Menopause

What is menopause?

Menopause, in the wider sense the menopausal transition, is according to the GP guideline “the period of a changing menstrual pattern and the first period-free years, in which a woman can experience complaints and symptoms related to changing ovarian function”. Menopause in the strict sense is one moment within it: the last menstrual period.

The four words pulled apart

They get used interchangeably, and the guideline keeps them cleanly apart.

The NHG guideline De overgang defines them like this:

1. The transition. The period of a changing menstrual pattern and the first period-free years.
2. Menopause. “The last menstrual period in a woman’s life; the timing of menopause is determined retrospectively, 1 year after the last period.”
3. Perimenopause. “The period before menopause in which menstruation changes, up to 1 year after the last period.”
4. Postmenopause. “The period from 1 year after the last menstrual period.”

The guideline also has early menopause: a menopause before the age of forty. The descriptions of menopause, peri- and postmenopause follow the World Health Organization’s definitions.

What follows from that is practical. You only know a year after your last period that it was the last, which means someone who says “I’m in menopause” almost always means perimenopause and can only confirm it afterward. Confusing, but that is how it is defined.

The figures for the Netherlands

From the GP guideline, and they are more concrete than most public information.

The average age at which Dutch women reach menopause is 50 to 51. In women who smoke that average age is lower. Whether it differs between ethnic backgrounds is not known.

About 80 percent of women have vasomotor symptoms, the hot flashes and night sweats. These are reported most in the first year after menopause, and the duration “varies and is usually 3 to 7 years, sometimes longer”.

Perimenopause lasts on average about four to six years, though women can also reach menopause after a short spell of irregular cycles. The guideline stresses that the individual course and the burden of the symptoms vary strongly and cannot be predicted well.

In general practice, the incidence of menopausal complaints is 26 per 1,000 women per year in the 45 to 64 age group.

What happens to sex

Two things, and the second is felt more often than it is discussed.

The first is physical. The prevalence of vaginal atrophy complaints rises after menopause and is highest four to five years postmenopause. According to the guideline, about 15 percent of perimenopausal women and 30 percent of postmenopausal women have such complaints.

Thuisarts.nl, based on the same guideline, puts the consequence in plain terms: “It takes longer for your vagina to become wet when you feel like sex.” About three in ten women have trouble with this.

The second is that the guideline gives an instruction that is rarely passed on. For pain during sex it says: “With complaints of dyspareunia, discuss the importance of adequate stimulation and arousal for sufficient lubrication.”

That is no aside. It says that more time and a better build-up are part of the approach, and not just a tube of lubricant. How arousal and desire relate to each other is on sexual response cycle.

Why vaginal atrophy now has a different name

Because the old term was too narrow for what people actually notice.

David Portman and Margery Gass published in 2014 in Maturitas the outcome of a consensus conference of the International Society for the Study of Women’s Sexual Health and The North American Menopause Society. Both boards formally adopted a new term that year: genitourinary syndrome of menopause, abbreviated GSM.

The objection to vulvovaginal atrophy was that the word describes the appearance without saying anything about complaints, and that it leaves the lower urinary tract out. GSM bundles three groups of symptoms: genital (“dryness, burning, and irritation”), sexual (“lack of lubrication, discomfort or pain, and impaired function”), and urinary (“urgency, dysuria and recurrent urinary tract infections”).

The Dutch guideline still uses vaginal atrophy. If you come across the abbreviation GSM in international literature or with a gynecologist, it is about the same area, taken more broadly.

Why menopause plays out so differently

Because there is no fixed course, and that is not sloppiness in the research but the finding itself.

The guideline says it twice, which stands out for a text otherwise sparing with emphasis. On the symptoms: the individual course and burden of vasomotor symptoms “varies and cannot be predicted well”. On the duration: women can also reach menopause after a short spell of irregular cycles, instead of after the average four to six years.

Even the blood value does not help. The FSH level, the hormone that rises as the egg supply drops, “can fluctuate strongly in perimenopause and has no predictive value”. Measuring says little here.

In practice that means two things. A test that tells you where you are does not exist, and friends’ experiences say little about your course. What does count is what you notice yourself over a longer time.

What the guideline says about treatment

Two things that often get mixed up, and the guideline separates them strictly.

For hot flashes and night sweats: “Only with vasomotor complaints is there an indication for hormone therapy.” That is a narrower indication than many people think. The guideline also prescribes that the doctor explains that these complaints fluctuate and that the course per person cannot be predicted well.

For vaginal complaints it is different. There are two equal routes: neutral products such as a moisturizing gel or a cream with hyaluronic acid, and vaginal estrogen. The latter is new in this version of the guideline; neutral products have become “an equal option to local treatment with estrogen”.

