Menopause — Causes, Symptoms, HRT & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Menopause is defined as the permanent cessation of menstruation resulting from loss of ovarian follicular activity, confirmed retrospectively after 12 consecutive months of amenorrhoea without another pathological or physiological cause. It marks the end of a woman's reproductive life and is accompanied by declining oestrogen, progesterone, and testosterone production. The average age at menopause in the UK is 51 years (range 45-55). Perimenopause (the menopausal transition) begins when menstrual cycle irregularity starts and ends 12 months after the last menstrual period — typically lasting 4-8 years. Premature ovarian insufficiency (POI) — menopause before age 40 — affects approximately 1% of women and has distinct health implications, requiring hormone replacement until at least the natural age of menopause. Menopause is a natural biological process but causes significant symptoms in 75% of women; 25% have severely impactful symptoms warranting treatment. Long-term oestrogen deficiency has implications for bone density (osteoporosis), cardiovascular health, cognitive function, and genitourinary health.

Natural menopause: primary ovarian ageing — women are born with approximately 1-2 million oocytes; by puberty, approximately 300,000 remain; by menopause, the supply is essentially exhausted. Declining follicular reserve leads to reduced oestradiol and inhibin B production, rising FSH and LH. Premature ovarian insufficiency (POI — formerly premature menopause): ovarian failure before age 40; causes include: idiopathic (most common — 90%); autoimmune oophoritis (associated with autoimmune thyroid disease, Addison's disease); Turner syndrome (45,X and mosaic variants); Fragile X permutation; galactosaemia; chemotherapy and radiotherapy (ovarian reserve highly radiosensitive — pelvic radiation or alkylating agents). Surgical menopause (bilateral oophorectomy): immediate, surgically induced menopause with abrupt oestrogen withdrawal — typically more severe vasomotor symptoms than natural menopause. Medical menopause: GnRH analogues (used for endometriosis, fibroids, and breast cancer) cause reversible ovarian suppression — chemical menopause; aromatase inhibitors (used for breast cancer) cause oestrogen deficiency. Risk factors for earlier natural menopause: smoking (up to 2 years earlier); low BMI; nulliparity; family history of early menopause; socioeconomic deprivation.

Vasomotor symptoms (most common — 75% of women): hot flushes — sudden sensation of intense heat spreading from chest to neck and face, lasting 1-5 minutes; associated flushing, sweating, and palpitations; occurring multiple times daily and nocturnally; night sweats — drenching perspiration during sleep (hot flushes at night) causing sleep disruption, fatigue, and irritability; persist for more than 7 years in 50% of women, more than 10 years in 25%. Genitourinary syndrome of menopause (GSM — previously vulvovaginal atrophy): vaginal dryness, soreness, and irritation (from reduced vaginal oestrogen — epithelial thinning, reduced lubrication); dyspareunia (painful sex); reduced sexual desire and arousal; urinary symptoms: urgency, frequency, recurrent UTIs, urinary incontinence; GSM is a chronic progressive condition (unlike vasomotor symptoms which eventually reduce with time — GSM worsens). Psychological symptoms: mood changes — irritability, anxiety, low mood (perimenopausal depression — distinct from major depressive disorder but may overlap); poor concentration and memory ('brain fog'); reduced self-esteem. Sleep disturbance: insomnia — often secondary to night sweats; bidirectional relationship with mood disturbance. Musculoskeletal: joint pains and myalgia (common but often not attributed to oestrogen deficiency). Physical changes: weight gain (particularly central adiposity — metabolic effects of oestrogen deficiency); skin thinning and dryness; hair thinning. Long-term effects of oestrogen deficiency: osteoporosis (accelerated bone loss — 10-15% of trabecular bone lost in first 5 years post-menopause); cardiovascular disease (oestrogen is cardioprotective — risk increases post-menopause, particularly after age 60).

Menopause is a clinical diagnosis in women over 45: no blood tests are required to diagnose menopause in women over 45 with characteristic symptoms (NICE NG23). FSH (follicle-stimulating hormone): elevated FSH above 30 IU/L confirms menopause in women under 45 and in certain clinical situations (women on hormonal contraception, surgical menopause); not required routinely in women over 45. For premature ovarian insufficiency (POI): FSH must be measured on two occasions at least 4-6 weeks apart — both above 40 IU/L confirms POI (can fluctuate during perimenopause); oestradiol typically low; AMH (anti-Mullerian hormone) very low; LH elevated. Additional tests in POI: karyotype (to detect Turner syndrome variants — 45,X, mosaicism); FMR1 premutation (Fragile X — 5% of POI); autoimmune screen (anti-adrenal antibodies, thyroid antibodies, thyroid function, adrenocortical antibodies); DEXA scan at diagnosis (bone density — risk of osteoporosis). Symptom severity tools: Greene Climacteric Scale; Menopause Symptom Questionnaire (MSQ); Menopause Rating Scale (MRS) — track symptom burden and treatment response. Cervical screening, mammography, and endometrial sampling (if post-menopausal bleeding — to exclude endometrial cancer) — not diagnostic for menopause but important in clinical context.

