FOUNDATIONS

The 6 phases of menopause, named, STRAW+10 in plain English

Pre-peri, early peri, late peri, menopause, early post-meno, late post-meno. The science gave us the names. Here's what each one actually feels like, when it tends to happen, and what you should be focusing on at each stage.

The 6-phase framework

STRAW+10 was published in The Journal of Clinical Endocrinology & Metabolism in 2012 and remains the international reference. It divides the menopausal transition into six stages, anchored to cycle behavior rather than age. The point of the framework is to give clinicians (and you) something more precise than “going through the change”.

Note: STRAW+10 doesn't map perfectly onto every body. If you're on the combined pill, the Mirena, the implant, or post-hysterectomy, your cycle isn't a reliable signal and your phase has to be estimated other ways. We cover that below.

1. Pre-perimenopause (reproductive years)

Definition: regular menstrual cycles, ovaries fully functional, normal cyclical estradiol and progesterone.

Typical age: from puberty through to around 40.

What it feels like: the baseline. Cycles arrive predictably. PMS may be present but doesn't escalate year-on-year. The neuroscientist Lisa Mosconi describes the reproductive brain as a “period brain”, synaptic connections forming and regressing in time with your monthly hormonal rhythm. Mood, memory and sleep can wobble around your cycle, but they reset.

What to focus on: bone density (you build most of your peak bone mass by your late twenties; peri-menopause is the wrong time to start), muscle, vitamin D and protein, plus addressing any contraception-related issues now so you understand your baseline.

2. Early perimenopause

Definition: cycle length varies by 7 or more days from your usual. One cycle 25 days, the next 34. Occasional missed periods.

Typical age: 40 to 47, sometimes earlier.

What it feels like: something is different but you can't name it. Your PMS feels harder, three days now, plus a new rage. You wake at 3am with your heart racing. Your anxiety has a new edge. You forget the word “fridge” in the middle of a sentence. You cry watching a TV commercial. Hot flashes may or may not have started.

The driver here is mostly progesterone, not estrogen. By two years before your final period, around half of your cycles are progesterone-deficient. The sedating, anxiolytic, GABA-mediated effect of progesterone fades, and that is what fragments sleep and frays nerves first.

What to focus on: sleep architecture (this is the phase where insomnia establishes itself), strength training, alcohol reduction (perimenopausal women lose tolerance), and starting the conversation about HRT before symptoms become severe. The depression risk in early peri is around 40% higher than in pre-peri women.

3. Late perimenopause

Definition: at least one interval of 60 or more days between periods. FSH is reliably elevated. Once you've skipped two consecutive periods, your final period is statistically about 95% likely within the next four years.

Typical age: 45 to 52.

What it feels like: for most women, the most symptomatic phase. Hot flashes and night sweats hit their peak. Sleep is chronically broken. The classic “menopause middle” weight gain establishes. Vaginal dryness and the first painful sex appear. Joint pain becomes daily. Libido often drops. Brain fog is at its loudest.

What to focus on: if you're going to consider HRT, this is firmly inside the “timing window”. Cardiovascular health (lipids, blood pressure, ApoB if you can get it), bone density baseline, and protein/strength training intensified. This is also the phase where women most often present to doctors and are most often misdiagnosed as anxious or depressed.

4. Menopause (the date)

Definition: the day that marks 12 consecutive months since your last menstrual period. Confirmed retrospectively.

Typical age: median 49 globally; 51 in the US and most of the Western world. Normal range 45–55. Before 45 is “early menopause”; before 40 is “primary ovarian insufficiency” (POI) and warrants specialist care.

What it feels like: there isn't a single experiential “menopause day”. Most women only realise after the fact, when they tot up the calendar. The transition runs through this date relatively unchanged.

What to focus on: any bleeding after this date, a single spot, even, is a red flag for endometrial cancer until proven otherwise and warrants a same-week doctor appointment. Around 6–10% of post-menopausal bleeding turns out to be endometrial cancer; 90% of endometrial cancers present with at least one bleeding episode.

5. Early post-menopause (1–5 years after the final period)

Definition: the first five years after the final period. STRAW+10 subdivides this further (1a, 1b, 1c) but the practical picture is the same.

