STRAW+10: the stages of reproductive ageing

STRAW stands for the Stages of Reproductive Aging Workshop. The first version came out in 2001. Ten years on, a 2011 workshop updated it, which is where the "+10" comes from, and Harlow and colleagues published the result in 2012. Its authors compare it to the stages doctors use to describe puberty.

Everything is counted from one point: your final menstrual period, stage 0. Stages before it have minus numbers, stages after it plus numbers.

The stages in plain words

• Reproductive years (stages −5 to −3). Regular periods. In the late reproductive stage fertility begins to fall, and in its later part, −3a, cycles may get a little shorter. Hormone changes start before the periods change.
• Early menopausal transition (stage −2). Cycle length starts to vary: a persistent difference of seven days or more between one cycle and the next. Persistent means it happens again within ten cycles.
• Late menopausal transition (stage −1). A gap of 60 days or more without a period. The authors estimate this lasts one to three years on average, and say hot flushes and night sweats are likely here.
• Final menstrual period (stage 0). Only known looking back, after 12 months without one.
• Early postmenopause (stages +1a, +1b, +1c). Stage +1a is the first year after the last period. Stages +1a and +1b together last about two years while hormones are still changing fast, and the authors say hot flushes are most likely then. Stage +1c is a settling period of three to six years.
• Late postmenopause (stage +2). Hormone changes slow and the body's general ageing takes over. Vaginal dryness and urinary symptoms become more common.

In STRAW+10 terms, perimenopause runs from stage −2 to the end of stage +1a, a year after the final period. Postmenopause is everything from stage 0 on.

Why periods come first

The authors wanted a system based on objective, cheap, non-invasive measures that would work anywhere. Hormone tests are not standardised and cost money, which matters most in countries with fewer resources, so the pattern of periods stays the main criterion. Symptoms are not among the criteria. Two kinds, hot flushes and vaginal and urinary changes, appear only as supporting description, because, the authors note, no universal set of menopause symptoms has been established across ethnic groups.

They say STRAW+10 applies regardless of age, ethnicity, body size or lifestyle, a change from the 2001 version, which left out many women. They also name better data on women in low-resource countries as a research priority. For Pakistan, that gap is real.

Who it does not fit

The authors list the women the bleeding criteria cannot stage:

• Women who have had a hysterectomy or endometrial ablation. Here, only hormone tests can help, at least three months after surgery, and often more than once.
• Women with premature ovarian insufficiency, whose ovaries can stop and start unpredictably.
• Women with polycystic ovary syndrome or hypothalamic amenorrhoea, whose periods are irregular or absent for reasons other than ovarian ageing.
• Women having cancer treatment, or living with some long-term illnesses.

How Where am I? uses it

Where am I? asks about your periods over the last year in the STRAW+10 way. A change in the pattern points to the early transition. Gaps of two months or more point to the late transition. Twelve months or more without a period points to after menopause. If you are 40 or over and your periods have not changed but symptoms have, the nearest name STRAW+10 offers is the late reproductive stage, the stage nobody names. If you cannot tell, because of a hysterectomy, a hormonal coil or contraception, or periods that were never regular, it says it cannot stage you, and that a doctor would go on your age and symptoms instead.

It names a stage. It does not diagnose one.

STRAW+10 is a map, not a diagnosis. In practice, the Pakistan Menopause Society says that in healthy women of 45 and over with typical symptoms, perimenopause and menopause are diagnosed from symptoms and periods, without laboratory tests (Table 3). See how menopause is diagnosed.

Some changes in bleeding are not a stage at all. The PMS lists bleeding after sex, unexplained bleeding between periods, and sudden heavy or prolonged bleeding as red flags that need checking. So are symptoms before 40 that could point to premature ovarian insufficiency. See irregular periods for what is usual and what is not.