Menopause: Symptoms, Treatment Options and Staying Well
Menopause is the point at which a woman has gone twelve consecutive months without a period, marking the end of natural reproductive years. In most countries it happens at an average age of about 51, but the years before it, called perimenopause, can begin in the forties and last several years. Although menopause is a normal stage of life, symptoms can be disruptive, and effective help is available.
What is happening in the body
The ovaries gradually produce less oestrogen and progesterone. During perimenopause, hormone levels fluctuate, which is why cycles become irregular and symptoms can be unpredictable. After menopause, oestrogen stays low. Menopause can also occur earlier because of surgery to remove the ovaries, chemotherapy or radiotherapy, or premature ovarian insufficiency before the age of 40.
Common symptoms
- Vasomotor symptoms: hot flushes and night sweats, affecting up to three quarters of women, lasting on average seven years
- Irregular periods, sometimes heavy, before they stop
- Sleep disturbance
- Mood changes: low mood, anxiety, irritability and tearfulness
- Brain fog, forgetfulness and difficulty concentrating
- Vaginal dryness, discomfort with sex and urinary symptoms such as urgency and recurrent infections (the genitourinary syndrome of menopause)
- Joint aches and muscle pain
- Reduced libido
- Palpitations, headaches and skin or hair changes
Not every woman has severe symptoms, and the experience is very individual.
How it is diagnosed
In women over 45 with typical symptoms, menopause is diagnosed clinically; blood tests are not usually needed. Hormone tests are considered for women under 45 with symptoms, or when the picture is unclear. Irregular bleeding after menopause, bleeding between periods or very heavy bleeding should always be checked.
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Lifestyle approaches
- Dress in layers, keep the bedroom cool, and identify personal triggers such as alcohol, spicy food, caffeine or stress
- Exercise regularly, which improves mood, sleep, weight and bone health
- Eat a balanced diet rich in vegetables, whole grains, fruit, lean protein and calcium
- Stop smoking, which brings on earlier menopause and worsens flushes
- Practise relaxation, paced breathing and CBT, which has good evidence for reducing the impact of hot flushes and low mood
Hormone replacement therapy
Menopausal hormone therapy (HRT) is the most effective treatment for hot flushes and night sweats, and it also protects bones and relieves vaginal symptoms. It replaces oestrogen, with progestogen added in women who still have a womb to protect the lining. It comes as tablets, patches, gels or sprays. Transdermal oestrogen (patch or gel) is generally preferred because it carries a lower risk of blood clots than tablets.
The benefits and risks depend on age, time since menopause and individual health. For most healthy women under 60 or within ten years of menopause, benefits outweigh risks. Risks include a small increase in breast cancer with combined therapy used long term, and clotting risk with oral oestrogen. HRT is not suitable for everyone, such as those with a history of certain cancers, unexplained vaginal bleeding or active clotting disorders. A personalised discussion with a clinician is essential.
Vaginal oestrogen, in creams, tablets or rings, treats genitourinary symptoms with very little absorption into the body and can be used alongside other options.
Non-hormonal options
- Fezolinetant and elinzanetant, newer non-hormonal drugs that target the brain’s temperature centre, reduce flushes
- Certain antidepressants (paroxetine, venlafaxine), gabapentin and oxybutynin
- Moisturisers and lubricants for vaginal dryness
- Cognitive behavioural therapy
Herbal products such as black cohosh and soy isoflavones have inconsistent evidence, and quality varies, so discuss them with your doctor.
Long-term health after menopause
Lower oestrogen increases the risk of osteoporosis and cardiovascular disease. After menopause it is wise to review blood pressure, cholesterol, bone health and cancer screening, and to maintain weight-bearing exercise and calcium and vitamin D intake. Contraception is still recommended for twelve months after the last period if you are over 50 (24 months if under 50).
Looking after your mental health
Low mood and anxiety can arise or worsen around menopause. Do not dismiss them as just hormones. Talk therapy, medication and HRT can all help.
When to see a doctor
See a clinician if symptoms are affecting your quality of life, if you have bleeding after menopause, or if menopause occurs before age 45. You do not have to just put up with it.
This article is for general information and is not a substitute for professional medical advice. If you are worried about your health or have symptoms, speak to a doctor or other qualified health professional.