Understanding The Menopause

We experience the specific transitional phase called menopause (MP) as part of the natural physiological process of female aging. Understanding the menopause helps as the MP is the final stage of ovarian aging and represents a significant hormonal, psychological, and physiological event, associated with an increased risk of comorbidities and overall mortality. During fetal life, the formation of ovarian germ cells establishes the full endowment of oocytes and follicles required for a woman’s entire reproductive lifespan. Gradually, there is a decline in both the quality of gametes, increasing the risk of miscarriage and congenital defects, and their quantity, eventually leading to cellular exhaustion.

MP marks the end of our reproductive lifetime, reflecting the loss of ovarian follicle function, decreased ovarian hormone production, and the irreversible cessation of menstrual cycles. It is important to note that, while average life expectancy for women has progressively increased over the past century, the timing of MP has remained relatively constant. As a result, women now spend a larger portion of their lives in the postmenopausal period. Moreover, an extended duration of post-menopause is associated with increased risks of cardiovascular disease, mood disorders, anxiety, osteoporosis, and premature death.

The perception and experience of MP vary significantly across different cultures and, more importantly, from woman to woman. For some, the symptoms associated with hormonal changes may be merely a mild discomfort, while for others, they can be severe or even debilitating in that they impact both work and family life. Society also assigns meaning to MP, often linking it to gender ideologies and drawing on stereotypes, which can overlook the importance of this phase to a woman’s identity.

Recent studies have shown that cultural, social, and psychological contexts play a crucial role in the severity of MP symptoms, revealing that women who perceive MP negatively tend to experience more pronounced symptoms. Life events, daily activities, family environment, and job satisfaction significantly influence women’s mood during MP. However, MP can also represent a turning point in a woman’s life, enabling greater focus and dedication to career pursuits, as well as fostering personal growth and a stronger sense of self-esteem. MP can be pictured as a time in a woman’s life when not only the body, mind, and social role change, but also the concept of well-being and the personal significance each woman attributes to it are transformed.

There is no specific set of symptoms unique to the menopausal transition, except for those associated with hormonal fluctuations and decline. The primary symptoms include hot flashes, low mood, anxiety, insomnia, and urogenital changes such as vaginal dryness and decreased libido, which are particularly disruptive to female intimacy and sexual desire. These symptoms can be intense and can significantly interfere with overall quality of life.

Hot flashes are sudden sensations of increased body temperature, primarily affecting the face, neck, and chest, and often accompanied by skin flushing and perspiration. They may be associated with an elevated heart rate and intense sweating, followed by an equally sudden and powerful sensation of cold. Additional symptoms can include fatigue, dizziness, and nausea. On average, women report experiencing 4–5 hot flashes per day; however, some women may experience up to 20 episodes daily. Although the duration varies from woman to woman and is relatively short (1–5 min), the frequency and intensity of these episodes can be extremely disruptive to productivity and overall well-being.

Several studies have determined that women’s outlook on this stage of life can affect their emotional health and shape their experience with mood challenges, including depression and anxiety. The relationship between these psychological symptoms and the stages of MP remains unclear. It is thought that such symptoms may be linked more to general midlife psychosocial factors rather than solely to hormonal changes associated with MP. These factors can include how women feel about aging or perceive their role in life, such as within family, interpersonal relationships, and career. Evidence suggests that women who perceive their role in life as meaningful often report less intense menopausal symptoms. Indeed, widowed, separated, and divorced women show higher rates of depression than women in relationships, regardless of MP status

Recent research suggests that social isolation, limited support from family and friends, and mood disorders are major risk factors that contribute to coronary heart disease However, endocrine changes associated with MP do not appear to directly cause a true clinical diagnosis of depression and anxiety. If symptoms such as depression, irritability, anxiety, and anhedonia arise during the menopausal transition, it is more likely to observe a reactivation of a pre-existing depressive or anxious state, intensified by environmental factors such as smoking, body image changes, dissatisfaction in personal relationships, and occupational challenges in key areas of life.

MP also affects human brain structure, connectivity, and energy metabolism. The decline in estrogen particularly impacts brain function, interfering with processes such as synaptogenesis, spinogenesis, glucose metabolism (which is a crucial energy source for brain cells), and neuronal morphology. This indicates that MP may represent a window of vulnerability to cognitive decline and the onset of neurodegenerative diseases, although individual risk may be modulated by genetic factors, lifestyle, and environmental support networks. However, not all women experience these changes with the same intensity, suggesting that individual experiences may vary significantly based on a combination of biological and psychosocial factors.

