This page collects the primary research, clinical guidelines, and scholarly sources cited throughout this guide. References are organized by topic with anchor links for easy navigation.
Foundational Studies
SWAN — Study of Women’s Health Across the Nation
The largest, longest-running longitudinal study of women through the menopausal transition. Much of what we know about symptom patterns, duration, and racial/ethnic differences comes from SWAN data.
Sowers M, et al. “SWAN: A Multicenter, Multiethnic, Community-Based Cohort Study of Women and the Menopausal Transition.” In: Menopause: Biology and Pathobiology. Academic Press, 2000. SWAN Study Site
Avis NE, et al. “Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition.” JAMA Internal Medicine. 2015;175(4):531-539. Key finding: Median total vasomotor symptom duration was 7.4 years, with significant variation by race/ethnicity.
Freeman EW, et al. “Duration of Menopausal Hot Flushes and Associated Risk Factors.” Obstetrics & Gynecology. 2011;117(5):1095-1104. Key finding: Black women experienced vasomotor symptoms for a median of 10 years, compared to 6.5 years for white women.
Bromberger JT, et al. “Depressive Symptoms During the Menopausal Transition: The Study of Women’s Health Across the Nation (SWAN).” Journal of Affective Disorders. 2007;103(1-3):267-272. Key finding: Risk of depression increases 2-4 times during perimenopause.
Greendale GA, et al. “Effects of the Menopause Transition and Hormone Use on Cognitive Performance in Midlife Women.” Neurology. 2009;72(21):1850-1857. Key finding: Cognitive difficulties during perimenopause are measurable and generally improve postmenopause.
Kravitz HM, et al. “Sleep Disturbance During the Menopausal Transition in a Multi-Ethnic Community Sample of Women.” Sleep. 2008;31(7):979-990.
Women’s Health Initiative (WHI)
The study that shaped—and complicated—our understanding of hormone therapy.
Writing Group for the WHI Investigators. “Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women.” JAMA. 2002;288(3):321-333. The original WHI findings that led to widespread abandonment of HT.
Rossouw JE, et al. “Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause.” JAMA. 2007;297(13):1465-1477. Key reanalysis showing timing matters—the basis for the timing hypothesis.
WHI Steering Committee. “Effects of Conjugated Equine Estrogen in Postmenopausal Women with Hysterectomy.” JAMA. 2004;291(14):1701-1712. Estrogen-alone arm showed different risk profile than combined therapy.
Manson JE, et al. “Menopausal Hormone Therapy and Health Outcomes During the Intervention and Extended Poststopping Phases of the Women’s Health Initiative Randomized Trials.” JAMA. 2013;310(13):1353-1368. Long-term follow-up data.
KEEPS and ELITE
Studies that helped establish the timing hypothesis for hormone therapy.
Harman SM, et al. “Timing and Duration of Menopausal Hormone Treatment May Affect Cardiovascular Outcomes.” American Journal of Medicine. 2011;124(3):199-205.
Hodis HN, et al. “Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol.” New England Journal of Medicine. 2016;374(13):1221-1231. Key finding: Early initiation (within 6 years of menopause) slowed atherosclerosis progression.
Hormonal Landscape & Physiology
Harlow SD, et al. “Executive Summary of the Stages of Reproductive Aging Workshop +10: Addressing the Unfinished Agenda of Staging Reproductive Aging.” Menopause. 2012;19(4):387-395. The STRAW+10 staging system that defines perimenopause.
Prior JC. “Perimenopause: The Complex Endocrinology of the Menopausal Transition.” Endocrine Reviews. 1998;19(4):397-428. Key finding: Estradiol levels during perimenopause can exceed premenopausal levels by 20-30% in many cycles.
Santoro N, et al. “Perimenopause: From Research to Practice.” Journal of Women’s Health. 2016;25(4):332-339.
Gold EB. “The Timing of the Age at Which Natural Menopause Occurs.” Obstetrics and Gynecology Clinics of North America. 2011;38(3):425-440.
Hot Flashes & Vasomotor Symptoms
Rance NE, et al. “Modulation of Body Temperature and LH Secretion by Hypothalamic KNDy (Kisspeptin, Neurokinin B and Dynorphin) Neurons: A Novel Hypothesis on the Mechanism of Hot Flushes.” Frontiers in Neuroendocrinology. 2013;34(3):211-227. Discovery of KNDy neurons and their role in thermoregulation.
Padilla SL, et al. “Kisspeptin Neurons in the Arcuate Nucleus of the Hypothalamus Orchestrate Circadian Rhythms and Metabolism.” Current Biology. 2019;29(4):592-604. Further research on KNDy neuron function.
Freeman EW, Sherif K. “Prevalence of Hot Flushes and Night Sweats Around the World: A Systematic Review.” Climacteric. 2007;10(3):197-214.
