What really happens to estrogen during perimenopause and menopause?

Estradiol, estrone, body fat and the hormonal changes that affect far more than your period.

Most women know that estrogen levels decline during menopause. But what does that actually mean?

Does estrogen simply disappear? Why can hormonal changes affect everything from sleep and body temperature to skin elasticity, vaginal comfort and urinary health? And if the ovaries stop producing estrogen, why does the body continue making some of it elsewhere?

The answer is more interesting than a simple hormonal decline.

Estrogen isn't just one hormone. It's a family of hormones involved in maintaining many of the tissues and systems that keep our bodies functioning.

And understanding what happens to them during perimenopause and menopause can explain a great deal about the changes we experience.

First, estrogen isn't just one hormone

When we talk about estrogen, we're actually referring to a group of related hormones.

The three main naturally occurring estrogens are:

Estradiol (E2): The most potent of the three main natural estrogens and the predominant circulating estrogen during the reproductive years. It's primarily produced by the ovaries and plays an essential role in the menstrual cycle, bone health, skin, vaginal tissues and many other functions.

Estrone (E1): A less potent estrogen that becomes the predominant circulating estrogen after menopause. Much of it is produced outside the ovaries, particularly through processes involving adipose tissue, commonly known as body fat.

Estriol (E3): A relatively weak estrogen that becomes especially important during pregnancy, when the placenta produces large amounts of it.

These hormones are related, but they aren't interchangeable. They differ in potency, concentration, metabolism and how they interact with estrogen receptors throughout the body.

And this distinction becomes particularly important during menopause.

What exactly is estradiol?

Estradiol is the main estrogen produced by the ovaries during the reproductive years.

But calling it a reproductive hormone doesn't come close to describing everything it does.

Estradiol interacts with estrogen receptors found in tissues throughout the body, including the brain, bones, skin, blood vessels, breasts, vagina and urinary tract.

Think of these receptors as biological communication systems. When estradiol binds to them, it can influence how cells grow, repair themselves, produce proteins and respond to their environment.

In the skin, estradiol helps support collagen production, hydration and elasticity.

In the bones, it helps regulate the balance between bone formation and bone breakdown.

In the vagina, it helps maintain tissue thickness, blood flow, elasticity and the conditions that support a healthy vaginal microbiome.

In the brain, estrogen participates in processes involved in temperature regulation, cognition, mood and sleep.

This is why changes in estradiol can have effects far beyond menstruation.

Perimenopause: when estrogen becomes unpredictable

One of the biggest misconceptions about perimenopause is that estrogen simply begins to fall in a straight line.

It doesn't.

During the reproductive years, the ovaries contain follicles that develop in response to hormonal signals from the brain. As ovarian follicles become fewer and less responsive with age, this communication becomes less predictable.

Early in perimenopause, estradiol levels can fluctuate dramatically.

Some cycles may involve relatively high estradiol levels. Others may involve much lower levels. Ovulation may occur inconsistently, and progesterone production can become irregular as a result.

This hormonal variability helps explain why symptoms can appear and disappear, or change significantly from one month to another.

You might experience breast tenderness, disrupted sleep or heavier periods during one cycle, followed by vaginal dryness or hot flushes during another.

It also explains why a single blood test doesn't always tell the full story. Estradiol and FSH levels can vary considerably during perimenopause.

Perimenopause isn't simply a state of low estrogen. It's often a period of unpredictable estrogen fluctuations.

The hormonal conversation: FSH, LH, progesterone and testosterone

Estradiol doesn't work independently. It's part of a hormonal communication system involving the brain, ovaries and other tissues.

Two important hormones in this system are FSH (follicle-stimulating hormone) and LH (luteinizing hormone).

Both are released by the pituitary gland in response to signals from the hypothalamus.

FSH helps stimulate ovarian follicle development. LH contributes to ovulation and the production of ovarian hormones.

As ovarian follicles decline, production of a hormone called inhibin B decreases. This reduces the feedback that normally helps regulate FSH, allowing FSH levels to rise.

Meanwhile, estradiol production becomes increasingly variable.

Progesterone is also part of this picture.

During reproductive years, progesterone is produced mainly by the corpus luteum after ovulation. When ovulation becomes irregular, progesterone production becomes irregular too.

This changing relationship between estradiol and progesterone can contribute to menstrual changes during perimenopause.

And then there's testosterone.

Although commonly described as a male hormone, testosterone is also naturally present in women's bodies. It is produced by the ovaries and adrenal glands, and through conversion in peripheral tissues.

Testosterone and other androgens are involved in sexual function and also serve as precursors for estrogen production.

That last point becomes particularly important after menopause.

What happens when the ovaries stop producing estradiol?

Menopause is officially diagnosed after 12 consecutive months without menstruation, provided there is no other explanation.

By this stage, ovarian follicular activity has declined substantially, and the ovaries produce much less estradiol.

But here's something worth understanding:

Your body doesn't stop producing estrogen entirely. It changes where and how much of it is produced.

