What Are The Phases of Menopause? STRAW+10

STRAW+10 provides a detailed and comprehensive system for tracking and assessing the phases of menopause. At various stages, it highlights key hormonal changes, such as fluctuations in estradiol levels and FSH levels during menopause, which are indicators of the menopausal transition.

As a result, it offers valuable insights and a more precise method for evaluating menopausal changes. The STRAW+10 system enhances the ability of researchers and healthcare providers to effectively assess and manage the menopausal journey, thereby making it an essential tool in everyday medical practice.

What is STRAW+10?  

To elaborate, the STRAW+10 (STRAW plus 10 years) system offers a structured sequence for understanding reproductive aging in women. It divides the process into three phases and seven sub-stages, thus providing an in-depth method for assessing the progression from the reproductive years, through perimenopause (menopause transition), and into postmenopause.

In order to develop this system, the STRAW+10 workshop, held in Washington, D.C. in 2011, brought together 41 experts in female reproductive aging. Participants included researchers and clinicians from leading institutions in the U.S., Canada, Australia, the Netherlands, and South Africa.

Notable contributors represented several NIH-funded studies, such as the Study of Women’s Health Across the Nation (SWAN), the Michigan Bone Health and Metabolism Study (MBHMS), the Seattle Midlife Women’s Health Study (SMWHS), the Biodemographic Models of Reproductive Aging (BIMORA), the Penn Ovarian Aging Study (POAS), and the Melbourne Women’s Midlife Health Project (MWMHP).

Hormonal Changes Across Menopausal Stages 

To achieve a deeper understanding of these changes, participants reviewed scientific advances in the hypothalamic-pituitary-ovarian (HPO) function before and after the final menstrual period (FMP). Additionally, they examined changes in menstrual, endocrine, and ovarian indicators of reproductive aging, including antimüllerian hormone (AMH), inhibin-B, follicle-stimulating hormone (FSH), and antral follicle count (AFC). 

HPO is a hormone system that controls a woman’s reproductive cycles. It involves three parts: hypothalamus, pituitary gland and ovaries.

These parts work together like a team, sending hormone signals back and forth. This teamwork controls periods, egg release, and prepares the body for possible pregnancy.

Consequently, these discussions clarified how AMH and inhibin-B signal fertility decline and ovarian aging, leading to the development of the STRAW+10 system.

However, despite significant progress in understanding ovarian ageing since the original STRAW in 2001, important gaps in scientific knowledge still remain.

Why Know the Phases of Menopause

While the information from the STRAW+10 workshop was primarily intended to help researchers and healthcare professionals better understand and manage the phases of menopause, it is important to note that it can also empower women by giving them a better understanding of the changes occurring in their bodies, including various hormone imbalances, such as changes in estradiol levels and FSH levels during menopause.  

Furthermore, this knowledge, in turn, can help women engage more actively in their healthcare, make informed decisions about managing their menopausal journey, and communicate more effectively with their doctors.

Practical Tips for Navigating Menopause Phases:

Recognise Symptoms

Be aware of common symptoms of menopause, such as hot flashes, night sweats, and mood changes, and discuss these with a doctor.

Maintain a Healthy Lifestyle

Maintain a healthy lifestyle with balanced nutrition, regular exercise, and stress management to help alleviate some menopausal symptoms.

Have Regular Check-ups

Schedule regular check-ups with healthcare providers to monitor hormone levels and overall health, ensuring timely intervention if needed.

Educate Yourself

Read books, articles, and reputable online resources about menopause and reproductive aging.

Understanding the science behind menopause can help you feel more in control.
 

What Causes Menopause?

What Causes Menopause?

Consider Hormone Therapy

Discuss with your healthcare provider whether hormone replacement therapy (HRT) or other medications might be appropriate for managing severe symptoms.

Explore Alternative Therapies

Some women find relief through alternative therapies such as acupuncture, yoga, or herbal supplements. Always consult with a healthcare provider before starting any new treatment.

Practice Mindfulness and Relaxation Techniques

Techniques such as meditation, deep breathing exercises, and mindfulness can help manage stress and improve overall well-being during menopause.