During the menopausal transition, reduced glycogen disrupts the vaginal bacterial flora, resulting in an elevated pH and creating an alkaline environment that is more susceptible to infections and associated discomfort, such as itching and burning. Additionally, there is a reduction in fibroblastic activity with a subsequent decrease in local collagen production, causing microstructural changes that affect both anatomy and function. The epithelium becomes thinner, elasticity decreases, the labia minora undergo size regression, and the vaginal opening narrows. These cumulative changes result in a chronic, progressive condition affecting nearly 50% of postmenopausal women, known as vulvovaginal atrophy (VA), often referred to as Genitourinary Syndrome of Menopause (GSM). Although some women with mild GSM remain asymptomatic, the majority experience significant symptoms, with a prevalence around 70%, impacting quality of life and overall well-being. Those affected by GSM often experience challenges in intimate relationships due to vaginal discomfort, with a decrease in libido and pain during intercourse. Common symptoms include vaginal dryness, burning, irritation, and reduced lubrication, leading to sexual dysfunction.

The female body provides clear markers of life’s transitional phases, from puberty to adulthood and MP. It also reflects aging and mortality. We must once again reorganise our self-esteem, re-evaluate our future, and confront the inevitability of limitations. The body serves as a crossroads for intergenerational transmission of the “feminine”, often acting as a metonym for past defences, traumas, and inconsistencies. Simultaneously, the female body offers a profound understanding and opportunity for transformation and mentalisation. MP marks the concrete realisation of the loss of youth, a reality that has always loomed but never fully materialised. Like young adolescents, menopausal women must grapple with bodily changes, particularly weight gain around the abdomen and decreased metabolic rate. Physical energy wanes, and joint pain may increase. Consequently, we must adapt our body image and self-perception to accommodate these changes. MP can lead to a significant narcissistic injury, challenging the self-image and sense of identity. One may feel a sense of castration, believing that one is losing femininity and sexual value. Moreover, a discrepancy often arises between physiological and psychological experiences, as unconscious desires persist despite changes in the body.

This discrepancy contributes to the crisis-like nature of MP. However, MP can also be a time of growth and renewal. We may discover new talents or passions or deepen our commitments to family and relationships. MP represents a potential for rebirth and further development, rather than an end to sexuality and purpose. In post=menopause, we undergo a new process of transformation in psychophysical identity. While the physical changes are well documented, the psychological consequences are equally profound and can significantly affect our quality of life.

Aesthetic surgery allows for the enhancement of physical appearance, counteracting the signs of aging and potentially increasing personal satisfaction and individual well-being. An appearance aligned with personal desires can foster a greater sense of confidence in interpersonal relationships, significantly improving quality of life. However, the narcissistic wound associated with the bodily changes of aging may lead to unrealistic expectations regarding the potential aesthetic outcomes of such procedures.

Additionally, as with any surgical intervention, aesthetic surgery carries risks, including infections, bleeding, anaesthetic complications, and the possibility of developing visible and permanent scars. Unsatisfactory results or medical complications can evoke a profound sense of failure, mirroring the emotional experiences of anxiety and depression often associated with the aging process. Our aging is frequently regarded as more challenging than men’s, primarily because of cultural norms that emphasize youthfulness and physical attractiveness in women, while men are not held to the same standards. This concept, referred to as the “double standard of aging”, underscores how aging in women is scrutinised more severely, as their worth is often linked to their looks, whereas men are typically assessed based on attributes that go beyond youthful appearance. The combination of physical, hormonal, and emotional changes during these phases underscores the need for a multidisciplinary approach to support women’s overall well-being and their relationships with partners.

Addressing these challenges ensures that both our physical health and emotional needs are met during these pivotal stages of life.

This article is not my own work and is taken from:

Marano, Giuseppe, Maria Benedetta Anesini, Greta Sfratta, Claudia d’Abate, Gianandrea Traversi, Sara Rossi, Francesco Maria Lisci, Caterina Brisi, Ida Paris, Roberto Pola, and et al. 2025. "Aesthetic Gynecology and Mental Health: What Does It Really Mean for Women?" Cosmetics 12, no. 1: 28. https://doi.org/10.3390/cosmetics12010028