Hormone replacement therapy (HRT) — most effective treatment for vasomotor symptoms and GSM; NICE NG23 recommends HRT as first-line for menopausal symptoms: Oestrogen: systemic oestrogen (oestradiol) — available as transdermal patch (Evorel, Estradot — 50-100 mcg twice weekly), gel (Oestrogel, Sandrena — once daily), spray (Lenzetto), or oral tablet (Elleste Solo, Progynova — oral oestrogen has first-pass effect and slightly higher VTE risk vs. transdermal); transdermal oestrogen avoids hepatic first-pass metabolism — safer in obesity, migraine, hypertension, and personal history of VTE; most effective formulation for vasomotor symptoms — reduces hot flushes by 75-80% and night sweats. Progestogen (only required if uterus intact — to protect endometrium from unopposed oestrogen causing endometrial cancer): body-identical progesterone (Utrogestan 100 mg — orally micronised progesterone — preferred as safest progestogen; or Utrogestan vaginal); synthetic progestogens (norethisterone, medroxyprogesterone acetate — associated with slightly higher breast cancer risk than micronised progesterone). Combined HRT preparations: Evorel Conti, Kliofem, Femoston. Testosterone: not licenced for menopause in the UK but used off-label; improves libido, energy, and cognitive function in symptomatic women with low testosterone; apply topically (TestoGel); monitor serum testosterone levels. Vaginal oestrogen (GSM — can be used by most women including most breast cancer patients): estriol (Ovestin cream, Gynest) or estradiol (Vagifem pessaries, Estring ring) — local, low systemic absorption; treats GSM without systemic effects; safe long-term; does not raise systemic oestrogen levels significantly; ospemifene (oral SERM — Osphena) for GSM in women who cannot use vaginal oestrogen. Non-hormonal options for vasomotor symptoms (if HRT contraindicated — e.g. hormone receptor-positive breast cancer): venlafaxine 75 mg/day (most evidence — reduces hot flushes by 50-60%; NICE recommended); oxybutynin (anticholinergic — reduces hot flushes 70-80%); gabapentin 300 mg TDS; clonidine; fezolinetant (Veoza — selective NK3 receptor antagonist, NICE approved 2024 — reduces hot flushes by 60-70%; non-hormonal; specifically for breast cancer patients and women who cannot use HRT). Lifestyle: maintain healthy weight; regular aerobic exercise (reduces vasomotor symptom severity); dress in layers; reduce alcohol and caffeine (trigger hot flushes); mindfulness and CBT reduce the impact of vasomotor symptoms (Menopause Mindfulness programme).

Untreated or prolonged menopausal oestrogen deficiency leads to significant long-term health consequences. Osteoporosis: accelerated bone loss begins in perimenopause (average 1–2% per year) and continues for 5–8 years after menopause; cumulative bone loss of 10–15% in the early postmenopausal period substantially increases fracture risk — hip fractures carry approximately 25% 1-year mortality in elderly women, and vertebral fractures cause significant chronic pain, height loss, and disability. Cardiovascular disease: oestrogen is vasculoprotective — its loss accelerates atherosclerosis, arterial stiffness, adverse lipid profile changes (rising LDL and triglycerides, falling HDL), and hypertension; coronary artery disease rates in women equalise with men within 10–15 years of menopause, and cardiovascular disease becomes the leading cause of death in postmenopausal women. Genitourinary syndrome of menopause (GSM): progressive vaginal atrophy, dryness, dyspareunia, and recurrent UTIs affect up to 50% of postmenopausal women and worsen progressively without treatment. Cognitive changes: the menopausal transition is associated with memory problems, reduced concentration, and 'brain fog'; observational data suggest associations between oestrogen deficiency and increased risk of Alzheimer's disease. Mental health: depression and anxiety are more prevalent in the perimenopause; sleep disruption from night sweats compounds mood disturbance; sexual dysfunction (low libido, dyspareunia) significantly affects relationships. Premature ovarian insufficiency (POI) before age 40 compounds these risks — women with POI have substantially higher cardiovascular and osteoporosis risks requiring early HRT.

Osteoporosis prevention: HRT effectively prevents postmenopausal bone loss — prevents osteoporotic fractures while taken (vertebral fractures by 34%, hip fractures by 16% — NICE analysis); DEXA scan at baseline for POI and for women with additional risk factors; calcium (1200 mg/day — preferably dietary) and vitamin D supplementation (800-1000 IU/day); weight-bearing and resistance exercise. Cardiovascular health: early HRT initiation (within 10 years of menopause or before age 60 — the 'timing hypothesis' / 'window of opportunity') is cardioprotective — reduces MI risk by approximately 30% (WHI reanalysis by age); oestrogen improves lipid profile, reduces arterial stiffness, and reduces insulin resistance; HRT started late (more than 20 years after menopause) may not carry the same benefit. Cognitive health: observational data suggests HRT initiated near menopause reduces dementia risk (CAIDE study, Cache County study) — causality debated; NICE NG23 acknowledges the need for further research. Genitourinary health: vaginal oestrogen prevents progression of GSM and recurrent UTIs — long-term use recommended. Breast cancer risk: combined oestrogen-progestogen HRT increases breast cancer risk by approximately 1 extra case per 1,000 women per year of use (similar to or less than risk of drinking 1 unit of alcohol daily or obesity); oestrogen-only HRT (women without uterus) does not appear to increase breast cancer risk significantly. Risk is reversible on stopping HRT within 5 years.

Seek urgent medical care for: post-menopausal bleeding (any vaginal bleeding more than 12 months after last period — must be investigated urgently to exclude endometrial cancer — typically with endometrial biopsy and pelvic USS); unscheduled bleeding when on HRT (after more than 3 months on a cyclical HRT regimen or any bleeding on continuous combined HRT after initial 3-6 month settling phase) — investigation for endometrial pathology. See your GP for discussion of HRT or menopausal treatment if: experiencing vasomotor symptoms (hot flushes, night sweats) impacting quality of life or sleep; vaginal dryness, pain during sex, or recurrent UTIs; mood changes, 'brain fog', or low libido that you believe may be related to perimenopause; irregular periods in your mid-to-late 40s — may indicate perimenopause; periods stopping before age 40 — urgent investigation for POI is required (bone health, cardiovascular risk, fertility implications). Review with GP or menopause specialist if you are unsure whether HRT is suitable given your medical history (breast cancer history, blood clot history, liver disease — requires specialist menopause review).