What it feels like: for many women, symptoms are still at or near their peak in year one and two, then start to subside. Vasomotor symptoms last a median 7.4 years across SWAN; a quarter of women are “super flashers” for 11 years or more. Genitourinary symptoms (vaginal dryness, recurrent UTIs, painful sex) tend to increase in this window without treatment, because local tissue is no longer being exposed to estrogen.

The brain is doing something interesting. Mosconi's imaging work shows the glucose metabolism of the female brain drops by around 30% across the transition, then partly recovers in early post-menopause as the brain neuroplastically adapts. Brain fog typically lifts by the end of this phase for the majority.

What to focus on: still inside the HRT timing window (within 10 years of the final period). Bone density scan if you have risk factors. Vaginal estrogen if you have any genitourinary symptoms, it is one of the safest interventions in all of menopause medicine and is endorsed even for many breast cancer survivors.

6. Late post-menopause (5+ years after the final period)

Definition: more than five years past the final period. Hormones have stabilised at their post-menopausal baseline.

What it feels like: for most women, the acute symptom load has eased. Vasomotor symptoms are subsiding. Mood is steadier. Cognition has often recovered. The amygdala, the brain's threat detector, is measurably less reactive to negative stimuli after menopause. This is the neurobiological underpinning of the “I give fewer f***s” effect that many women report.

What replaces the acute symptoms are the chronic risks, bone loss, cardiovascular disease, cognitive decline. One in three women will die of cardiovascular disease; one in two will have an osteoporotic fracture. This is the phase where the choices made in your forties pay off, or don't.

What to focus on: cardiovascular prevention (ApoB, blood pressure, fitness, weight), bone preservation (strength, vitamin D, protein, DEXA), cognitive reserve (cardio exercise, sleep, social engagement), and continuing vaginal estrogen if needed for life. HRT outside the timing window is a more individual conversation, net benefit becomes less clear after age 60 or more than 10 years post-menopause.

How phase changes what you should focus on

Phase is not just a label. It changes the priority order of interventions:

• · Early peri, sleep, mood, progesterone-driven symptoms, baseline labs, conversation with your doctor before things escalate.
• · Late peri, vasomotor symptoms, HRT decision, GU symptoms, lipid panel.
• · Early post-meno, still inside HRT timing window; vaginal estrogen; bone scan if risk factors.
• · Late post-meno, chronic risk prevention (cardio, bone, cognition); HRT becomes a more individual cost-benefit conversation.

Why phase detection is harder when you're on contraception

STRAW+10 leans heavily on cycle pattern, which is exactly what hormonal contraception erases. If you're on the combined pill in your forties, you're bleeding monthly because of the seven-day break, not because your ovaries are still ovulating. The Mirena IUS often stops periods entirely. The implant and the progestogen-only pill produce unpredictable bleeding that doesn't track ovarian status.

In these situations, phase has to be inferred from symptoms and, sometimes, cautiously timed blood tests. Current menopause guidelines suggest checking FSH twice, 4–6 weeks apart, in women aged 40–45 with menopausal symptoms while on the progestogen-only pill, Mirena or implant, but the result still needs careful clinical interpretation.

Post-hysterectomy women (without ovary removal) experience the same hormonal transition with no menstrual signal at all, phase is symptom-based by necessity. For women who had a bilateral oophorectomy (BSO), menopause is instantaneous on the operating table and HRT is normally recommended until at least the average age of natural menopause.

When labs help vs when they don't

Current menopause guidelines are direct: in women over 45 with typical symptoms, no blood test is needed. Phase is clinical.

Where labs help:

• · Women under 40 with menopausal symptoms (suspected POI), FSH twice, 4 weeks apart, plus estradiol.
• · Women 40–45 with menopausal symptoms, FSH can help confirm.
• · Women on hormonal contraception, where cycle pattern is unreliable.
• · Symptoms that don't fit perimenopause, to rule out thyroid disease, anaemia, vitamin D deficiency, diabetes.

Where labs mislead: a single FSH reading in early peri can come back fully pre-menopausal one week and fully post-menopausal the next. Salivary hormone panels, the DUTCH test, and most direct-to-consumer “menopause home test kits” are not validated for diagnosis and should not change clinical decisions.

Related reading

If you arrived here looking for a starting point, our plain-English guide to perimenopause is the place to begin. For an HRT-focused next step, see HRT, what you need to know in 2026. To identify the symptoms you're tracking, head to all 47 menopause symptoms.