In the years leading up to menopause, there are a lot of hormonal shifts occurring. Everyone’s experience is different, but it can help to know what to expect from this transition beforehand—and we’re here to help with that.
By OBGYN and reproductive health specialist Dr. Mare Mbaye
In the years leading up to menopause, there are a lot of hormonal shifts occurring. These hormonal shifts can often lead to significant symptoms like mood swings, sleep problems, difficulty concentrating, and, the most dreaded of all, hot flashes. These menopausal symptoms are more common than people think and drive about 90% of people to seek out their healthcare provider for recommendations on how to cope.
Because everyone’s experience is so different, it can be stressful trying to understand what on earth is going on with your body and whether or not it’s normal. It can help to know what to expect from this transition beforehand and we’re here to help with that.
So…what is ovulation?
During the menstrual years, people who menstruate will typically have a regular monthly period because they are ovulating monthly. But what exactly is ovulation? Let’s go through it.
At the beginning of each menstrual cycle, when someone is on their period, their pituitary gland (in the brain) will release follicle stimulating hormone (FSH) which will trigger certain fluid-filled spheres in both ovaries called “follicles” to grow rapidly. These follicles contain eggs, which grow until a second signal allows only one follicle to fully mature and release its egg—this egg being released is ovulation. Meanwhile, the other follicles stop growing and degenerate. So, it’s basically survival of the fittest in there every month—yikes!
After ovulation, pregnancy happens when a sperm fertilizes the released egg and implants into the lining of the uterus (the womb). If this doesn’t happen, the lining of the uterus sheds, and the person has their next menstrual period. This process continues monthly for most people until they reach their late 30s to early 40s, when cycles may start to become shorter or change in quality (e.g., number of days of bleeding, heaviness of flow, etc). As more years pass and more eggs are used, ovulation will become less and less consistent leading to missed periods until they stop completely. Once you have not had a period for 12 months straight, you are considered menopausal.
How can I track my ovulation?
So, how do you know if you are or aren’t ovulating? The first clue to this is whether or not you have a monthly period. If you do, it means you are ovulating regularly, but if your periods come every few months (or never), then you are not ovulating each month.
There are a few simple ways you can figure out if you are ovulating.
Ovulation Test Kits: There are many ovulation prediction kits (OPK) on the market. Most work by measuring LH (luteinizing hormone) levels in your urine. A quick rise in LH (the “LH surge”) is what prompts your ovaries to ovulate every month. This usually occurs in the 12-36 hours right before ovulation. This means that once you see a positive ovulation test, the LH surge has taken place, and you are about to ovulate.
Note: These tests are not always accurate for everyone. Conditions like polycystic ovary syndrome (PCOS) can affect LH test results and give false results.
Trackers and Calendars: There are several trackers and calendars available both online and as apps on your phone. We've even put together an Ovulation Tracker for you here and included a Cycle Tracker in our Ovulation Test Kit!
Cervical Mucus: Keep an eye out for “fertile-quality” cervical mucus. This is vaginal discharge that is stretchy and translucent. It is often compared to egg whites. To test your cervical mucus, gently insert a (freshly washed!!) finger into your vagina and try to gauge the consistency and quantity of the discharge you collect. If you see lots of the egg white-like mucus, it’s a good sign that you are about to ovulate. This is not as accurate of a method since it depends on how familiar someone is with their cervical mucus. Many people use this method along with an OPK or tracker.
Note: Your body is always creating cervical mucus to protect against infections and lubricate during sex. You produce the least amount of mucus right after your period. In general, normal vaginal discharge is yellow or cloudy white and has a sticky texture. If you’re concerned about a possible infection, see your healthcare provider.
Basal Body Temperature: This is another one that is not an exact science. Your basal body temperature (BBT) usually rises a little after you ovulate, so you can use daily temperature measurements to track your cycle. A person's BBT generally stays in the range of 97-98 degrees Fahrenheit. After you ovulate, hormones like progesterone lead to a rise in the BBT of about 0.5-1 degree Fahrenheit. As a result, this can be a useful method, but only after the fact since the temperature rise is after ovulation. If you are planning to use this method when trying to conceive, you will need to record your BBT for several cycles to help predict your ovulation accurately.