Before menopause, the ovaries are the principal source of circulating estradiol.

After menopause, estrogen production depends much more heavily on tissues outside the ovaries.

And one of the most important is adipose tissue.

Your body fat produces estrogen. But it's mostly estrone, not estradiol.

Body fat is far more than an energy reserve.

Adipose tissue is metabolically and hormonally active. It participates in inflammation, energy regulation and the metabolism of several hormones.

It also contains an enzyme called aromatase.

Aromatase converts certain androgens into estrogens.

For example, androstenedione, an androgen produced by the adrenal glands and ovaries, can be converted into estrone.

Testosterone can also be converted into estradiol.

After menopause, the conversion of androgen precursors into estrogen in peripheral tissues becomes a particularly important source of estrogenic activity.

Estrone becomes the predominant circulating estrogen, although its levels are generally much lower than the estradiol concentrations seen during reproductive years.

And estrone isn't biologically inactive.

It can bind to estrogen receptors, although it is generally less potent than estradiol. It can also be converted into estradiol within certain tissues through enzymes called 17β-hydroxysteroid dehydrogenases.

This means that some tissues can produce or activate estrogens locally, even when circulating estradiol levels are low.

However, local estrogen production doesn't necessarily translate into the same systemic effects as the estradiol previously produced by the ovaries.

Does having more body fat mean having more estrogen?

In general, greater adipose tissue mass can be associated with higher estrogen production after menopause because more tissue is available for peripheral aromatization.

But that doesn't mean gaining weight is an effective or advisable way to manage menopause.

Adipose tissue also influences insulin sensitivity, inflammation and cardiovascular risk. Higher body fat levels after menopause are associated with important metabolic and health considerations, including an increased risk of certain estrogen-sensitive cancers.

More estrogen production from body fat does not automatically mean better hormonal balance or healthier tissues.

The relationship is much more complex.

What happens to your skin when estradiol declines?

Skin is an estrogen-responsive organ.

Estrogen receptors are found in several types of skin cells, including fibroblasts, keratinocytes and cells involved in skin repair.

Estradiol influences several processes that help maintain skin structure and function.

Collagen production

Collagen is one of the main structural proteins responsible for skin strength and firmness.

Declining estrogen levels are associated with a reduction in skin collagen, contributing to changes in thickness, firmness and elasticity.

Hydration

Estrogen influences components of the skin's extracellular matrix, including molecules involved in retaining water, such as hyaluronic acid.

As estrogen levels decline, skin may become drier and less comfortable.

Elasticity and repair

Estrogen contributes to tissue maintenance, wound healing and the regulation of certain inflammatory processes.

Lower estrogen levels may contribute to slower skin repair and changes in elasticity.

Skin barrier function

Hormonal changes can also affect how effectively skin retains moisture and responds to environmental stress.

However, not every skin change during midlife is caused by estrogen alone. Chronological ageing, genetics, UV exposure, environmental factors and overall health also play important roles.

Your intimate skin is especially sensitive to estrogen changes

The vulva, vagina and lower urinary tract contain estrogen-responsive tissues.

And these tissues can be particularly affected when estrogen levels decline.

Estradiol helps maintain the thickness, elasticity, blood supply and hydration of vaginal tissues.

It also influences collagen and other structural components that help tissues stretch and recover.

As estrogen levels fall, several changes may occur:

• Vaginal tissues can become thinner and more fragile.

• Natural lubrication and vaginal secretions may decrease.

• Tissue elasticity can decline.

• Vulvar skin and mucosal surfaces may become more sensitive to friction.

• Burning, irritation and discomfort may become more common.

• Sexual activity may become uncomfortable or painful.

These changes can begin during perimenopause, not just after menopause.

And they aren't simply a question of producing less lubrication.

They involve changes in the structure and function of the tissues themselves.

Estrogen also helps maintain your vaginal microbiome

One of estrogen's lesser-known roles is its relationship with the vaginal microbiome.

During reproductive years, estrogen supports the maturation of vaginal epithelial cells and the accumulation of glycogen within them.

As these cells naturally shed, glycogen-derived carbohydrates become available to microorganisms living in the vagina.

Certain Lactobacillus species contribute to the production of lactic acid, helping maintain the typically acidic vaginal environment.

This acidity is one of the mechanisms that helps protect the vaginal ecosystem.

When estrogen levels decline, the vaginal epithelium may contain less glycogen, and the microbial environment can change.

Some women experience a reduction in Lactobacillus dominance and an increase in vaginal pH.

These changes can contribute to irritation, altered vaginal flora and greater susceptibility to certain infections.

Not every postmenopausal woman experiences the same microbiome changes, but the relationship between estrogen, vaginal tissues and microbial balance is well established.

Hormones influence your intimate microbiome. And your intimate microbiome is part of your overall intimate health.

Why can menopause affect your bladder too?

The vagina and urinary tract share developmental and hormonal characteristics.