The difference is in the pace. Neutral products give “a direct but short-lived reduction of complaints”. With vaginal estrogen “it can take up to 2 months before the effect is optimal”, and the first days it can feel like burning.

What this gives you if you raise it with your GP: this is a conversation with options and not a single prescription. Which route suits you is up to the two of you, and this page prescribes nothing.

What people get wrong about menopause

“Menopause and the transition are the same.” Menopause is one menstrual period, pointed out afterward. The transition is the whole period around it.

“You know when you are in it.” Only a year after your last period is it certain that it was the last. Before that it is perimenopause, and the guideline notes that the FSH level in that phase can fluctuate strongly and has no predictive value.

“It lasts a few months.” Perimenopause lasts on average four to six years, and hot flashes usually three to seven years.

“You fix dryness with lube.” That helps, but for pain during sex the guideline explicitly also names the importance of enough stimulation and arousal. Time is a remedy here.

“Everyone is troubled by it equally.” The guideline states, on the contrary, that the individual course and burden vary strongly and cannot be predicted well.

What you can do with this

• Use the right word when you talk about it with a doctor. Perimenopause and postmenopause say different things, and it saves explaining.
• Count on years, not months. That changes what you expect of yourself.
• Take more time for the build-up if sex starts to hurt. The guideline names that explicitly as part of the approach.
• Tell your GP if complaints affect your life. The incidence in general practice shows you are not the first there with it.
• Ask about both routes for vaginal complaints. The guideline names neutral products and vaginal estrogen as equal, with a difference in how fast they work.
• Do not expect a fixed course. That the course cannot be predicted is in the guideline itself. This page explains a term and is not medical advice.

More reading on menopause

Within this glossary, the sexual response cycle explains why arousal and desire do not come in a fixed order, and libido describes how often stretches with little desire occur, apart from menopause too.

Beyond this site, Thuisarts.nl is the patient version of the same guideline and so the best starting point. Anyone who wants the underpinning finds it in the NHG guideline itself.

Where this fits on this site

Some of the women who write me are around this age, and the question that comes with it rarely is about hormones. Usually it is about whether it can still be the way it was. What a date holds if what you are mainly after is time and calm is on intimate togetherness.

Sources

• NHG-Standaard De overgang (M73). Nederlands Huisartsen Genootschap, version 3.0, June 2022. The guideline Dutch GPs base their policy on. Supplies the definitions of the transition, menopause, perimenopause, postmenopause, and early menopause, the statement that these conform to the World Health Organization’s definitions, the average age of 50 to 51 and that it is lower in smokers, the figure of about 80 percent with vasomotor symptoms lasting usually 3 to 7 years, the average perimenopause duration of 4 to 6 years, the prevalence of vaginal atrophy in about 15 percent of perimenopausal and 30 percent of postmenopausal women, the incidence of 26 per 1,000 women per year aged 45 to 64, and the recommendation “With complaints of dyspareunia, discuss the importance of adequate stimulation and arousal for sufficient lubrication”. The official edition on richtlijnen.nhg.org blocks automated access; this is a fully published copy of the same guideline.
• Ik ben in de overgang. Thuisarts.nl, Nederlands Huisartsen Genootschap. The patient version, based on the guideline above. Supplies the age range of 40 to 60 in which the transition can begin, the average menopause age of 51, the finding that 8 in 10 women have hot flashes, that about 3 in 10 women have trouble with vaginal dryness, and the line “It takes longer for your vagina to become wet when you feel like sex”.
• Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. David J. Portman & Margery L. S. Gass on behalf of the Vulvovaginal Atrophy Terminology Consensus Conference Panel, Maturitas 79(3), 349–354, 2014 (DOI 10.1016/j.maturitas.2014.07.013). Supplies the introduction of the term genitourinary syndrome of menopause, the formal endorsement by the boards of both societies in 2014, the objection that vulvovaginal atrophy describes the appearance without naming complaints and leaves the lower urinary tract out, and the three symptom groups genital (“dryness, burning, and irritation”), sexual (“lack of lubrication, discomfort or pain, and impaired function”), and urinary (“urgency, dysuria and recurrent urinary tract infections”).

Related terms

Menopause is the period; the terms below are about what happens to sex during it.

• Sexual response cycle. Why arousal takes time, and why desire can also come later.
• Libido. How often stretches with little desire occur, and when it is called a problem.
• Attachment style. What happens to closeness when the body changes and the conversation gets harder.
• Vaginismus. Pain on penetration with a different mechanism beneath it, where the pelvic floor contracts involuntarily.