Menopause: what happens in the body, the stages and when to see a doctor

Deep dive · Menopause at Health Royals · 10 min read

Menopause is not a date in the calendar but a process that runs for most of a decade, and almost everything that feels scattered along the way traces back to one signal.

Midlife at Health Royals

Peak Performance Formula, a multivitamin for women with omega 3 from algae, brings together nutrients for the systems that recalibrate in midlife: vitamin D3 25 µg as Quali-D®, vitamin K2 90 µg as MenaQ7®, folate, vitamin B12, niacin, zinc, selenium and 375 mg omega 3 from algal oil. Vitamin D contributes to the maintenance of normal bones and to normal muscle function. Vitamin K contributes to the maintenance of normal bones. Niacin, folate and vitamin B12 contribute to the reduction of tiredness and fatigue.

See Peak Performance, multivitamin for women with omega 3

In the SWAN cohort, follicle stimulating hormone starts climbing about six years before a woman's final period. Oestradiol, the hormone almost everyone associates with the transition, holds steady until roughly two years before that period, then falls fastest at the period itself and settles two years afterwards. That pattern was measured in 1,215 women with a documented final menstrual period, whatever their age when it happened.

So the hormone that moves first is not the one most women have heard of, and the whole thing takes most of a decade. This article follows that arc tissue by tissue and explains, where a raw material has a documented place in it, how we at Health Royals chose ours. Whether what you notice now is the start of it is covered in our article on the first signs of perimenopause.

What happens in the body during menopause, and how long does it take?

Menopause is the point at which the ovaries run out of follicles that still respond, and from the first endocrine changes to a stable postmenopausal state is usually eight to ten years, not one or two.

As the pool of follicles shrinks, the pituitary answers with more follicle stimulating hormone; cycles shorten, then lengthen, then become erratic, and eventually ovulation stops. The final period can only be identified in hindsight, twelve months later. The formal framework is the Stages of Reproductive Aging Workshop, revised in 2012, and in Sweden 1177 puts the usual age range at 45 to 57, most often around 51 to 52.

The hormonal part spans about eight years: follicle stimulating hormone begins rising roughly six years before the final period, accelerates two years before it, and stabilises two years after. Symptoms run on their own clock: in a SWAN analysis of 1,449 women with frequent hot flushes or night sweats, the median duration was 7.4 years, 4.5 of them after the final period, and some women have almost none.

One hormone reaches so many tissues because oestrogen receptors are not confined to the reproductive organs: a 2022 review in Frontiers in Endocrinology describes them in bone, fat tissue, liver, brain, heart, immune system, muscle and blood vessels, which is why this article is organised by tissue. Skin, joints, sleep, energy and mood are five expressions of one change.

What happens to the skin, and how fast does collagen fall?

The studies usually cited report skin collagen falling by roughly 1 to 2 percent per postmenopausal year, a real decline and a slower one than the figure often printed next to it.

In a 1987 paper in Obstetrics and Gynecology, skin collagen, skin thickness and bone measures in postmenopausal women all showed "a similar decline of between 1 to 2 percent per year after the menopause". A companion paper measured thigh skin collagen in 69 untreated women and 37 on hormone implants, and an earlier 1985 paper from the same group showed that collagen declined with menopausal age, not chronological age. You will often see a larger number: a 2013 review in Dermato-Endocrinology writes that skin collagen "is thought to decrease by as much as 30% in the first five years after menopause", citing the 1985 paper and a 1999 study in Maturitas, and neither reports that figure. Compounding 1.5 percent a year over five years gives roughly 7 percent, a change worth planning around. Hyaluronic acid in the dermis falls in parallel, which is why skin feels drier and thinner at once. Our articles on what collagen is and on the skin's structure and barrier go deeper.

That decline is why the skin conversation at midlife turns to supplements, and where the quality of the answer starts to matter. The authorised wording in Regulation 432/2012 belongs to vitamin C: "Vitamin C contributes to normal collagen formation for the normal function of skin". Beyond the vitamin, a skin supplement is judged on its raw materials: which material, who makes it, whether it was studied in women of the relevant age, and whether the capsule carries that dose. A higher number is not automatically a better or more evidence-based dose.

