Menopause has been associated with increases in many cardiovascular risk factors including higher total serum cholesterol, triglycerides, and diastolic blood pressure.^[11] Longitudinal research has found that HDL levels decrease postmenopausally, and this change appears to be more pronounced among women with a high BMI.^[12] Furthermore, menopause has been associated with changes in lipoprotein metabolism and increased inflammation.^[13]

The association between menopause timing and cardiovascular disease (CVD) risk may be bidirectional, meaning that younger age at natural menopause is considered a marker of increased risk of CVD.^[14]

Keep in mind, though, that menopause is not a disease. It is a natural phase of life. Overall the association between menopause and CVD risk is mixed, particularly in otherwise healthy women (e.g., nonsmoking women with a healthy BMI) who transition into menopause at a typical age.^[15]

Vasomotor symptoms (VMS), more commonly known as hot flashes and night sweats, affect roughly 80% of women in their late-forties to mid-fifties. They often begin in perimenopause (i.e., the time around menopause), and peak in the later perimenopause and early postmenopausal years. Hot flashes present as a feeling of intense heat, resulting in sweating and flushing, predominantly around the head, neck, chest, and upper back. The physiology of hot flashes is not fully known, but they are presumed to be linked to low estrogen and elevated luteinizing hormone.^[18]

Not all menopausal women experience hot flashes, so there may be other biological mechanisms at play. Some evidence points to a narrowing of the thermal neutral zone (the range of body temperatures where an organism doesn’t have to expend extra energy to warm or cool) during menopause, meaning slight temperature fluctuations can trigger thermoregulatory processes that dissipate heat, resulting in flushing and sweating.^[19]

Genitourinary syndrome of menopause (GSM), or vaginal atrophy, results from a loss of estrogen. GSM results in a variety of adverse consequences, like vaginal dryness, burning, increased urinary frequency, and recurring bladder infections. For many women, this condition requires long-term management. For moderate to severe cases of GSM, low-dose vaginal estrogen is regarded as the most effective treatment, and for mild cases, non-hormonal topical lubricants are recommended.^[20]

The following are some other conditions that commonly occur during menopause:

• Perimenopausal women are 2 to 4 times more likely to suffer from depression, and some women have reported increased episodes of forgetfulness during this time.
• The risk of developing heart disease increases with age, and it increases even more in women after menopause due to declining estrogen and increased blood pressure, LDL-cholesterol, and triglycerides.
• Osteoporosis risk increases in menopause. Bone loss occurs in two phases: the first phase occurs in perimenopause, as bone resorption increases due to estrogen deficiency; the second phase occurs 4 to 8 ye

Bioidentical hormones are hormones that are identical to what is found naturally in the body, and compounded medications are those that are prepared in a pharmacy (as opposed to being commercially manufactured). Compounded bioidentical hormones are often marketed as being a “natural” HRT alternative, but many people don’t realize that some conventional, commercially-manufactured HRT medications also use bioidentical hormones.

Compounded bioidentical hormones can be advantageous for people requiring a unique formulation that is not commercially made, or who are allergic to an ingredient in a commercially-made product.^[7] However, there is little research on the effectiveness or safety of compounded bioidentical hormone therapies.^[21] There are also inherent risks with compounded medications due to variations in compounding methods, ingredients used, and quality control practices between pharmacies. This can increase the risk of bacterial contamination and lead to inconsistencies in drug potency and absorption. For example, one study comparing compounded bioidentical hormone medications prepared by 13 different pharmacies found that the products contained anywhere from 26% less to 31% more of the active ingredient than intended.^[22]

Compared to compounded bioidentical hormones, commercially-made bioidentical hormones should be preferentially used, as they have a substantial evidence base defining their safety and efficacy and are held to higher quality control measures during manufacturing.^[7]

HRT may increase the risk of blood clots (venous thromboembolism), breast cancer, stroke, and dementia.^[6] However, these risks are influenced by several factors, including the type or combination of hormones used, the dosage form (e.g., oral pill, patch, vaginal cream), a woman's age or time since menopause onset, and personal or family medical history. For example, HRT for local use in the vagina is not significantly absorbed into the blood and does not seem to contribute to the above risks (accordingly, it also does not improve hot flashes).^[23][24]

To put the potential risks (and benefits) of HRT into context, let’s imagine we have a group of 1,000 postmenopausal women and we follow them for 5–7 years. Compared to women who are not receiving HRT, the group of 1,000 women taking HRT might experience the following:^[6]

* Taking estrogen alone is only appropriate for women who have had their uterus removed, due to an increased risk of endometrial cancer when estrogen is taken without progesterone.^[7]

Importantly, these numbers are based on studies that primarily used oral HRT in postmenopausal women over 60. Some research suggests that when HRT is started within 10 years of menopause onset, or before the age of 60, there is little to no increased risk of stroke or dementia.^[25][26][23] Additionally, observational research suggests that transdermal HRT (e.g., topical gel or patch) may not carry the same risk of blood clots as oral HRT.^[27][28] This may be due to how the medications interact with the liver. Oral HRT must first pass through the liver before entering the blood, and this interaction can increase the production of several proteins that promote clotting. In contrast, transdermal HRT absorbs directly into the blood through the skin, bypassing the liver, which allows for lower overall doses and reduced production of clotting proteins.^[28]

Ultimately, the choice for or against HRT needs to be made in consultation with a healthcare provider and on a case-by-case basis depending on one's unique situation.

Young women with primary ovarian insufficiency (POI) experience symptoms similar to menopause. For women with POI and no contraindications (like breast cancer), the American College of Obstetricians and Gynecologists recommends hormone replacement therapy. This includes the use of prescription estrogen therapy until around age 50 to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy. Some women may require vaginal estrogen in addition to systemic estrogen. Young women with POI should have an annual thyroid exam as they are at increased risk of developing Hashimoto's thyroiditis.^[29]

In addition to medical management, women with POI may find the following lifestyle interventions helpful: eat a diet rich in calcium, maintain adequate vitamin D levels, perform weight-bearing exercises, limit caffeine and alcohol intake, and avoid smoking.^[30]

During menopause, the decline in estrogen and testosterone can diminish one’s sex drive, arousal, and interest in sex. However, not all postmenopausal women report a loss of sex drive and, in fact, lower levels of stress and anxiety due to motherhood may actually lead to improved intimacy and libido during this stage of life. Low estrogen levels do contribute to vulvovaginal atrophy (characterized by dryness, itching, irritation, and reduced vaginal lubrication),reduced vaginal blood flow, and the capacity for arousal and orgasm.^[16] Treatment with estrogen therapy seems to improve many of these symptoms.^[17]