When does ovulation stop?
Everyone with ovaries is born with all the eggs they will have in a lifetime—around two million! But most of these eggs will never be viable, so although this is an awe-inspiring number, it’s not the same as having two million chances to get pregnant. By the time most people reach puberty at the average age of 11, their egg counts are less than 400,000 eggs. Given that the average age of menopause is around 51 years old, most people are ovulating for about 40 years of their life. This is considered the menstrual or pre-menopausal stage.
During those menstrual years, people typically lose about 1,000 eggs per month, but ovulate only one egg each time. This adds up to only a few hundred eggs (around 300-400) being ovulated during those years. What is happening to all those other eggs? Well, the majority of egg-containing follicles are used up through an ongoing gradual process of loss called atresia. Atresia is a process that happens whether you are pregnant, have regular or irregular periods, use birth control, or are undergoing fertility treatments.
What are perimenopause and menopause?
Menopause is defined as the point in time when it has been 12 months since a person’s last period. The years leading up to that point, when someone may see hot flashes, changes in their menstrual cycle, or other symptoms are called the menopausal transition or perimenopause.
Menopause is a natural part of aging that is mostly due to hormonal changes as the ovaries stop ovulating (more on this shortly) and producing estrogen, one of the driving hormones behind menstruation. The average age of menopause is 51 years old and the transition, while different for everyone, typically lasts about two years. Each person going through menopause has their own unique experience, though irregular cycles is universal. Whether or not someone will notice other symptoms, how long they will have symptoms for, and how severe those symptoms are varies greatly from person to person.
There are four symptoms that are considered to be central to the perimenopause transition: hot flashes, poor sleep, vaginal dryness/painful sex, and poor mood. After this transition is complete and a person is menopausal, they will notice an improvement of both period and perimenopausal symptoms over time. Unfortunately, this can take anywhere from a few months to several years. Of the four cardinal symptoms, hot flashes and vaginal dryness tend to persist most often post-menopause, hot flashes can last up to 14 years after menopause, and vaginal dryness can last indefinitely until it is addressed. Both of these symptoms thankfully have many over the counter and prescription options for management.
Supplements for perimenopause and menopause
So what can you do to deal with some of the bothersome symptoms during perimenopause? You may have heard of over-the-counter supplements that may help during this stage. For people who can’t or don’t want to be on prescription medications or hormone replacement therapy, these can sometimes be a great alternative.
But first, there are a few things to consider when it comes to supplements. Since the FDA does not regulate the supplement industry, there is a justified concern from medical providers that the advertised ingredients and concentrations are not always accurate.
Additionally, the National Center for Complementary and Integrative Health (NCCIH) states that there is no clear evidence that dietary supplements can relieve menopause symptoms. And there hasn’t been nearly enough research on the long-term safety of many dietary supplements.
All this to say, it’s crucial to discuss any new supplements with your provider. Your doctor can review your medical and family history and the medications you are taking to make sure there are no reasons for you not to take certain supplements.
The following are some menopause supplements a person may use, along with their effectiveness and any potential side effects.
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Calcium and vitamin D
Calcium and vitamin D are both excellent supplements since low levels of either can lead to osteoporosis, a medical condition where the bones become brittle and fragile from loss of tissue. Unfortunately, they haven’t been found to be that effective on menopausal symptoms. The Women’s Health Initiative Trial looked at the effects of calcium and vitamin D supplements on menopausal symptoms. They found that after an average of 5.7 years, there was no difference in symptoms between the group that took supplements and the group that didn’t.
Too much calcium can lead to vomiting, drowsiness, dehydration, muscle spasms, bone and joint pain, irregular heartbeat, or high blood pressure. If you have a history of kidney stones, ask your doctor about taking calcium. Too much vitamin D can cause you to retain too much calcium.
Black cohosh is probably one of the most often heard-of supplements for menopause. People sometimes use black cohosh to treat symptoms like hot flashes, night sweats, and irritability. However, there is no evidence to suggest that black cohosh has an effect on hormone levels in the body, including estradiol.