That was the test we applied at Health Royals when we chose the collagen in Beauty Complete. The material is Cartidyss®, a type II fish cartilage collagen made by Abyss Ingredients in Brittany, a specialist in marine raw materials. In a double-blind, placebo-controlled study published in Molecules in 2021, 46 healthy women aged 45 to 59, the window this article describes, took 500 mg per day or placebo for 90 days, and the paper reported reductions in wrinkle measurements and increases in dermis thickness. Cartidyss was studied at 500 mg per day. Beauty Complete contains 500 mg per daily dose. For us, the ingredient cannot be separated from its source, manufacturer and studied dose.

Beauty Complete contains six ingredients: Cartidyss® fish cartilage collagen 500 mg, Hyabest® hyaluronic acid 120 mg, bio-fermented by Kewpie in Japan, Ceramosides™ phytoceramides 30 mg from Seppic in France, vitamin C 60 mg as PureWay-C, vitamin B2 1.4 mg and biotin 50 µg. The three named materials sit at the daily dose used in their own human studies, the vitamins at a nutritional level. Ninety days in the study means ninety days of actually taking it, which is why the jar is made to stand on a shelf rather than in a cupboard. More on our skin page.

Why do joints ache and feel stiff?

Because oestrogen also helps maintain the elasticity of connective tissue, and its fall is felt in cartilage, tendons and joint fluid before anything is wrong with the joint itself.

Oestrogen influences the production of glycosaminoglycans, the family that includes hyaluronic acid and chondroitin sulphate, both central to cartilage and joint fluid, and collagen turnover in tendons and ligaments slows at the same time. That is often felt as morning stiffness and a mild discomfort that eases once you are moving: signals of recalibration, not of damage, and the same receptors explain why skin and joints tend to change together. Muscle strengthening activity supports the joints from the outside, and the recommendations at the end of this article come back to it. Stiffness that comes and goes with the morning is common in midlife; persistent joint pain is a question for a doctor.

Does hair change during menopause?

Hair density and diameter do change across midlife, and the evidence points to several drivers rather than to menopause alone.

A 2011 review in the British Journal of Dermatology calls female pattern hair loss a common problem "beset by a paucity of research" and leaves the role of oestrogen open. Better established is that hair sits downstream of everything else at midlife: thyroid function, iron status, illness and weight change can each produce shedding that gets blamed on the transition, and they are what a doctor checks first. See our article on the scalp and our hair page.

For nutrients and hair, the authorised wordings are precise: "Zinc contributes to the maintenance of normal hair" and "Biotin contributes to the maintenance of normal hair". For a botanical ingredient, what counts is the study it was tested in, the population and the dose, and that the same dose is in the pack. In a study on Keranat®, a millet seed extract made by Robertet in Grasse, women took 300 mg per day for twelve weeks in a randomised, double-blind, placebo-controlled design, and 300 mg is the daily dose in Hair Beautification, alongside zinc 10 mg as zinc citrate, vitamin B6 1.4 mg and biotin 50 µg.

What happens to the skeleton after menopause?

Bone loss is concentrated in a narrow window around the final period rather than spread over the years that follow.

In a SWAN study of 862 women followed with repeated bone density scans, loss began one year before the final menstrual period and decelerated, without stopping, two years after it. Over ten years, lumbar spine bone mineral density fell 10.6 percent, and 7.38 of those percentage points were lost in the three years around the final period. At the femoral neck the figures were 9.1 and 5.8 percent.

On the nutritional side, the Swedish reference values derived from the Nordic Nutrition Recommendations 2023 set the recommended intake of calcium for adult women at 950 mg per day, and vitamin D at 10 micrograms per day, rising to 20 micrograms above age 70. Calcium at that level is a food question; vitamin D is the nutrient a Swedish winter makes worth watching, because the skin makes none from October to March. The authorised wordings are precise: "Vitamin D contributes to the maintenance of normal bones", "Vitamin D contributes to normal muscle function" and "Vitamin K contributes to the maintenance of normal bones", each about normal function rather than the transition. The label then tells you the form of each vitamin and whether the level has a nutritional reason; we have written separately about vitamin D3 and vitamin K2.

