Menopause describes the stage of a woman’s life when the ovaries stop releasing eggs and periods stop. Many women experience symptoms, due to changing hormone levels.

Menopause is diagnosed after 12 consecutive months without a natural period.

Stages of menopause

• Perimenopause: The time when most women experience some physical, psychological or cognitive symptoms due to fluctuating hormone levels. Periods often change. They may become heavier, lighter, or more or less frequent.

• Menopause: The day following 12 consecutive months without a period.

• Postmenopause: The years following 12 consecutive months without a period.

Menopause happens because the ovaries are essentially running out of eggs. As the store of eggs declines, associated hormone levels begin to fluctuate and eventually fall which can result in menopause symptoms.

Once the store of eggs in the ovaries is depleted, the associated hormones, oestrogen and progesterone become more erratic, and it’s these fluctuating hormone levels that can lead to menopause symptoms.

Hormone levels can fluctuate significantly during perimenopause as they continue to fall. You have oestrogen receptors all over your body, which might help to explain why the symptoms can be physical, psychological or cognitive or some of each.

Progesterone levels are usually the first to fall. As well as helping to regulate monthly periods and maintain pregnancy, progesterone can be sleep-inducing and calming so when this hormone starts to deplete, sometimes quite rapidly, sleep can become disrupted.

While the progesterone levels continue to fall, the oestrogen levels start to rise and fall, sometimes dramatically, and this can lead to a host of symptoms. If these symptoms aren’t recognised as being related to the perimenopause, they can appear to be unconnected.

Some of the most common symptoms are anxiety, irritability, low mood, difficulty sleeping, brain fog, fatigue, muscle and joint pain, hot flushes, vaginal dryness, and soreness, increased urinary symptoms and dry itchy skin.

The average age of menopause is 51 however it can happen earlier or later.

• Early menopause is when menopause happens under the age of 45.

• Premature menopause, also known as premature ovarian insufficiency (POI), is when menopause happens under the age of 40. In the UK, POI affects 1 in 100 women under 40, 1 in 1,000 under 30 and 1 in 10,000 under 20.

• Medical menopause, also known as medically induced menopause, can occur as a result of chemotherapy or radiotherapy which affects the ovaries. It may also occur when a woman is taking medication to suppress ovarian function, for example as part of some breast cancer treatments, or due to endometriosis or premenstrual dysphoric disorder (PMDD).

• Surgical menopause happens when both ovaries are removed during surgery. This is called bilateral oophorectomy.

National Institute for Health and Care Excellence (NICE) guidelines advise:

• For healthy women over the age of 45, menopause should be diagnosed based on symptoms, and without blood tests
• For women under the age of 45 a blood test may be appropriate
• For women under the age of 40 blood tests are required and at least 2 should be taken about 4 to 6 weeks apart

No. About 1 in 4 women will have almost no symptoms, and the only thing they’ll notice is that they eventually stop having periods.

About 3 in 4 women will have some symptoms and about 1 in 4 of all women will describe their symptoms as severely affecting their quality of life.

The National Institute for Health and Care Excellence (NICE) publishes national guidelines for menopause. They cover diagnosis and management and aim to improve the support and information provided to patients.

The guidelines are for patients as well as healthcare professionals so, if you can, it’s a good idea to familiarise yourself with them before making an appointment to see your GP.

GPs are expected to be familiar with and follow the guidelines and to provide treatments based on the best available evidence.

Your GP should explain the stages of menopause, the possible symptoms and their method of diagnosis.

They should discuss the benefits and risks of all treatment options, helpful lifestyle changes and the potential long-term health considerations related to falling oestrogen levels which include bone and heart health.

Menopause can be an excellent time to review your lifestyle.

This could include ensuring that you’re eating a healthy balanced diet, and taking an average of two and a half hours of moderate exercise every week, including some weight bearing exercise.

You could also review your alcohol consumption, stop smoking and assess your stress levels and what you might be able to do to improve all these areas of your life.

The government recommends that everyone should consider taking 10 micrograms of Vitamin D a day during autumn and winter to help keep bones and muscles healthy.

HRT should be offered as the recommended first line treatment for symptoms related to perimenopause and menopause. HRT is designed to relieve the symptoms associated with oestrogen deficiency and is available as tablets, patches, gels and a spray all of which need to be prescribed at the right dose for individual women; there is absolutely no one size fits all.

Most women use oestrogen in conjunction with progesterone. This is known as combined HRT.