Estrogen receptors are present in tissues of the urethra, bladder and surrounding structures.

When estrogen levels decline, changes in tissue thickness, elasticity and local microbial conditions can contribute to urinary symptoms.

These may include increased urgency, frequency, discomfort during urination and recurrent urinary tract infections.

The combination of vulvovaginal and urinary changes associated with declining estrogen and other sex hormones is known as genitourinary syndrome of menopause, or GSM.

Unlike some menopausal symptoms, which may become less troublesome over time, GSM symptoms can persist or progress without appropriate management.

They are common, but they are not something women simply have to accept.

Estrogen matters to your bones, brain and cardiovascular system too

The effects of estrogen extend well beyond intimate health.

Bone health

Estradiol helps regulate bone remodelling by limiting excessive bone breakdown.

When estrogen declines, bone resorption can accelerate, increasing the risk of bone loss and osteoporosis.

This is one reason why bone health becomes particularly important during and after the menopausal transition.

Brain and temperature regulation

Estrogen interacts with several neurological systems involved in temperature regulation, sleep and cognitive function.

Changes in estrogen signalling are associated with vasomotor symptoms such as hot flushes and night sweats.

Sleep disruption, mood changes and difficulties with concentration may also occur during the menopausal transition, although their causes are often multifactorial.

Cardiovascular and metabolic health

Estrogen influences blood vessel function, lipid metabolism and fat distribution.

During the menopausal transition, many women experience changes in cholesterol levels, insulin sensitivity and the distribution of body fat, with a tendency toward greater abdominal fat accumulation.

Ageing and lifestyle factors also contribute to these changes.

Estrogen has important physiological effects on cardiovascular tissues, but that doesn't mean menopausal hormone therapy should be used solely to prevent cardiovascular disease.

Treatment decisions depend on individual symptoms, age, medical history and risk factors.

Can we replace the estradiol our ovaries no longer produce?

For some women, menopausal hormone therapy can be an effective option for managing symptoms associated with declining estrogen.

Systemic hormone therapy, which may contain estradiol, can help treat symptoms such as hot flushes and night sweats, and can help prevent bone loss in appropriately selected patients.

For women with a uterus, systemic estrogen generally needs to be combined with adequate progesterone or another progestogen to protect the endometrium.

For vulvovaginal symptoms, low-dose local vaginal estrogen may be recommended.

Unlike non-hormonal moisturizers or lubricants, local estrogen therapy can directly address some of the estrogen-related structural changes in vaginal tissues.

Non-hormonal moisturizers, lubricants and appropriate external skin care can also play an important role in improving comfort, reducing friction and supporting everyday intimate care.

These approaches aren't necessarily alternatives to one another. Depending on individual needs, they can be complementary.

And none should be presented as a universal solution.

A healthcare professional can help determine the most appropriate approach, particularly for women with a history of hormone-sensitive conditions.

What does all this mean for your intimate care routine?

Understanding estrogen changes helps explain why a routine that worked perfectly in your thirties might not feel right in your forties or fifties.

Your tissues may have different needs.

Skin that once tolerated fragranced cleansers or frequent washing may become more reactive.

Vulvar skin may feel drier or more sensitive to friction.

Intimacy may require additional lubrication.

And discomfort that once seemed temporary may become more persistent.

These changes don't mean your body is failing.

They mean its hormonal environment has changed, and the tissues responding to that environment may need different care.

Gentle cleansing, avoiding unnecessary irritants, appropriate moisturization and lubrication can all help support comfort.

Persistent dryness, burning, urinary symptoms or pain deserve medical assessment, because they may require targeted treatment rather than skincare alone.

Menopause isn't the end of estrogen. It's a change in how your body produces and responds to it.

The transition from estradiol-dominant ovarian production to lower levels of estrogen, with estrone becoming the predominant circulating form, is one of the most significant hormonal changes in a woman's life.

But it's not just a reproductive event.

It affects tissues throughout the body, from the bones and brain to the skin, vagina and urinary tract.

Understanding these changes gives us a better way to respond to them.

Not by treating every symptom as inevitable. Not by assuming that all women experience menopause in the same way. And certainly not by ignoring intimate health because it remains an uncomfortable subject.

At nudd., we believe understanding your body is the first step toward caring for it properly.

hormones change. your intimate skin does too.

And your intimate care should be able to change with it.

Sources:

• Endotext — The Postmenopausal Women. Fisiología de la transición menopáusica, metabolismo y cambios sistémicos.

• Adipose Tissue Sex Steroids in Postmenopausal Women. Producción y metabolismo de estrona y estradiol en tejido adiposo.

• Genitourinary Syndrome of Menopause. Efectos de los estrógenos sobre el epitelio vaginal, colágeno, microbioma y tejidos urinarios.

• ACOG — Vulvovaginal Health. Cambios vulvovaginales y opciones de tratamiento.

• ACOG — Experiencing Vaginal Dryness?. Sequedad, lubricación y tratamiento local.