World Menopause Day was on October 18, and this year’s campaign highlights chronic pain, including migraine, fibromyalgia and pelvic pain. Menopause is usually defined as the point reached 12 months after the cessation of menstrual periods, when there is no other explanation for the absence of menstruation. It usually occurs between the ages of 45 and 55. The years of hormonal fluctuation before that point are called ‘perimenopause’.
For some, the transition is barely noticeable. Others experience hot flushes, night sweats, disrupted sleep, vaginal dryness, mood changes, joint discomfort or difficulty concentrating.
It is easy to attribute non-specific symptoms to this ‘change of life’, but persistent palpitations, exhaustion or weight fluctuations may not be due to falling oestrogen levels. Thyroid disease, anaemia, sleep disorders, medication effects and other ailments should be excluded. Chest pain, fainting or significant breathlessness requires assessment of the heart or lungs.
Current guidance from the UK’s National Institute for Health and Care Excellence (NICE) advises that healthy women aged 45 or over with typical symptoms and menstrual changes do not require hormonal blood tests to diagnose menopause. Loss of ovarian function before the age of 40 requires particular attention to possible premature ovarian insufficiency. These women may need advice about fertility, bone health and hormone replacement.
Pregnancy remains possible during perimenopause. Hormone replacement therapy (HRT) is not contraception but remains the most effective treatment for troublesome hot flushes and night sweats. For appropriately selected symptomatic women younger than 60, or within 10 years of menopause onset, the benefits of HRT generally outweigh the risks.
Removing the uterus stops periods, but the ovaries, if left in place, may continue producing hormones. Removing both ovaries before natural menopause causes surgical menopause, with an abrupt hormonal change.
A woman who still has her uterus generally needs a progestogen alongside systemic oestrogen to protect the womb lining. After a total hysterectomy, oestrogen alone is usually appropriate.
Oestrogen can be delivered through tablets, patches, gels or sprays. Transdermal treatment, absorbed through the skin, has a more favourable blood-clot risk profile than oral oestrogen and may be preferred when clotting risk is a concern.
A history of breast cancer, unexplained vaginal bleeding, blood clots, stroke or significant liver disease requires careful assessment, as systemic HRT may be unsuitable.
Combined oestrogen-progestogen treatment can increase certain risks, particularly with longer use. Oestrogen-only treatment has a different risk profile.
Equally, HRT should not be marketed as a guarantee against heart disease, dementia, ageing or an expanding waistline.
NICE recommends reviewing treatment at about three months and annually thereafter, or sooner when symptoms, side effects or concerns require it.
Your doctor’s visit should begin with a short record of menstrual changes, sleep, flushes, mood and symptoms affecting daily life. Bring your medicine list and mention herbal remedies, contraception, previous blood clots, cancer history and unexplained bleeding. Explain which problem most needs relief.
A woman may experience vaginal dryness, burning, urinary discomfort or painful intercourse. Low-dose vaginal oestrogen can reduce recurrent urinary infections in suitable peri- and postmenopausal women.
Lubricants can help during sex, while vaginal moisturisers can help with ongoing dryness. Low-dose vaginal oestrogen can be effective, with much less absorption into the bloodstream than systemic treatment.
Bleeding after 12 months without natural periods requires assessment, even if it happens once or amounts to spotting. Common causes are benign, but cancer must be excluded when appropriate.
Bleeding while taking HRT also deserves medical advice. Some patterns are expected early in treatment or with certain regimens; persistent, heavy or unexpected bleeding needs review.
Evidence supports testosterone for appropriately assessed postmenopausal women with persistent, distressing low sexual desire. Evidence does not establish it as a general treatment for fatigue, brain fog or low mood, or as a means of maintaining muscle mass.
For women who cannot or prefer not to use HRT, treatment remains possible.
Newer medicines, including fezolinetant and elinzanetant, block receptors involved in the brain’s temperature-control pathways, reducing hot flushes and night sweats without supplying oestrogen. Certain antidepressants can also reduce these symptoms, whether or not a mood disorder is present. Beware of expensive collections of supplements and individually compounded ‘bioidentical’ preparations promoted as inherently safer.
Cognitive behavioural therapy can help with the impact of hot flushes and sleep difficulties. Regular exercise in the great outdoors can also help alleviate symptoms.
Difficulty finding words, remembering details or maintaining concentration is recognised during the transition. These complaints do not mean a woman is developing Alzheimer’s disease.
Oestrogen decline accelerates bone loss. Midlife is a useful time to review fracture risk, particularly after a low-trauma fracture or where other risk factors exist. Bone-density testing should be considered where appropriate.
Weight-bearing activity and resistance exercise help preserve function and bone health. Adequate protein, calcium-containing foods and vitamin D are useful dietary adjuncts. Blood pressure, cholesterol, glucose, smoking, alcohol and appropriate cancer screening also belong in this review.
At work, practical consideration can include access to water, ventilation, suitable uniforms, breaks and flexibility where feasible. At home, partners can listen without immediately reaching for a joke. Families can redistribute tasks. Many women will spend decades beyond menopause. Those years deserve ambition, pleasure, intimacy, useful work and ordinary peace.
According to Donna Ashworth in The Art of Being Easily Pleased, “you are warriors without a choice. But your weapon is mighty - an ancient and umbilical knowing tied to creation. And you do not fight alone.”
