The Stages of Reproductive Aging Workshop (STRAW+10) is the consensus framework clinicians worldwide use to describe where a woman is in the menopausal transition. Published in 2012 by an international working group, it replaced the older two-stage (premenopause / postmenopause) language with a more granular 10-stage system that maps cleanly to symptoms, hormone levels, and treatment decisions.
The 10 stages, briefly
STRAW+10 divides reproductive life into reproductive, menopausal transition, and postmenopausal phases. Each phase has substages defined by menstrual cycle changes and, secondarily, by hormonal markers.
- Stage −5 to −3b: reproductive years — regular cycles, full fertility window
- Stage −3a: late reproductive — subtle cycle shortening, FSH starts rising
- Stage −2: early menopausal transition — cycles vary by 7+ days month-to-month
- Stage −1: late menopausal transition — skipped cycles, 60+ day gaps, vasomotor symptoms common
- Stage 0: the final menstrual period (FMP), identified only retrospectively after 12 months of amenorrhea
- Stage +1a, +1b, +1c: early postmenopause (first 5 years post-FMP) — vasomotor symptoms peak here
- Stage +2: late postmenopause — vasomotor symptoms typically resolve; urogenital symptoms persist
Why staging matters for treatment
The "timing hypothesis" — supported by the WHI re-analyses and ELITE/KEEPS trials — suggests that hormone therapy benefits are strongest when started in the early postmenopausal window (stage +1a/+1b, roughly within 10 years of the final period or before age 60). Starting HRT in stage −2 is also common and well-tolerated; starting at stage +2 carries higher cardiovascular risk and changes the risk-benefit math.
Knowing your stage also calibrates symptom expectations. Brain fog and mood changes are most prominent in late perimenopause (stage −1). Vasomotor symptoms peak in early postmenopause. Genitourinary symptoms tend to emerge later and worsen across stage +2.
How clinicians stage you
The primary tool is your menstrual history, not a blood test. STRAW+10 explicitly notes that FSH testing is unreliable across the transition because levels fluctuate widely. Most clinicians stage based on cycle pattern over the past 12 months plus symptom profile. FSH is used adjunctively if cycle history is unclear (for example, after hormonal contraception or hysterectomy with ovaries intact).
When STRAW+10 doesn't apply
STRAW+10 was developed for healthy women undergoing natural reproductive aging. It does not apply to surgical menopause (oophorectomy), premature ovarian insufficiency (POI) before age 40, or women on hormonal contraception during the transition. Each of those scenarios uses different staging frameworks and has different HRT eligibility considerations.
Informational only — discuss your specific stage and treatment options with a NAMS-certified clinician.