Older studies suggested that black cohosh may be effective for the relief of menopausal symptoms, either alone or in combination with other herbs. However, more recent research suggests that black cohosh has no significant effect on menopause symptoms.
Side effects of black cohosh may include: gastrointestinal problems, rash, uterine bleeding, breast pain, and acute hepatitis. It should not be used by people with liver problems, or people who take tamoxifen, chemotherapy drugs, simvastatin, and drugs that are metabolized by specific liver enzymes, known as cytochrome P450.
Red clover is another popular supplement. It is a legume that contains isoflavones. Isoflavones are compounds that are similar to the hormone estrogen. It has been used for help with menopause symptoms and osteoporosis. However, all studies investigating the effects of red clover on menopausal symptoms and bone density have had inconsistent results. There is therefore not enough evidence to suggest red clover can effectively relieve symptoms of menopause.
Red clover doesn’t have many side effects, but it can interact with other medications including blood thinners, methotrexate (a chemo drug), and drugs metabolized by cytochrome P450 enzymes.
Soy products are often used to treat menopausal symptoms, especially hot flashes and bone health. A 2015 review of studies found that soy isoflavones can reduce the severity of hot flashes. The study showed it took much longer to notice these effects when compared to estrogen hormone replacement therapy (HRT). While it took about 13 weeks for people to notice the effect of the soy isoflavones, it only took about three weeks for those using HRT.
In terms of bone health, the NCCIH states that soy isoflavone products may have a beneficial effect on bone health in menopause, but the current evidence is inconsistent.
The most common side effects of soy are an upset stomach, constipation, and diarrhea. People who are allergic to soy should not use soy supplements or take in food or drinks that contain soy.
Ginseng is a herbal supplement that people sometimes use during menopause as well. A 2016 systematic review of studies that looked at the effectiveness of ginseng for menopause symptoms noted that many of the studies were at a high risk of bias, which makes some of the results less trustworthy. Despite this, the review did find that ginseng may have a positive effect on arousal, sexual function, and hot flash severity. Ginseng did not seem to affect how often people have hot flashes, their hormone levels, or the thickness of the uterine lining (the endometrium).
Ginseng is not recommended for people who are currently taking medications like calcium channel blockers, statins, or antidepressants. It is also not recommended if you have a history of breast cancer. Side effects from ginseng can include breast pain, changes in menstrual bleeding, increased heart rate, changes in blood pressure, headache and loss of appetite.
St. John’s wort
St. John’s wort is a traditional European herbal remedy that is used for many things, including depression and menopause symptoms.
Older research has found that St. John’s wort decreased how often people were reporting hot flashes after about eight weeks. However, more research needs to be done to prove this supplement’s efficacy since many of the studies on it have been with small groups of test subjects.
St. John’s wort can interact with many medications, making them less effective. Some examples include antidepressants, birth control pills, certain heart, cancer and HIV medications, warfarin, and statins.
Possible side effects of St. John’s wort include sensitivity to sunlight, headache, dry mouth, trouble sleeping and anxiety.
Evening primrose oil
Evening primrose oil (EPO) is the oil from the seed of the evening primrose plant. It contains essential omega-6 fatty acids and has been used to treat multiple inflammatory diseases and women’s health conditions. Unfortunately, the research has been inconsistent about its use for menopausal symptoms. In a study comparing the effects of EPO to no medication, hot flashes were the same in both groups after six months. Another similar study found that 500 mg of EPO daily did decrease hot flash frequency and severity. But even though the differences between EPO and placebo were statistically significant, clinically the improvements were not significant. Other studies have had similarly mixed results. Ultimately, the NICCH does not believe there is enough evidence to support the use of EPO for menopausal symptoms.
As always, speak with your healthcare provider before adding any supplements to your routine, especially if you are on any other medications.
Menopause is a natural stage in life, as the ovaries’ egg stores wind down. This phase can cause symptoms that affect a person’s quality of life, and many people consider natural supplements as a way to manage their symptoms.
Much of the research on these supplements has been inconsistent, and there is currently only a little evidence that some of these supplements are effective. Always contact your healthcare provider for advice before taking any dietary supplements, especially if you are on any other medications. Your provider can also give you options to consider in addition to supplements that may be a better fit for you.