Women with a uterus (womb) need combined HRT. Women who have had their womb removed (hysterectomy) usually only need oestrogen.

Women who have had their ovaries removed (surgical menopause) will need oestrogen, and possibly progesterone too if they still have their womb.

Some women will also require testosterone replacement – also see What about testosterone?

What type of HRT is right for me?

This depends on whether you’re still having periods.

HRT is available from your GP as tablets, patches, gels, and a spray. Some women may be offered an implant through a menopause specialist clinic, but this isn’t a first line treatment.

Some treatments are combined oestrogen and progesterone; others are separate and allow the option of using a soft gel progesterone capsule or a Mirena, Levosert or Benilexa hormonal IUD (hormonal coil) as the progesterone part of your HRT and simply adding oestrogen, usually as a patch, gel or spray.

If you’re still having periods you should be offered a type of HRT called cyclical or sequential. This means that you use oestrogen every day and progesterone for 12 to 14 days of each month.

If you’ve not had a period for over 12 months you should be offered continuous combined HRT which is oestrogen and progesterone used every day.

When can I start HRT?

Ideally HRT should be started as soon as your perimenopausal symptoms begin to have a negative effect on your quality of life. There’s no need to wait until you’ve stopped having periods or have reached the age of 51.

No, HRT doesn’t delay menopause. It relieves symptoms and helps to protect long-term health.

No. Many women are wrongly told that they can’t have HRT, but there are no defined age limits. However, HRT is safest when started below the age of 60 and within 10 years of your final period.

Some women may need to start HRT after the age of 60, if the benefits for that individual outweigh the risks. This decision should be made by you with the help of a doctor or nurse with a special interest in menopause, or a menopause specialist.

There’s currently no defined time period or upper limit, yet many women are wrongly told that they can use HRT for a maximum of 5 years or until the age of natural menopause. This decision should be based on your own informed choice and be reviewed annually with your health care provider.

What is the difference between body identical and bioidentical HRT?

Body identical HRT describes licensed, regulated hormones – usually derived from the yam root vegetable – which are chemically identical to the hormones produced naturally by the body. These can be prescribed by NHS and private GPs or menopause specialists.

Bioidentical HRT is a marketing term for unlicensed, unregulated hormone preparations prescribed in some private clinics. These are not approved or recommended for use by the British Menopause Society (BMS).

What are the benefits and risks of HRT?

Taking HRT can relieve your menopause symptoms and help to protect your long-term bone health, reducing your risk of osteoporosis (thinning of the bones) and bone fracture.

According to the Royal Osteoporosis Society, the lifetime risk of bone fracture for women over the age of 50 is about 1 in 2, compared to 1 in 5 for men. It’s important to consider this during perimenopause when oestrogen levels are falling.

Evidence suggests that starting HRT within 10 years of menopause under the age of 60 reduces the risk of cardiovascular disease. You can read more about this on the British Heart Foundation website – menopause and your heart.

The subject of HRT often raises concerns about breast cancer as a result of news headlines that appeared after the Women’s Health Initiative study was published in 2002. The long-term follow up from that study found that for most women the benefits of HRT outweigh the risks. You can read more about this on the British Menopause Society (BMS) website.

What is local oestrogen?

Local oestrogen is tiny doses of oestrogen hormone, applied directly to the vulva and vagina. It’s used to manage urinary, vaginal and vulval symptoms, including dryness, soreness, irritation, urinary urgency (a sudden need to pee), and repeated urinary tract infections.

Local oestrogen is available as creams, pessaries, gels, or a vaginal ring and is safe to take lifelong.

Yes, you can use local oestrogen alongside HRT. It’s estimated that about 1 in 5 women need to use both.

Testosterone is usually associated with male health and sex drive. However, it has an important role to play in the lives of both men and women – but it’s not all about libido.

Testosterone supports bone strength, muscle strength, energy levels, cognitive (brain) function and confidence.

Women, like men, experience a reduction in testosterone production as they age and like men, some women will be more affected than others.

Those in surgical menopause will experience a rapid reduction in testosterone when their ovaries are removed.

NICE guidelines are clear that testosterone should be considered for women experiencing low sexual desire if HRT alone is not effective.

Your GP should discuss all available options to manage your symptoms.

There are alternative medications for those women who aren’t able to use HRT or for those who choose not to. However, these are all regarded as second line options.

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) must not be prescribed for menopausal symptoms unless clinical depression has been formally diagnosed. However, these drugs can help alleviate hot flushes in women who aren’t able to take HRT.