For us the dose is as important as the raw material, and that is how Peak Performance is put together: a multivitamin for women with omega 3 from algae, twelve named components with every amount on the label. The relevant ones here are vitamin D3 25 µg as Quali-D® from dsm-firmenich, a deliberate middle level meant to be taken every day of the year and a quarter of the upper limit, vitamin K2 90 µg as MenaQ7®, the MK-7 form from Gnosis by Lesaffre, and OMEGATEX® algal oil 500 mg giving 375 mg omega 3, of which 300 mg DHA and 50 mg EPA. EPA and DHA contribute to the normal function of the heart. The jar is amber glass with a scent core, made to stand out on the counter, with refill pouches by subscription, because a nutrient taken through a winter is a routine first.

Why does energy fade and sleep get lighter?

Self reported sleep problems rise clearly across the transition, and energy sits downstream of sleep, of the brain's signalling and of the cells' own energy production, all of which the same hormone touches.

A 2018 review in Nature and Science of Sleep puts self reported sleep difficulties at 40 to 56 percent in perimenopausal and postmenopausal women, against 31 percent in the late reproductive stage, and notes that polysomnography measures "do not necessarily reflect self-report sleep quality ratings": night sweats fragment sleep for the women who have them, and the experience is not fully captured in a laboratory. Oestrogen also influences serotonin, dopamine and acetylcholine, the neurotransmitters behind mood, memory and learning, and has a described role in mitochondrial function, so brain fog, lower drive and a shorter fuse for stress are real transitions rather than imagined ones. More in our articles on stress and sleep and on cortisol.

Here is what has been measured. In a study on Extramel®, the melon extract in Peak Performance, 70 healthy adults aged 30 to 55 with everyday stress and fatigue took 10 mg or placebo daily for four weeks in a randomised, double-blind, placebo-controlled design, published in Nutrition Journal in 2009, and the Extramel group reported a 38 percent greater improvement in sleep-related problems than the placebo group. Extramel, made by Robertet, was studied at 10 mg per day, and Peak Performance contains 10 mg per daily dose; our article on SOD from melon goes through both studies. Alongside it sit folate 200 µg as Quatrefolic® 5-MTHF, vitamin B12 10 µg as MecobalActive® methylcobalamin and niacin 16 mg, at nutritional levels. Niacin and vitamin B12 contribute to normal energy-yielding metabolism, and niacin, folate and vitamin B12 contribute to the reduction of tiredness and fatigue.

What happens to weight, blood sugar and the heart in midlife?

Body composition shifts during the transition even when total weight does not, and the way the body stores and uses energy shifts with it.

In a SWAN analysis using repeated scans, the rate of fat gain doubled at the start of the transition and lean mass began to fall, both continuing until two years after the final period, while weight itself "climbed linearly during premenopause without acceleration". The scale is a poor instrument for this change. Blood sugar belongs in the same picture: insulin sensitivity often declines across midlife, which can show up as more weight around the middle and an afternoon dip in energy. That is not a loss of discipline but a sign that the body handles energy differently, as our article on healthy ageing describes. Chromium contributes to the maintenance of normal blood glucose levels, the authorised wording for a mineral Peak Performance carries at 20 µg as chromium picolinate.

A 2020 scientific statement from the American Heart Association describes the transition as a period of accelerating cardiovascular risk and argues that midlife is therefore the window for prevention. Timing matters too: a pooled analysis of 301,438 women across 15 studies found a hazard ratio for a first cardiovascular event of 1.55 for menopause before 40, against menopause at 50 to 51. That is a reason to treat midlife as the decade for habits, not for alarm.

What does the evidence show clearly?

The evidence draws a clearer map than the popular claims, and most of it is reassuring.

Thinking recovers. In a study of 2,362 women followed for four years, a dip in processing speed during late perimenopause returned to premenopausal levels afterwards. What shifts is body composition rather than weight as such, and skin collagen falls by 1 to 2 percent a year rather than 30 percent in five years.

One change is different: it does not pass on its own. The 2020 position statement of The North American Menopause Society on the genitourinary syndrome of menopause reports prevalence of 27 to 84 percent of postmenopausal women, and states that "in contrast to vasomotor symptoms (VMS) that usually improve over time, GSM is generally progressive without effective therapy". That is a reason to raise it with a doctor rather than to wait it out.

