabolic diseases, or idiopathic (unknown) causes may lead to this condition. In some women, no cause can be found.

Ovarian function in POI may not stop completely; it may function intermittently and, albeit rarely, spontaneous pregnancy may occur. Therefore, the term “primary ovarian insufficiency” is preferred over “premature menopause.” In treatment, hormone support (estrogen and progesterone) is important to protect bone health, the cardiovascular system, and sexual health. Psychological support, fertility counseling, and monitoring of any accompanying diseases are also important parts of the treatment plan.

3. Systemic and Clinical Effects of Menopause

Menopause is not a disease but a natural life stage. However, in addition to estrogen, decreases in progesterone, androgens, and even dehydroepiandrosterone sulfate (DHEA-SO4) secreted by the adrenal glands lead to significant consequences affecting the entire body. Symptoms are individualized; while some women experience mild symptoms, for others, quality of life can be seriously affected.

The number of complaints menopause causes across body systems varies depending on how symptoms are classified, individual physiological characteristics, and cultural perceptions. However, according to current scientific sources, menopause may cause approximately 30–40 different signs and symptoms. The frequency, severity, and perception of these symptoms may vary depending on age, genetic predisposition, lifestyle, environmental factors, and how menopause is interpreted in a given society.

More than 75% of women experience at least one pronounced complaint during menopause. Among the most common symptoms are hot flashes and night sweats; these occur in 60–80% of women and typically last about 7 years. Sleep disorders become particularly prominent during perimenopause and affect 40–60% of women. Mood changes, anxiety, and depression have been reported at around 30–50%. Urogenital symptoms such as vaginal dryness, decreased sexual desire, and pain during intercourse occur in about half of postmenopausal women. Some women experience these symptoms mildly for only a few years, whereas for others they can turn into a chronic struggle lasting more than 10 years and significantly affecting quality of life.

Central Nervous System and Neuropsychological Effects

In the central nervous system, “brain fog” (difficulty concentrating), reduced analytical thinking, a distinct slowing of executive functions compared to earlier periods, forgetfulness, migraine attacks, sleep disorders, as well as depression and anxiety are frequently observed.

Vasomotor Symptoms

Vasomotor symptoms are signs that affect the body’s thermoregulation due to estrogen fluctuations in menopause and perimenopause. These include hot flashes, “hot flush” (sudden heat, flushing, sweating), night sweats (heavy sweating during sleep), and cold sweats (shivering/chills after a hot flash). They are seen in 75–85% of women and typically last 2–10 years (average 7–8 years). In Turkey, hot flashes (60–70%) and night sweats (50–60%) are most commonly reported.

All these neuropsychological effects can have repercussions on work life, social relationships, and self-care; menopause is a transition period that requires adaptation not only biologically but also psychosocially. In the long term, an increase in the risk of Alzheimer’s disease and dementia has been reported; indeed, two out of every three patients with Alzheimer’s are women.

Cardiometabolic System Effects

The menopausal period is a transition characterized by the natural decline of estrogen levels in women. These hormonal changes directly affect the cardiovascular and metabolic systems, creating various symptoms and long-term health risks. In the postmenopausal period, in addition to acute symptoms such as heart rhythm disturbances, metabolic slowdown and deterioration in lipid profile increase the risks of atherosclerosis and diabetes.

Cardiovascular Effects: Sudden Palpitations (Palpitation) Attacks

The effects on the cardiometabolic system in menopause frequently present as sudden palpitation attacks. This is due to the diminished protective effect of estrogen on the heart’s sinoatrial (SA) node, which regulates heart rhythm. Estrogen stabilizes the SA node to balance heartbeats; when its level drops, node function may be impaired and irregular rhythms may occur. Additionally, a disturbance in the balance of the autonomic nervous system (sympathetic-parasympathetic) makes sympathetic activity—which increases heart rate—dominant. This is related to hot flashes and sleep problems during the menopausal transition and leads to palpitations by affecting heart rate variability (HRV).