Brown JN, et al. “Association of Menopausal Vasomotor Symptom Severity with Sleep and Work Impairments: A US Survey.” Menopause. 2023;30(9):897-904. Key finding: 90.8% of women reported VMS affects sleep; 83.1% reported sleep-related changes in productivity. For severe VMS, 97.7% reported sleep impact.
Zhu D, et al. “Vasomotor Menopausal Symptoms and Risk of Cardiovascular Disease: A Pooled Analysis of Six Prospective Studies.” American Journal of Obstetrics & Gynecology. 2020;223(6):898.e1-898.e16. Key finding: Severe hot flashes associated with 83% higher CVD risk; night sweats with 59% higher risk. VMS may serve as markers for cardiovascular risk.
Thurston RC, et al. “Hot Flashes and Subclinical Cardiovascular Disease: Findings from the Study of Women’s Health Across the Nation Heart Study.” Circulation. 2008;118(12):1234-1240. Key finding: Women with hot flashes had evidence of poorer endothelial function and higher aortic calcification, suggesting hot flashes may be markers of adverse vascular changes.
Mood & Mental Health
Freeman EW, et al. “Hormones and Menopausal Status as Predictors of Depression in Women in Transition to Menopause.” Archives of General Psychiatry. 2004;61(1):62-70. Key finding: Women with no history of depression were 2-4 times more likely to develop depression during perimenopause.
Bromberger JT, Epperson CN. “Depression During and After the Perimenopause: Impact of Hormones, Genetics, and Environmental Determinants of Disease.” Obstetrics and Gynecology Clinics of North America. 2018;45(4):663-678.
Perich T, et al. “Menopause and Illness Course in Bipolar Disorder: A Systematic Review.” Bipolar Disorders. 2021;23(1):29-41.
Di Florio A, et al. “Exploration of First Onsets of Mania, Schizophrenia Spectrum Disorders and Major Depressive Disorder in Perimenopause.” Nature Mental Health. 2024. Key finding: Women are over twice as likely (112% increase) to develop bipolar disorder for the first time during perimenopause compared to before menopause.
Cognitive Changes
Maki PM, Henderson VW. “Cognition and the Menopause Transition.” Menopause. 2016;23(7):803-805.
Kilpi F, et al. “Cognitive Functioning in Perimenopause: An Updated Systematic Review and Meta-Analysis.” Maturitas. 2024. Key finding: Perimenopausal women show measurable deficits in verbal memory, processing speed, attention, and working memory compared to premenopausal women.
Weber MT, et al. “Cognition and Mood in Perimenopause: A Systematic Review and Meta-Analysis.” Journal of Steroid Biochemistry and Molecular Biology. 2014;142:90-98. Key finding: Cognitive difficulties during perimenopause are measurable but generally temporary.
Sleep
Baker FC, et al. “Sleep Problems During the Menopausal Transition: Prevalence, Impact, and Management Challenges.” Nature and Science of Sleep. 2018;10:73-95. Key finding: Approximately 40% of perimenopausal women experience significant sleep disruption.
Mirer AG, et al. “Menopausal Hormone Therapy and Sleep-Disordered Breathing: Evidence from the Wisconsin Sleep Cohort.” Menopause. 2017;24(8):856-863.
Young T, et al. “Predictors of Sleep-Disordered Breathing in Community-Dwelling Adults: The Sleep Heart Health Study.” Archives of Internal Medicine. 2002;162(8):893-900.
Young T, et al. “Menopausal Status and Sleep-Disordered Breathing in the Wisconsin Sleep Cohort Study.” American Journal of Respiratory and Critical Care Medicine. 2003;167(9):1181-1185. Key finding: Postmenopausal women have significantly higher prevalence of sleep apnea; the Wisconsin Sleep Cohort found 2.6-fold increased risk in postmenopausal vs premenopausal women.
Peppard PE, et al. “Increased Prevalence of Sleep-Disordered Breathing in Adults.” American Journal of Epidemiology. 2013;177(9):1006-1014.
Body Composition & Weight
Lovejoy JC, et al. “Increased Visceral Fat and Decreased Energy Expenditure During the Menopausal Transition.” International Journal of Obesity. 2008;32(6):949-958.
Greendale GA, et al. “Changes in Body Composition and Weight During the Menopause Transition.” JCI Insight. 2019;4(5):e124865. Key finding: Fat redistribution to visceral stores occurs regardless of total weight change.
Lundgren JR, et al. “Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined.” New England Journal of Medicine. 2021;384(18):1719-1730.
