Menopause research has a lot of catching up to do, and perimenopause even more so. Many of the questions in this guide still don't have firm answers.
So it's no surprise that experts don't agree on everything yet. Rather than hide the debates, we've gathered them here on one page, so you can see both sides and discuss them with your doctor.
23 topics
Defining menopause
One view
Standard: 12 months without a period (AHA, STRAW, WHO).
Another view
Doesn't fit women without periods, such as after hysterectomy or with an IUD; NICE allows diagnosis from age and symptoms in women over 45, including those without a uterus (NICE (opens in a new tab)).
Length of perimenopause
One view
About 8.5 years on average when it starts before 45, about 4.4 years when it starts at 51 or later (SWAN, via University of Michigan (opens in a new tab)).
Another view
Late transition of about 1 to 3 years, early transition variable (STRAW, in AHA statement).
Hormone swings
One view
Big estrogen spikes and drops are common as FSH rises (Hale et al., 2009 (opens in a new tab)).
Another view
Only some women show surges; about 29% have a fairly flat pattern (AHA).
Sleep
One view
Sleep disruption is a key symptom (Dr Mosconi).
Another view
Only about 15% show clearly worsening sleep in perimenopause; the rest is mostly ageing (AHA).
Mood by stage
One view
Highest bother in early perimenopause; stage still explains depression after accounting for age (2024 study).
Another view
Anxiety highest in late perimenopause; some studies find depression highest after menopause (other studies cited).
Age vs hormones in the brain
One view
Brain energy decline is tied to menopause, not age (Dr Mosconi).
Another view
Age explains differences in stress and anxiety (2024 study); brain energy use declines with ageing generally (brain review).
Treating perimenopausal depression
One view
Hormone therapy may lower the chance of new depressive symptoms in early perimenopause (one small trial, Gordon et al., 2018 (opens in a new tab)).
Another view
Estrogen isn't a standard depression treatment; antidepressants and talking therapy remain the proven options, though estrogen may help them work better (guidelines summary (opens in a new tab)); long-term benefits still uncertain (2024 study).
Hormone therapy and dementia
One view
Some clinicians believe early use may help protect the brain; research is ongoing (Dr Mosconi).
Another view
Not recommended to prevent dementia (USPSTF (opens in a new tab)); greater absolute dementia risk if started after 60 or 10+ years past menopause (Menopause Society (opens in a new tab)).
Hormone therapy and lifespan
One view
Started within 10 years of menopause, randomised studies show lower death rates from any cause (FDA (opens in a new tab), 2026; WHI pooled data).
Another view
Unlikely to increase or decrease overall life expectancy (NICE draft (opens in a new tab), 2023).
Hormone therapy for heart prevention
One view
Started early, it may lower heart disease and death (trial reviews in the AHA statement).
Another view
AHA 2011 and 2014 guidelines advised against using it specifically for heart or stroke prevention, and the USPSTF (opens in a new tab) recommends against it for preventing chronic disease.
Size of breast cancer risk
One view
About 5 to 20 extra cases per 1,000 women after 5 years, depending on type (MHRA (opens in a new tab), from a 2019 Lancet analysis).
Another view
Smaller: fewer than 1 extra case per 1,000 a year for women in their 50s on short-term combined therapy; estrogen-only risk marginal (BMJ 2020, via NIHR (opens in a new tab)). Some clinicians argue estrogen itself doesn't cause breast cancer (see the treatment chapter).
Vaginal estrogen after breast cancer
One view
Safe for virtually all women, including survivors (the view of some clinicians, such as US menopause specialist Dr Mary Claire Haver).
Another view
Appears safe for select survivors whose symptoms haven't responded to non-hormonal treatment (Menopause Society (opens in a new tab)).
The FDA's 2025–26 label change
One view
Removing boxed warnings gives women accurate, less fear-driven information (FDA (opens in a new tab)).
Another view
The FDA bypassed its usual public review process, and debate continues (AP (opens in a new tab)).
Stopping hormone therapy
One view
Neutral heart results after stopping (WHI).
Another view
Higher heart and stroke deaths in the first year after stopping (Finnish study).
Statins in women
One view
Older analyses found clearer benefit for women who already have heart disease than for prevention (AHA).
Another view
The largest analysis found similar benefit in women and men, including at low risk (CTT, Lancet 2015 (opens in a new tab)); guidelines recommend statins first-line regardless of sex (AHA).
When to stop contraception
One view
12 months without a period (WHO (opens in a new tab)).
Another view
2 years if your last period was before 50, 1 year if after, or at 55 (UK guidance (opens in a new tab)).
Plant estrogens and hot flashes
One view
A phytoestrogen-rich Mediterranean diet is linked to fewer hot flashes (Dr Mosconi).
Another view
The Menopause Society doesn't recommend soy or other supplements for hot flashes (2023 statement (opens in a new tab)). Note: one concerns whole diets, the other supplements.
Contraception and menopause timing
One view
Past pill use was linked to a later menopause in SWAN (Gold et al., 2013 (opens in a new tab)).
Another view
Evidence not conclusive (AHA).
Alcohol and menopause timing
One view
Research is limited, and alcohol has well-known health downsides.
Another view
Light to moderate drinking possibly linked to a slightly later menopause, but the effect is small (AHA).
Ethnicity and timing
One view
Some studies report differences between ethnic groups (AHA).
Another view
In SWAN, no difference once other factors were accounted for (Gold et al., 2013 (opens in a new tab)); differences may reflect socioeconomic factors (AHA).
Protein targets
One view
About 1.0 to 1.2 g per kg of body weight for older adults, more if active or ill (PROT-AGE (opens in a new tab)).
Another view
Up to 1 g per pound of body weight (about 2.2 g per kg), promoted by some fitness voices.
Intermittent fasting
One view
Protective for the brain in animal studies (brain review).
Another view
In people, no better than ordinary calorie cutting for weight loss (BMJ, 2025 (opens in a new tab)); evidence in menopause unclear.
Weighted vests and bone
One view
A small study found a vest plus jumping exercises helped stop hip bone loss.
Another view
A larger trial found vests didn't prevent bone loss during weight loss (Healio, 2026 (opens in a new tab)).
A note on the sources#
Not all evidence carries the same weight, so it helps to know where each piece comes from:
- Interviews and talks by clinicians, including two podcast interviews with US menopause specialist Dr Mary Claire Haver, were used as background. Where a statement rests on one clinician's opinion rather than published evidence, this guide names them. Dr Haver has a commercial interest in menopause supplements.
- Dr Mosconi's points come from a short public talk summarising her team's research, which she says still needs confirming.
- The probiotic trial was small, and some authors have ties to a probiotic company.
- The brain metabolism review is mostly based on animal research and isn't specific to menopause.
- The elinzanetant trials were funded by the drug's manufacturer.