Additional Factors

Vasomotor symptoms such as hot flashes can trigger the autonomic nervous system, accelerating the heart rate. Research shows that transdermal estrogen therapy can improve these symptoms and autonomic modulation.

4. Metabolic Changes: Basal Metabolism, Weight Gain, and Lipid Profile

Menopause causes significant disruptions in metabolic balance. Basal metabolic rate (BMR) slows down because estrogen supports energy expenditure and muscle mass; with its decline, physical inactivity and increased energy intake trigger weight gain. In particular, abdominal (waist circumference) fat becomes more pronounced, increasing visceral fat around organs and promoting insulin resistance and metabolic syndrome.

Changes observed in the blood lipid profile are a critical aspect of the menopausal transition. Estrogen regulates lipid metabolism and keeps atherogenic lipids low; when levels drop, the following changes occur:

• Increases in total cholesterol (TC) and LDL cholesterol (LDL-C)
• Increases in triglycerides (TG)
• Decreases in HDL cholesterol (HDL-C)
• Increases in small dense LDL particles and total particle number, which raises the risk of atherosclerosis

There are also numerous effects on the gastrointestinal system. With declining estrogen levels, marked changes occur in the gut microbiota. The microbial structure called the estrobolome, which includes microbial groups involved in estrogen metabolism, weakens; while microbial diversity decreases, the proportion of proinflammatory bacteria may increase. This can trigger systemic inflammation, increase insulin resistance, and even negatively affect bone health, raising the risk of osteoporosis.

At the same time, gastrointestinal motility may slow with menopause; this leads to increased constipation, gas, and bloating. Due to hormonal imbalances, IBS-like symptoms may develop. The reduction in estrogen levels also affects bile composition, increasing the risk of gallstone formation. In addition, delayed gastric emptying and reduced lower esophageal sphincter pressure make reflux complaints more frequent.

Skin and mucosa are affected. Noticeable changes include skin thinning, loss of elasticity, and increased wrinkling, as well as more pronounced hair loss. Dryness can occur in the cornea and lens of the eye, and even eczema in the external auditory canal. A highly specific intraoral finding during menopause is burning mouth syndrome (BMS). This condition is characterized by unexplained burning, stinging, and tingling sensations, particularly on the tongue, palate, and lips. It is often accompanied by dry mouth and taste changes. It arises due to neurological and mucosal changes associated with estrogen deficiency and is considered one of the characteristic oral signs of menopause.

The decrease in estrogen levels during menopause can affect inner ear fluid balance, vascular structures, and nerve conduction, leading to the development of tinnitus. At the same time, dryness and loss of elasticity in mucosal tissues can cause Eustachian tube dysfunction, creating symptoms of ear fullness, pressure sensitivity, and changes in hearing. This may also be accompanied by balance problems in some women and should be evaluated within the context of the neurosensory effects of menopause.

In the urogenital system, frequent urinary tract infections, burning on urination, urgency, and vaginal itching and burning may occur.

With menopause, declining estrogen levels lead to dryness, thinning (vaginal atrophy), and loss of elasticity in vaginal tissues; this can make sexual intercourse painful (dyspareunia). Vaginal fluid production is markedly reduced compared to the premenopausal period. In parallel, important changes occur in the vaginal microbiome: Lactobacillus species decrease, vaginal pH rises, and the protective flora deteriorates. This predisposes to vaginal infections, irritation, and malodorous discharge. These changes in the vaginal ecosystem can affect both local and systemic health.

Along with menopause, not only vaginal changes but also a general decline in hormone levels can lead to reduced libido, difficulty with arousal, and orgasm problems. This is associated with reductions in both estrogen and testosterone and DHEA levels. Decreased sexual desire should be considered not only physically, but also in terms of psychological and relational dimensions.