Korytkowski MT, et al. “Body Weight Reduction in Women Treated with Tirzepatide by Reproductive Stage: A Post Hoc Analysis from the SURMOUNT Program.” Diabetes, Obesity & Metabolism. 2025;27(5):2399-2407. Key finding: Tirzepatide produced approximately 20-23% weight reduction regardless of whether women were pre-, peri-, or postmenopausal.
Pelvic Floor & Urogenital
Nygaard I, et al. “Prevalence of Symptomatic Pelvic Floor Disorders in US Women.” JAMA. 2008;300(11):1311-1316. Key finding: Nearly 1 in 4 women experience pelvic floor disorders; prevalence increases significantly with menopause.
Nappi RE, Kokot-Kierepa M. “Vaginal Health: Insights, Views and Attitudes (VIVA) Survey.” Climacteric. 2012;15(Suppl 1):36-44. Key finding: 45% of postmenopausal women reported experiencing vaginal symptoms.
Portman DJ, Gass ML. “Genitourinary Syndrome of Menopause: New Terminology for Vulvovaginal Atrophy.” Menopause. 2014;21(10):1063-1068. Key finding: Unlike vasomotor symptoms, GSM symptoms are progressive and do not resolve without treatment.
Wu JM, et al. “Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women.” Obstetrics & Gynecology. 2014;123(1):141-148.
ACOG Committee Opinion No. 659. “The Use of Vaginal Estrogen in Women with a History of Estrogen-Dependent Breast Cancer.” Obstetrics & Gynecology. 2016;127(3):e93-e96.
Skin Changes
Brincat M, et al. “A Study of the Decrease of Skin Collagen Content, Skin Thickness, and Bone Mass in the Postmenopausal Woman.” Obstetrics & Gynecology. 1987;70(6):840-845. Key finding: Women lose approximately 30% of skin collagen in the first 5 years after menopause, correlating more closely with duration of estrogen deficiency than chronological age.
Eyes
Menopause Society. “Dry Eye and Menopause: Mechanisms and Management.” The Menopause Society. 2025. Key finding: Over 57% of menopausal women report dry eye symptoms, with hormonal changes affecting tear production and tear film composition.
Bone Health
Finkelstein JS, et al. “Bone Mineral Density Changes During the Menopause Transition in a Multiethnic Cohort of Women.” Journal of Clinical Endocrinology & Metabolism. 2008;93(3):861-868. Key finding: Most rapid bone loss occurs in late perimenopause and early postmenopause.
Cardiovascular
El Khoudary SR, et al. “Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association.” Circulation. 2020;142(25):e506-e532.
NK3 Receptor Antagonists
Johnson KA, et al. “Efficacy and Safety of Fezolinetant in Moderate to Severe Vasomotor Symptoms Associated With Menopause: A Phase 3 RCT.” Journal of Clinical Endocrinology & Metabolism. 2023;108(8):1981-1997.
Depypere H, et al. “Efficacy and Safety of Elinzanetant, a Selective Neurokinin Receptor Antagonist for Vasomotor Symptoms.” Menopause. 2024;31(1):9-18.
FDA News Release. “FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause.” December 2024.
Non-Hormonal Treatments
The Menopause Society. “2023 Nonhormone Therapy Position Statement.” Menopause. 2023;30(6):573-590.
Loprinzi CL, et al. “Venlafaxine in Management of Hot Flashes in Survivors of Breast Cancer: A Randomised Controlled Trial.” Lancet. 2000;356(9247):2059-2063.
Guttuso T Jr, et al. “Gabapentin’s Effects on Hot Flashes in Postmenopausal Women: A Randomized Controlled Trial.” Obstetrics & Gynecology. 2003;101(2):337-345.
Hormone Therapy Guidelines
The Menopause Society. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society.” Menopause. 2022;29(7):767-794.
National Institute for Health and Care Excellence. “Menopause: Diagnosis and Management.” NICE Guideline NG23. November 2015, updated 2019.
Herbal & Complementary Approaches
Leach MJ, Moore V. “Black Cohosh (Cimicifuga spp.) for Menopausal Symptoms.” Cochrane Database of Systematic Reviews. 2012;(9):CD007244. Key finding: Insufficient evidence to support efficacy; no significant difference from placebo in hot flush frequency, though safe for short-term use.
Lethaby A, et al. “Phytoestrogens for Menopausal Vasomotor Symptoms.” Cochrane Database of Systematic Reviews. 2013;(12):CD001395.
Kanadys W, et al. “Evaluation of Clinical Meaningfulness of Red Clover (Trifolium pratense L.) Extract to Relieve Hot Flushes and Menopausal Symptoms in Peri- and Post-Menopausal Women: A Systematic Review and Meta-Analysis.” Nutrients. 2021;13(4):1258. Key finding: Statistically significant reduction in hot flushes (−1.73/day vs placebo); more effective at ≥80mg/day isoflavones and in women with ≥5 hot flushes daily.
