Originally published August 2017. Reviewed and updated August 2026 to reflect current guidance from The Menopause Society, the American Urological Association and the FDA.

Being a woman practitioner, I take care of a lot of women, and menopause is one of the most common conversations I have. Almost every time, the patient says some version of: “Nobody tells you it’s going to be like this.”

So let’s talk about the parts that get overlooked.

1. Irritability, anxiety and mood

A very common early symptom is irritability — and it is often aimed squarely at your spouse. The classic line in my office is “I can’t stand my husband and I have no idea why.” As estrogen falls, irritability, anger and anxiety often rise. You are not going crazy, and your marriage is probably fine.

But I want to correct something I wrote in the original version of this article. I said not to think you might have depression. That was wrong, and I’d rather say so than leave it.

Perimenopause is a genuine window of vulnerability for depression — including a first episode in women who have never had one. Mood symptoms here are not automatically “just hormones,” and they are treatable. So: you are not broken, and if you feel persistently low, hopeless, or not yourself, please tell someone. That is a thing to look at, not a thing to wait out.

2. Hot flashes

These are not a little sweat on the brow. This is waking at 2 a.m. soaked through. Patients describe it as “my body is on fire from the inside out.” Expect summer pajamas in February, and expect the fan to become your closest friend.

Good news since I first wrote this: there are now non-hormonal prescription options specifically for hot flashes — a newer class of medicines that works on the brain’s temperature-control pathway rather than on hormones. If hormone therapy isn’t right for you, that is no longer the end of the conversation.

3. Vaginal dryness, painful sex and repeat UTIs — one problem, not three

We used to treat these as separate complaints. We now call the whole cluster genitourinary syndrome of menopause, and the name is useful because it points to one cause and one treatment.

As estrogen falls, the vaginal walls thin and produce less glycogen. Glycogen feeds the good bacteria that keep the vagina acidic. Lose them and the pH climbs — and that shift lets the bacteria that cause urinary tract infections take hold. Same hormone, same tissue, three different-looking symptoms.

Which is why treating one improves the others. National guidelines now recommend vaginal estrogen for peri- and postmenopausal women with recurrent UTIs, specifically to prevent them.

And this matters, because old warning labels scared a lot of women off: low-dose vaginal estrogen is not the same as taking hormones systemically. Very little is absorbed into the bloodstream, and the FDA removed the boxed warning from these products in 2025. There are non-estrogen options too.

One more thing. Hot flashes eventually pass for most women. This doesn’t. Left alone it tends to get worse — so this is the one I’d not wait out.

I ask my patients at their annual exam whether sex hurts, because most women don’t volunteer it and most don’t realize how common it is. God made sex, and it is supposed to be enjoyable. There are easy remedies. Please ask.

4. Low libido

Between discomfort and the loss of both estrogen and testosterone, desire often drops. It is not a character flaw and it is not just “being tired.” Treating the discomfort helps more than people expect.

5. Weight — and what actually helps

“I haven’t changed a thing and I keep gaining weight.” I hear it constantly, and the research explains it better than “your metabolism slowed down.”

Through the transition, the rate of fat gain roughly doubles while lean muscle starts to drop. Those two partly cancel out, so the scale may barely move while your shape and how your clothes fit change completely. You are not imagining it. The fat also shifts inward, around the organs — the type that matters most for your heart.

That changes what actually works:

• Lift something heavy. This is what I left out of the original article and it is the most important piece. Cardio is good for your heart and I still want you doing it — but resistance training is the specific signal that tells your body to keep muscle. Two or three sessions a week. Weights, bands, or your own body weight all count.
• Eat more protein than you think. Estrogen loss makes it harder to build and keep muscle from the protein you eat, so the usual recommendations run low for women in midlife. And it works with lifting, not instead of it.
• On carbs — I’d rather you cut refined carbohydrates and added sugar than swear off bread and rice forever. Whole grains are good for your heart and your gut, and this is exactly the stage of life when both need attention.

6. The ones I left out

My original list was missing things women actually describe to me:

• Sleep. Not just “hot flashes wake me” — real insomnia that shows up on its own, wide awake at 3 a.m. for no reason. It drives a lot of the irritability and the brain fog.
• Brain fog. About 60% of women report it, and it is measurable — mostly word-finding and mental speed. Here is the part I most want you to hear: for the large majority of women it is temporary and settles after the transition. It is not early dementia. That fear brings women into my office in tears and it is almost always unfounded.
• Aching joints. One of the most common symptoms and least talked about — stiff hands in the morning, sore hips, a shoulder that suddenly won’t move. Estrogen has a role in joints and tendons, and this is often the result.
• Your bones. Bone loss speeds up sharply around your final period. Most women should have a bone density scan at 65, earlier with risk factors.
• Your heart. Cholesterol, blood pressure and where your body stores fat all shift now, and cardiovascular risk starts climbing. This is the one nobody warns you about, and long-term it’s the one that matters most. Menopause is a good moment to get those numbers checked.

So what do we do about it?

I tell women this: if your quality of life is fine, let the process happen and do nothing. But if you can’t sleep because of hot flashes, or you can’t have sex because of pain, let’s talk about treatment.

On hormone therapy specifically — the picture has changed a great deal since 2017. Much of the fear dates to early reporting from a large study whose participants were, on average, well past menopause; the risk-benefit balance looks different for healthy women who start closer to menopause. In 2025 the FDA removed the boxed warning from menopausal hormone therapy products, reflecting that reappraisal.

That is not the same as saying it is right for everyone. Unexplained bleeding, liver disease, or a history of breast cancer, clots, stroke or heart attack all change the calculation. Hormone therapy also treats symptoms — it is not something to take preventively if you feel fine. That is exactly the conversation to have with us, based on your history and your family’s.

You may also see supplements marketed for menopause. Some women find them helpful; the evidence behind most of them is weak, and “natural” does not mean inert or safe alongside your other medications. Tell us what you’re taking.

Come talk to us

We do this here. You can read about our hormone replacement therapy services, or just call (417) 332-3639 and let’s talk it through. If you’d rather start somewhere else, that is completely fine — just talk to someone. You do not have to white-knuckle this.

As always, I hope you stay happy and healthy.

Carolyn Clark, NP-C

This article is for general education and is not a substitute for individual medical advice. Whether any treatment described here is right for you depends on your personal and family medical history.