Symptoms of menopausal transition


The symptoms associated with menopausal-transition (pre-menopause) include fertility decline, irregular cycles, heavy periods, irregular bleeding, hot flushes.

  • Fertility decline: Fertility in the pre-menopause is diminished due to the decline in the number of ovarian follicles. The loss of follicles accelerates after the age of 38 years and very few oocytes remain by the last menstrual period.1,11 The pre-menopause presumably begins when a critical number of functional follicles are lost through the process of follicular atresia.
  • Irregular cycles: There is an increase in the mean cycle lengths, however very long cycles may be interspaced with extremely short cycles.10 Peri-menopause is characterized by ovulatory cycles interspersed with anovulatory cycles of varying lengths.8 The cycle lengths although regular become shorter initially usually due to earlier ovulation and a shortened follicular phase. A short cycle may also be due to a short luteal phase. Then the cycles become irregular and later they get longer, up to two or three months or more in length. The irregular cycles in the >45 age group may well indicate anovulation.1
  • Heavy periods, irregular bleeding: Prolonged raised oestrogen levels which occurs in the long anovulatory cycles, and/or altered oestrogen to progesterone levels may lead to a greater build-up of the endometrium. Due to fluctuating oestrogen levels the thickened endometrium can break down causing menorrhagia (heavy and prolonged periods), or irregular bleeding or spotting. The irregular bleeding occurring at different times in the cycle e.g. in the late luteal phase or at ovulation, may be associated with low levels of circulating oestrogen and progesterone. If intermittent bleeding persists the woman should consult her doctor
  • Hot flush: The hot flush is related to vasomotor instability and results in a sudden sensation of heat or a warm feeling. Its duration varies from part of a second to several minutes and its frequency from once weekly to numerous hot flushes daily. Generally the rate of occurrence of the hot flush increases until the menopause and gradually disappears during the years after menopause.6


  1. Liu JH, Gass ML; ‘Management of the perimenopause’; 2006; Pub. McGraw-Hill, ISBN 0-0-142281-1
  2. Odeblad Erik; ‘The discovery of different types of cervical mucus and the Billings Ovulation Method’; Bulletin of the Ovulation Method Research and Reference Centre of Australia, Vol 21, No3; 3-35; Sept 1994. (on the internet if you google ‘Erik Odeblad, cervical mucus’).
  3. Odeblad E, ‘Investigations on the physiological basis for fertility awareness’ page 7; Bulletin for the Ovulation Method Research and ReferenceCentre of Australia, vol 29, no 1, p2-11, march 2002, (internet, Billings Ovulation Method)
  4. Flynn A, Brooks M; ‘The Manual of Natural Family Planning’; pages 74-80; 1996; ISBN 0 7225 3115 X
  5. Soules MR, Sherman S, Parrot E et al; Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertil Steril. 2001; 76: 874
  6. Flynn A, Worthington W; ‘Teachers Training Manual’; ‘symptothermal multiple index method’ of natural family planning.
  7. Harlow S D, Mitchell ES, Crawford S; ‘The ReStage Collaboration: defining optimal bleeding criteriafor onset of early menopausal transition’; Fertil Steril; vol 89, No1, Jan 2008.
  8. Alvero Ruben, Schlaff William D; ‘Reproductive endocrinology and infertility, The Requisites in Obstetrics and Gynecology’; 2007, page 229; ISBN-13:978-0-323-04054-9
  9. McKinlay SM; ‘The normal menopause tradition: and overview ‘; Maturitas; 1996; 23:137
  10. Wallace RB, Sherman BM et al; ‘Probability of menopause with increasing duration of amenorrhea in middle-aged women’; Am. J. Obstet. Gynecol. 135: 1021, 1979.
  11. Richardson SJ, Senikas V, Nelson JF; ‘Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion’; J Clin Endocrinol Metab. 1987; 65:1231
  12. Brown JB; ‘Types of ovarian activity in women and their significance: the continuum (a reinterpretation of early findings)'; Human Reproduction Update; Vol 17; No 2; p141-158. (this is a classic article which gives a greater understanding of the menstrual cycle throughout the reproductive life).
  13. Cynthia A. Stuenkel, MD, Margery Gass MD et al; ‘A decade after the Women’s Health Initiative – the experts agree'; Fertility and Sterility; vol 98, no 2; August 2012; p313-314.
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