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): 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 premutation; 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; 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 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; dyspareunia (painful sex); reduced sexual desire and arousal; urinary symptoms: urgency, frequency, recurrent UTIs, urinary incontinence; GSM is a chronic progressive condition — worsens without treatment unlike vasomotor symptoms. Psychological symptoms: mood changes — irritability, anxiety, low mood; 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 (central adiposity); skin and 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; 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; additional tests: karyotype (Turner syndrome), FMR1 premutation (Fragile X — 5% of POI), autoimmune screen, DEXA scan at diagnosis. Symptom severity tools: Greene Climacteric Scale; Menopause Rating Scale (MRS) — track symptom burden and treatment response. Important investigations: post-menopausal bleeding must be investigated urgently (pelvic USS and endometrial biopsy) to exclude endometrial cancer.

Hormone replacement therapy (HRT) — most effective treatment for vasomotor symptoms and GSM; NICE NG23 recommends HRT as first-line for menopausal symptoms: Systemic oestrogen (oestradiol): transdermal patch (Evorel, Estradot — 50-100 mcg twice weekly), gel (Oestrogel, Sandrena — once daily), spray (Lenzetto), or oral tablet (Elleste Solo, Progynova); transdermal oestrogen avoids hepatic first-pass metabolism — safer in obesity, migraine, hypertension, and personal history of VTE; reduces hot flushes by 75-80%. Progestogen (required if uterus intact): body-identical micronised progesterone (Utrogestan 100 mg — preferred; associated with lower breast cancer risk than synthetic progestogens); or synthetic progestogens (norethisterone, medroxyprogesterone acetate). Testosterone: off-label for menopausal women with low libido and fatigue — improves libido, energy, and cognitive function; topical application. Vaginal oestrogen (GSM): estriol (Ovestin cream, Gynest) or estradiol (Vagifem pessaries, Estring ring) — local, low systemic absorption; treats GSM without systemic effects; safe long-term; safe in most breast cancer patients. Non-hormonal options (if HRT contraindicated): venlafaxine 75 mg/day (most evidence — reduces hot flushes by 50-60%); oxybutynin; gabapentin; fezolinetant (Veoza — NK3 receptor antagonist, NICE approved 2024 — reduces hot flushes 60-70%; non-hormonal; specifically for breast cancer patients and women who cannot use HRT). Lifestyle: maintain healthy weight; regular aerobic exercise; reduce alcohol and caffeine (hot flush triggers); mindfulness-based CBT reduces impact of symptoms.

Osteoporosis (accelerated bone loss begins at menopause — 10-15% of trabecular bone is lost in the first 5 years post-menopause; lifetime fracture risk in women: hip 15%, vertebral 25%, wrist 15%; HRT prevents bone loss while taken; bisphosphonates such as alendronate or denosumab treat established osteoporosis). Cardiovascular disease (oestrogen is cardioprotective — post-menopause cardiovascular disease risk rises sharply; HRT started within 10 years of menopause or before age 60 is cardioprotective — the timing hypothesis). Genitourinary syndrome of menopause (GSM — progressive and chronic: vaginal atrophy, dryness, recurrent urinary tract infections, urinary urgency, and incontinence; worsens progressively without treatment and requires long-term vaginal oestrogen). Cognitive decline (oestrogen deficiency associated with increased dementia risk in women; timing of HRT initiation may be important for neuroprotection). Premature cardiovascular and skeletal morbidity in women with premature ovarian insufficiency who do not receive HRT until the natural age of menopause.

Osteoporosis prevention: HRT effectively prevents postmenopausal bone loss — prevents fractures while taken; DEXA scan at baseline for POI and women with additional risk factors; calcium (1200 mg/day — dietary) and vitamin D supplementation (800-1000 IU/day); weight-bearing and resistance exercise; bisphosphonates (alendronate, risedronate) or denosumab for established osteoporosis. Cardiovascular health: early HRT initiation (within 10 years of menopause or before age 60 — the 'timing hypothesis') is cardioprotective — reduces MI risk by approximately 30%; transdermal oestrogen is the safest cardiovascular formulation. Cognitive health: observational data suggests HRT initiated near menopause may reduce dementia risk — NICE NG23 recommends more research before definitive guidance. 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; body-identical micronised progesterone carries lower risk than synthetic progestogens; oestrogen-only HRT does not appear to significantly increase risk.

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 via pelvic ultrasound and endometrial biopsy); unscheduled bleeding when on HRT after initial settling period — investigation for endometrial pathology required. See your GP for: vasomotor symptoms (hot flushes, night sweats) impacting quality of life or sleep — HRT discussion; vaginal dryness, pain during sex, or recurrent UTIs — vaginal oestrogen therapy; mood changes, 'brain fog', or low libido that may be perimenopausal; irregular periods in mid-to-late 40s — perimenopause discussion; periods stopping before age 40 — urgent POI investigation required (bone, cardiovascular, and fertility implications). Review with GP or BMS-accredited menopause specialist if: uncertain whether HRT is suitable given medical history (breast cancer, blood clots, liver disease); struggling with symptom management on current HRT.