Stay Hydrated

Drink plenty of water, as hydration can help alleviate some symptoms, such as dryness and fatigue.

Maintain a Sleep Routine

Establish a regular sleep schedule and create a calming bedtime routine to improve sleep quality, which can be disrupted during menopause.

Seek Professional Counseling

If you’re experiencing significant emotional changes, consider talking to a therapist or counselor who specializes in women’s health or menopause.

Join Educational Workshops or Webinars

Participating in workshops or online webinars can provide valuable information and connect you with other women going through similar experiences.

Understanding the Phases of Menopause

While the average age for reaching menopause is 51, it can naturally occur anytime between the ages of 40 to 58. To clarify this process, the STRAW+10 system offers a structured approach to reproductive aging, dividing a woman’s life into three main phases: reproductive, menopausal transition, and postmenopause.

By clearly defining these phases and their specific stages, STRAW+10 helps women and healthcare providers identify where they are in the process, thereby enabling a more personalised and effective management of menopause symptoms and health plans.

It’s important to mention that while most women typically move steadily from one stage to the next, some may experience a “see-saw” effect, moving back and forth between stages or even skipping a stage entirely.

STRAW+10 System: Phases and Stages Overview

3 Phases of Reproductive Aging

• • Reproductive Phase
    This phase includes the early, peak, and late reproductive stages. In the late reproductive stage, changes in the menstrual cycle and hormone levels occur, fertility begins to decline.
    
    
  • Menopausal Transition Phase
    During this phase, menstrual cycles become irregular, and symptoms like hot flashes and mood swings often appear. Hormonal changes, such as low estrogen and fluctuating FSH levels, are common.
    
    
  • Postmenopause Phase
    This phase begins after your final menstrual period. Hormone levels, including estradiol and FSH, stabilize, but the risk of issues like osteoporosis and cardiovascular disease can increase due to low estrogen levels.

These phases included a total of seven stages centred around the final menstrual period (FMP, Stage 0).

• • • Reproductive Phase:

      Duration:  variable
      The Reproductive stage is characterised by regular menstrual cycles and is divided into three sub-stages:
      
      
      • • Stage -5: Early reproductive – (Typically teens to late 20’s)
          This stage begins with menarche (first menstruation). Menstrual cycles are often irregular and unpredictable during the first few years. Cycle length can vary widely, and anovulatory cycles (cycles without ovulation) are common. As time progresses, cycles generally become more regular, though some variability may persist.
          
          
        • Stage -4: Peak reproductive – (Late teens to late 20’s)
          During this phase, menstrual cycles typically stabilise and become more regular. Most cycles are ovulatory, and women experience their peak fertility. Cycle length usually settles into a consistent pattern, often ranging from 21 to 35 days.
          
          
        • Stages -3b / 3a: Late reproductive – (Early 30’s to early 40’s)
          During this stage, when fertility starts to decline, cycles remain regular, but subtle changes may begin to occur. This stage is divided into two sub-stages.
          
          
      • • • Stage 3b: Menstrual cycles remain regular and FSH levels are normal at this stage, but other indicators of ovarian health, such as AMH (Anti-Müllerian Hormone) and AFC (antral follicle counts), start to decline. This decrease, along with low levels of inhibin-B observed in some studies, signals the early signs of diminishing egg supply.
            
            
          • Stage 3a: Subtle changes in menstrual cycle begin, particularly shorter cycles. FSH levels increase above normal. AMH, AFC, and inhibin-B remain low.
            
            
            

    • Menopausal Transition Phase (PERIMENOPAUSE):

      The menopausal transition is a critical phase that marks the shift from the reproductive years to menopause. It is divided into two key stages:
      
      
      • • Stage -2: Early Menopause transition – (Early to mid 40’s)
          Duration: Variable
          Symptoms: See List
          
          

          Menstrual cycles become irregular with the gap between cycles varying by 7 days or less. This pattern must repeat within 10 cycles to signal menopause.