Musculoskeletal System

During menopause, the musculoskeletal system undergoes significant changes due to declining estrogen levels, leading to various complaints. Particularly common are joint pains (arthralgia), sarcopenia (reduced muscle mass and strength), and frozen shoulder (adhesive capsulitis). These complaints generally reflect the overall effects of menopause on the musculoskeletal system and can be grouped under a definition called Menopausal Musculoskeletal Syndrome (MMS). MMS encompasses inflammation, joint instability, and tissue degeneration triggered by the reduced protective role of estrogen; it may affect approximately 80% of women in menopause and diminish quality of life.

The primary reason for this syndrome is the loss of estrogen’s anti-inflammatory and anabolic effects that protect muscles, bones, tendons, and joints. For example, arthralgia typically presents as swelling, stiffness, and pain in the joints; this stems from estrogen deficiency weakening cartilage tissue and increasing inflammation. Sarcopenia progresses with shrinkage of muscle fibers and metabolic changes, leading to weakness, balance loss, and increased fall risk; in postmenopausal women, muscle mass may decrease by 1–2% per year. Frozen shoulder particularly affects women during the menopausal transition; the shoulder capsule thickens, movement becomes restricted, and pain increases—this may last for months or years.

In the postmenopausal period, with the reduction of estrogen’s regulatory effects on the immune system, some autoimmune diseases may become more pronounced or show flares. In particular, increases may be observed in the symptoms of diseases such as rheumatoid arthritis, systemic lupus erythematosus (SLE), Hashimoto’s thyroiditis, Sjögren’s syndrome, and multiple sclerosis with menopause. During this period, intensified inflammatory responses and accelerated tissue damage can negatively affect the clinical course of these diseases.

5. Bone Health During Menopause

In the postmenopausal period, bone loss progresses silently and insidiously. A sudden decrease in estrogen reduces bone formation while increasing bone resorption. With this imbalance, women may lose 20–30% of their total bone mass within the first 5–10 years after menopause. This dramatic loss sets a strong stage for the development of osteopenia and osteoporosis.

Osteopenia is a condition in which bone mineral density is below age-adjusted normal but not yet at osteoporosis level.

Osteoporosis is a bone disease in which bone density is significantly decreased and bones become porous and fragile. According to the World Health Organization (WHO), osteoporosis is defined as a T-score below –2.5 on DEXA measurement.

However, the problem is not only the decrease in bone density but also its clinical consequences: hip fractures that occur during the postmenopausal period carry a serious risk of death and disability. Research shows that approximately 30% of postmenopausal women who suffer a hip fracture die within the first year, and 50% never regain full functional capacity. This deeply affects not only physical health but also independent living capacity, quality of life, and psychological status.

Therefore, early and accurate evaluation of bone health is of vital importance. Today, the gold standard in measuring bone mineral density is the DEXA (Dual-Energy X-ray Absorptiometry) scan. The scan particularly evaluates the lumbar spine (L1–L4), hip (total femur), and sometimes the forearm. Classical recommendations include performing DEXA in all women aged 65 and over. However, at LaraHealth, we approach this more proactively and in a personalized manner:

• We recommend a baseline DEXA measurement during the perimenopausal period (the transition just before menopause).
• For women with risk factors—for example, early menopause, smoking, low body mass index, a first-degree relative with a history of osteoporosis (mother, aunt)—we advocate for much earlier screening.
• Follow-up frequency should be individualized:
  • Normal DEXA result: check every 3–5 years
  • If osteopenia is present: check every 1–2 years
  • If osteoporosis is present or fracture risk is high: evaluate annually

In addition, fracture risk assessment should be performed using algorithms such as FRAX; if necessary, response to treatment should be monitored with bone turnover markers (e.g., serum PINP, serum β-CTX).

It should be remembered that when osteoporosis presents with a fracture, it often leads to irreversible consequences. Therefore, taking preventive measures before a fracture occurs—i.e., implementing protective bone health strategies and screening bone health at the right time with biochemical parameters and DEXA—are fundamental steps to maintaining quality of life.