Linde K, et al. “St John’s Wort for Major Depression.” Cochrane Database of Systematic Reviews. 2008;(4):CD000448. Key finding: Superior to placebo for mild-moderate depression; similarly effective as standard antidepressants with fewer side effects. Significant drug interactions.
Ghazanfarpour M, et al. “The Effect of Salvia Officinalis on Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis.” Journal of Multidisciplinary Healthcare. 2023;16:1857-1867. Key finding: Multiple RCTs show significant reduction in hot flash frequency and severity; considered safe for short-term use.
Akhgarjand C, et al. “Does Ashwagandha Supplementation Have a Beneficial Effect on the Management of Anxiety and Stress? A Systematic Review and Meta-Analysis.” Journal of Ethnopharmacology. 2022;295:115471. Key finding: Significant reductions in anxiety (SMD: −1.55) and stress levels (SMD: −1.75) vs placebo; also reduces serum cortisol.
Bent S, et al. “Valerian for Sleep: A Systematic Review and Meta-Analysis.” American Journal of Medicine. 2006;119(12):1005-1012. Key finding: May improve subjective sleep quality (RR 1.8 for improved sleep); evidence limited by methodological issues.
Kongkeaw C, et al. “Meta-Analysis of Randomized Controlled Trials on Cognitive Effects of Bacopa monnieri Extract.” Journal of Ethnopharmacology. 2014;151(1):528-535. Key finding: Improved speed of attention and cognitive processing in 9 RCTs (437 subjects); well-tolerated.
Heyerick A, et al. “A First Prospective, Randomized, Double-Blind, Placebo-Controlled Study on the Use of a Standardized Hop Extract to Alleviate Menopausal Discomforts.” Maturitas. 2006;54(2):164-175. Key finding: 8-prenylnaringenin (100μg) significantly reduced menopausal symptoms vs placebo at 6 weeks; rapid improvement in hot flushes.
Bhosal SK, et al. “Efficacy and Safety of Shatavari (Asparagus racemosus) Root Extract for Perimenopause.” International Journal of Women’s Health. 2025;17:999-1014. Key finding: Significant reduction in Menopausal Rating Scale (51-73% depending on dose); phytoestrogens bind to estrogen receptors.
Chen LR, et al. “Chinese Herbal Formulae for the Treatment of Menopausal Hot Flushes: A Systematic Review and Meta-Analysis.” PLOS ONE. 2019;14(9):e0222383. Key finding: 19 RCTs (2469 patients); similar effectiveness to HT with fewer adverse events; quality of evidence moderate.
Ayers B, et al. “Effectiveness of Group and Self-Help Cognitive Behavior Therapy in Reducing Problematic Menopausal Hot Flushes and Night Sweats (MENOS 2): A Randomized Controlled Trial.” Menopause. 2012;19(7):749-759.
Race, Ethnicity & Health Disparities
Gold EB, et al. “Factors Related to Age at Natural Menopause: Longitudinal Analyses From SWAN.” American Journal of Epidemiology. 2013;178(1):70-83. Key finding: Black and Hispanic women experience menopause approximately 2 years earlier than white women.
Pinkerton JV, et al. “Racial and Ethnic Differences in Access to Menopause Care in the US.” Menopause. 2023;30(9):897-905.
Hoffman KM, et al. “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites.” Proceedings of the National Academy of Sciences. 2016;113(16):4296-4301.
LGBTQ+ Health
Bryson MK, et al. “Menopause and Aging LGBTQ2S+ Canadians: A Scoping Review.” Sociology of Health & Illness. 2023;45(4):778-797.
UCSF Transgender Care. “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.” 2016, updated 2022.
Surgical & Premature Menopause
Rocca WA, et al. “Oophorectomy, Menopause, Estrogen, and Cognitive Aging: The Timing Hypothesis.” Neurodegenerative Diseases. 2010;7(1-3):163-166.
Shuster LT, et al. “Premature Menopause or Early Menopause: Long-Term Health Consequences.” Maturitas. 2010;65(2):161-166.
Neurodivergence & Menopause
Quinn PO, Madhoo M. “A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis.” Primary Care Companion for CNS Disorders. 2014;16(3):PCC.13r01596.
Moseley RL, et al. “Autistic Women’s Experiences of the Menopause and Perimenopause.” Autism. 2024;28(1):254-272.
Medical Education
Kling JM, et al. “Needs Assessment of Menopause Education in United States Obstetrics and Gynecology Residency Training Programs.” Menopause. 2023;30(11):1102-1108. Key finding: Only 31% of US OB/GYN residency programs have a menopause curriculum; 83.8% of program directors agree they need more menopause educational resources.
This reference list is maintained alongside content updates. Last reviewed: January 2026.