          Levels of FSH are elevated but fluctuate, while levels of AMH and AFC are low. These hormonal changes reflect the declining ovarian function typical of this transition period.

          
          
        • Stage -1: Late Menopause transition – (Mid 40’s to early 50’s)
          Duration: typically lasts 1-3 years
          Symptoms: See List
          
          

          This stage is characterised by the absence of menstruation (amenorrhea), for 60 days or more. During this period, menstrual cycles become irregular, with significant fluctuations in hormone levels and frequent anovulation (no ovulation/egg release).

          FSH levels can vary widely during this stage. They may be high, indicating menopause, or low if estradiol is high, which can suppress FSH levels. AMH drops to very low or undetectable levels.

          This stage signifies that the body is nearing the end of its reproductive years.

          
          

  • Menopause

    Menopause (0):  is defined as the final menstrual period (FMP) and is confirmed after 12 consecutive months without menstruation, typically occurring in women in their late 40s to early 50s; this pivotal moment is marked by significant hormonal changes, including a sharp decline in estradiol levels and a rise in follicle-stimulating hormone (FSH) levels.
    
    

    •  What Causes Menopause?

      
      What Causes Menopause?

       

  • 
    

    • Postmenopause Phase:
      

      Duration: 5-8 years
      Symptoms: See List
      
      Menopause, typically occurring at an average age of 51 in Western countries, marks the final menstrual period (FMP) and is confirmed after 12 months without menstruation. During this time, FSH levels continue to rise while estradiol levels fall, with these hormonal changes stabilizing approximately two years after the FMP. Following menopause, women enter the postmenopausal phase, which is divided into early and late stages, with Early Menopause further subdivided into 3 sub-stages.
      
      

      • • Stage +1: Early Postmenopause: (Early to mid 50’s)
          Postmenopause is the phase that follows menopause and is divided into early and late stages, with Early Menopause having 3 sub-stages. 

          • Stage +1a: (First year postmenopause)
            This stage marks the initial 12 months after the final menstrual period. Hormone levels, particularly estradiol, drop significantly, often leading to intense symptoms like hot flashes and night sweats. Women may begin experiencing changes in bone density and face an increased risk of cardiovascular issues.
            
            
          • Stage +1b: (Second year postmenopause)
            During the second year, some women may notice a decrease in the intensity of symptoms like hot flashes. Hormone levels stabilize at lower levels as the body continues adjusting to the absence of menstrual cycles. This period is crucial for focusing on bone health due to the increasing risk of osteoporosis.
            
            
          • Stage +1c: (3 to 6 years postmenopause)
            By this stage, the body has largely adapted to postmenopausal hormone levels. While vasomotor symptoms may persist, they are generally less severe. The focus shifts more prominently to long-term health concerns, such as bone density loss and cardiovascular disease, necessitating ongoing monitoring and preventive care.
            
            
            

        • Stage +2: Late postmenopause: (Mid 50’s onwards)
          Duration: Remaining lifespan
          

          This stage represents the remaining lifespan after menopause, typically beginning in the mid-50s and extending for the rest of a woman’s life.
          
          Hormonal levels stabilise as the body adjusts to low levels of reproductive hormones.

          While menopausal symptoms usually subside, aging-related issues become increasingly prevalent. Women may experience symptoms of genitourinary syndrome of menopause (GSM), such as vaginal dryness, thinning of the vaginal lining, and urinary symptoms due to low estrogen levels.

          Although average FSH levels may decrease many years after menopause in very elderly individuals, this remains a high-risk phase for women.

          The decreased estrogen levels increase the risk of developing osteoporosis, cardiovascular disease (CVD), dementia, Alzheimer’s disease (AD), and cancer. This necessitates ongoing healthcare management to address these potential health concerns.

Symptoms Across Menopause Phases

These lists provide an overview of common symptoms associated with the phases of menopause. However, they are for informational purposes only, and they are not exhaustive, and are not a substitute for professional medical advice, diagnosis, or treatment. Menopause symptoms vary widely among women, differing in both severity and type. For this reason, if you experience these symptoms or have health concerns, consult a healthcare professional

Inclusions / Exclusions