The rest of the map is just as clear: a mapped hormonal timeline, a datable bone window, a collagen decline of 1 to 2 percent a year and a body composition shift the scale does not register. Those are the things worth planning around.

When should you see a doctor about menopause symptoms?

For most women over 45, the diagnosis is made on symptoms and bleeding pattern, and blood tests add little, which is reassuring: the pattern you notice is the evidence.

The NICE guideline NG23 is explicit: diagnose on symptoms and bleeding pattern, without laboratory tests, in otherwise healthy women over 45. Midlife is also a period when other conditions become more common, so some symptoms should not be filed under hormones. Contact a doctor about bleeding that returns after twelve months without a period, however light, about heavy or prolonged bleeding, persistent joint pain, low mood or anxiety that does not lift, and symptoms that dictate your day. Hormone therapy is a medical decision, taken with a doctor on your symptoms, your history and your own weighing of benefit and risk, and this article takes no position on it. Bone health belongs in that conversation too, because the years around the final period are the fastest window of change in bone density across a woman's life.

What is reasonable to do?

Plan around the things the evidence maps well: the bone window, the lean mass shift, the skin's slower collagen turnover, and a Swedish winter without vitamin D from the sun.

On the things within reach, the Swedish Public Health Agency, Folkhälsomyndigheten, recommends 150 to 300 minutes of moderate intensity activity per week, or 75 to 150 minutes at high intensity, plus muscle strengthening activity on at least two days a week. Given the lean mass and bone window above, the muscle strengthening half is the one most often skipped, and it is the half that supports the joints.

On supplements, the reasonable position is the one this article has taken throughout: named raw materials, named manufacturers, human studies in women of the relevant age, and the studied dose in the pack. Health Royals works with specialist manufacturers, researchers and supplier networks when raw materials are selected. We have done the selection so that you do not have to. Beauty Complete is the skin formula, with Cartidyss® at the 500 mg its study used. Peak Performance carries the vitamin D3, K2, B vitamins and omega 3 from algae, with Hytolive® and Extramel® at their studied doses. Hair Beautification is there if hair is the question. Our guide to menopause and midlife puts the three side by side. You can stop looking.

Read the menopause and midlife guide

Go deeper

• Guide: wellbeing from within
• Menopause and midlife: what changes in the body
• Perimenopause: the first signs, and when they usually begin
• Skin biology: structure, collagen and the barrier
• Stress and sleep: cortisol, rhythm and real recovery
• Healthy ageing: what happens in the body's cells
• Oral hyaluronic acid for skin
• Vitamin D3 for immunity, muscles and bones
• Vitamin K2: why it is taken with D3
• Branded ingredients: what the name actually guarantees

Frequently asked questions

Are perimenopause and menopause the same thing?
No. Perimenopause is the stage when levels swing but periods continue, often for several years. Menopause is the point at which periods have been absent for twelve months, identified in hindsight.

Do I need a blood test to know it is menopause?
Usually not. In otherwise healthy women over 45, NICE recommends diagnosing on symptoms and bleeding pattern without laboratory tests, because hormone levels swing widely during perimenopause.

Is joint pain really connected to menopause?
Stiffness and reduced mobility are common at this stage and have a described mechanism through connective tissue and glycosaminoglycans. Other conditions cause similar complaints, so persistent joint pain should be assessed by a doctor.

Which Health Royals supplement fits this decade?
Peak Performance carries the vitamin D3, K2, B vitamins and omega 3 from algae, for every day of the year. Beauty Complete is the skin supplement, with Cartidyss® at the 500 mg its study used, and Hair Beautification is there if hair is the question. Treatment for hot flushes is a medical matter to raise with a doctor.

How long before a supplement makes a difference?
Twelve weeks is the shortest sensible period to judge by, because skin and hair change on the timescale of their own renewal cycles. The study on Cartidyss® ran for 90 days and the study on Keranat® for twelve weeks.

Sources

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Important information

This article is general information and educational reading. It is not medical advice, and it does not diagnose, treat, cure or prevent any condition, including menopause or any of its symptoms. Food supplements are not a substitute for a varied diet and a balanced lifestyle. Decisions about hormone therapy or any other treatment should be made with a qualified healthcare professional. If you are pregnant, breastfeeding, taking medication or have a medical condition, speak to your doctor before taking a supplement.