Symptoms of the menopause, its long-term risks and the hormonal and non-hormonal treatment options.
Start with the overview: What the Menopause Is
The menopause is the permanent end of periods as the reproductive function of the ovaries stops. It is diagnosed once 12 consecutive months have passed without a period; natural menopause usually happens between the ages of 45 and 55. The most common symptoms are hot flushes and night sweats, but about one in four women has none at all. It is not an illness, yet it raises the risk of osteoporosis (thinning of the bones) and heart disease.
Menopause treatment covers the hormonal and non-hormonal options for relieving menopausal symptoms such as hot flushes. Hormone therapy is not used in situations such as breast cancer, vaginal bleeding of unexplained cause or a blood clot; for these women there are non-hormonal prescription medicines and cognitive behavioural therapy. None of the medicines is as effective as hormone therapy; the therapy does not remove hot flushes but reduces the distress they cause.
Body-identical hormones are hormones with a chemical structure similar to those the ovaries produce. For menopausal symptoms, oestrogen is given by mouth or through the skin; people whose womb is intact also take progesterone to protect the lining of the womb. Hormones compounded individually in a pharmacy are not subject to the same rigorous oversight, and the guideline advises avoiding them. The decision to treat is made individually, after the benefits and risks, including breast cancer risk, have been discussed.
A menopause health check is a review of the health screening recommended around the menopause. The main elements are a bone density scan (DEXA), cardiovascular risk monitoring (blood pressure, cholesterol, blood sugar), mammography (breast X-ray) and cervical screening. Who is screened and how often depends on age, on whether the menopause was early, and on the use of hormone therapy. The intervals come from international guidelines; national screening programmes may differ.
The long-term risks of the menopause are the effects of falling oestrogen on the bones, heart and blood vessels, brain, muscles, genital area and urinary tract. Bone loss begins before the last period, blood fats worsen and fat collects around the abdomen. After an early menopause the risks rise markedly, and guidelines recommend hormone therapy up to the natural age of menopause even without symptoms. In natural menopause, however, starting hormone therapy solely to prevent dementia is not recommended.
A hot flush is the response of the brain's temperature centre to the withdrawal of oestrogen; it brings sudden heat, redness and sweating in the face and chest. It affects 70-80% of women going through the menopausal transition and lasts 7.4 years on average. Hormone therapy reduces the frequency of episodes by about 75%; cognitive behavioural therapy and clinical hypnosis also have evidence behind them. Most herbal supplements have not been shown to differ from placebo (a dummy pill); whether hormone therapy is suitable is assessed individually.
Brain fog is the forgetfulness, difficulty finding words and trouble concentrating seen during the menopausal transition. According to studies it settles by itself in most women after the last period, and in natural menopause it is not a forerunner of dementia. Treating hot flushes and disturbed sleep eases it. Early menopause, or removal of the ovaries at a young age, does however raise the risk of dementia if left untreated. Other causes, such as thyroid disease or B12 deficiency, should also be assessed.
Osteoporosis (thinning of the bones) is a loss of bone mass that leaves the bones fragile; at the menopause the loss speeds up about a year before the last period. It has no symptoms, and the first sign is often a fracture. A bone density scan (DEXA) is advised from the age of 65; in younger women fracture risk is calculated first. Calcium, vitamin D, exercise and, in suitable women, hormone therapy play a part in prevention. The risk rises markedly after an early menopause.
Vaginal dryness means the vagina has lost its natural moisture and elasticity. The most common cause is the fall in oestrogen (the main female hormone) at the menopause; breastfeeding, some medicines, cancer treatment and smoking can also cause it. Burning, itching, pain during intercourse and frequent urinary infections may occur. Treatment is stepwise: first regular moisturisers and lubricants for intercourse, then low-dose oestrogen applied in the vagina if needed. Evidence for laser and similar methods is still limited.
After the menopause the risk of cardiovascular disease rises markedly, because the protective effect of oestrogen on the blood vessels is lost. Cholesterol values worsen, blood pressure rises and fat shifts to the abdomen; the risk is higher after an early or surgical menopause. The effect of hormone therapy on the heart depends on timing: benefit has been reported when it is started within the first 10 years of the menopause or before 60; started late and by mouth, it gives no protection and may increase the risk of clots and stroke.