Some GPs can refer you for cognitive behavioural therapy (CBT) which has been shown to help some women cope with their menopause symptoms.

What about menopause clinics?

Your GP may feel that they need to refer you to an NHS menopause clinic if you have a complex medical history or they’re uncertain about the most suitable treatment for you. You can search for NHS and private accredited menopause specialists on the British Menopause Society (BMS) website.

Can I use alternative treatments?

There are hundreds of over-the-counter treatments marketed for menopause but there’s little independent scientific research available to show these are effective.

If you’re considering what are often referred to as ‘natural’ products, be aware that natural doesn’t always mean safe. Some herbs, vitamins and minerals have contraindications (reasons you shouldn’t use them), side effects, and interactions (they may not work well with other medication).

It’s important to take professional advice before using alternative treatments.

Do I need to continue with contraception?

If you’re using contraception to avoid pregnancy, it needs to be used:

• for 1 year after your final menstrual period if you’re aged over 50
• for 2 years after your final menstrual period if aged under 50

How can I get the most from my GP appointment?

• Do your research, read the NICE guidelines on menopause. This will help you to understand what your GP can offer and what you should expect, and enable you to have an informed conversation.
• When booking your appointment ask the receptionist if there’s a GP or practice nurse who takes a special interest in menopause; request a double appointment if possible.
• Make a list of all your symptoms. Having everything written down can be so helpful. You can print a symptom checker from MenopauseSupport.co.uk
• Take a supportive friend or family member with you if you’re feeling anxious. Having support can be invaluable.
• Be prepared to wait for answers; your GP may feel that they need to contact a colleague or menopause specialist before advising you.

Initially treatment should be reviewed after 3 months and then annually going forwards.

• In England, you have to pay a prescription charge for NHS HRT treatment. There is a separate charge for each item, so if you’re prescribed 2 different treatments (for example, separate oestrogen and progesterone) you’ll need to pay 2 prescription charges.After an initial 3-month period of being on HRT, your GP can give you a prescription for 12 months’ worth of treatment for each different treatment you are using.
  If you will need more than 2 prescriptions for HRT items in a year, it may be more cost effective to get an HRT prescription prepayment certificate (PPC). This covers the cost of all your prescriptions over 1 year for HRT medicines licensed to treat menopause symptoms. See Save money with a prescription prepayment certificate (PPC) at nhs.uk for more information and current costs.
  

• In Northern Ireland, Scotland and Wales HRT is free on the NHS.

Communication is key during menopause.

If you don’t understand what’s going on then it stands to reason that your partner, family and friends probably don’t either.

Menopause can have an impact on our most intimate relationships and it’s vital to keep the lines of communication open. Loved ones often try to work out how they can help but it won’t always be what you need.

Do share how you’re feeling if you can and tell your family and friends how they can help you through this time in your life.

See FPA’s Guide to Menopause, Sex and Relationships for more information, help and support.

There are around 4.5 million women over the age of 50 in the workplace and this number is rising. It makes sense to raise awareness and offer support for menopausal women in the workplace. About 1 in 4 women consider leaving the workplace during menopause and some do.

If you’ve identified that you’re struggling with menopause symptoms and they’re affecting you at work, do seek help.

Unfortunately, many workplaces don’t have menopause guidelines, but the Health and Safety at Work Legislation and the 2010 Equality Act are there to protect you.

Speak to your line manager or HR department about possible reasonable adjustments and how they can help you to remain at work. There are some excellent resources available from The Faculty of Occupational Medicine, ACAS, and the Chartered Institute of Personal Development (CIPD) – see Where can I get more information and advice?

• ACAS: acas.org.uk
• British Heart Foundation: Menopause and your heart
• British Menopause Society: thebms.org.uk
• Find a menopause specialist: thebms.org.uk/find-a-menopause-specialist
• Chartered Institute of Personal Development (CIPD): cipd.co.uk
• Daisy Network: daisynetwork.org
• Endometriosis UK: endometriosis-uk.org
• Faculty of Occupational Medicine: fom.ac.uk
• International Association for Premenstrual Disorders (IAPMD): iapmd.org
• Menopause Matters: menopausematters.co.uk
• Menopause Support: menopausesupport.co.uk
• NHS website: nhs.uk/conditions/menopause
• NICE guidelines: nice.org.uk/guidance/ng23
• Women’s Health Concern: womens-health-concern.org