Menopause — Frequently Asked Questions

Body-identical hormones have a chemical structure similar to the hormones the human ovary produces. Compared with synthetic options they have been described as having more neutral effects on clot risk and on breast cancer risk. Micronised progesterone, for example, is plant-derived and similar in structure to ovarian progesterone.

No — this is an important misunderstanding. Compounded body-identical hormones are not subject to the same rigorous oversight as regulated (licensed) ones; there are concerns about purity and safety. The source guideline recommends avoiding these preparations and obtaining a prescription for a regulated preparation from your doctor.

Oestrogen given through the skin has a very neutral effect on the way the body breaks hormones down and does not increase clot risk compared with not being on treatment. For people at higher risk of clots — for example those who are overweight — the skin route is the one to prefer. The decision is individual.

No. For people whose womb has not been removed, progesterone or a progestogen is always given as well, to protect the lining of the womb from the effect of oestrogen. If you are still having periods it can be given so as to produce a monthly bleed; if you have reached the menopause it can be given continuously without a bleed.

Combined (oestrogen + progestogen) treatment is associated with a small increase in breast cancer risk, low both medically and statistically. With oestrogen-only treatment, little or no increase has been shown. For context: the risk from two units of alcohol every evening is higher than that from hormone therapy, and the risk from being overweight is markedly higher.

Timing affects the outcome. Hormone therapy started under the age of 60 or within the first 10 years after the menopause has been shown to produce a clear reduction in the risk of heart disease and in deaths from cardiovascular disease.

Usually not, over the age of 45. The diagnosis is made by assessing symptoms together with the change in the pattern of periods. Because the FSH level fluctuates from month to month it can be misleading in this age group. Under 40, FSH is measured if premature ovarian insufficiency is suspected and repeated if unclear; between 40 and 45 it may help. A single test may not give the diagnosis.

Complementary methods may help with symptoms, but most are less effective than hormone therapy at controlling them and are not expected to have a clear effect on bone strength or heart health. Some herbal products may also contain substances with oestrogen-like activity, so they are unsuitable for people for whom hormone therapy would be inadvisable. Cognitive behavioural therapy, by contrast, is an effective option for hot flushes and night sweats.

A scan at least once is advised for all postmenopausal women aged 65 and over, even with no other risk factor. Under 65, going straight to DEXA is not considered appropriate as general screening — the 10-year fracture probability is first calculated with a tool such as FRAX, and DEXA follows if the risk is high.

In early menopause and ovarian insufficiency a DEXA scan must be done at the time of diagnosis, to establish a baseline. Because cardiovascular risk is markedly higher in this group, blood pressure, weight, cholesterol and blood sugar should also be checked once a year.

No. If the baseline scan is normal and adequate oestrogen therapy has been started, there is little clinical value in repeating it within 5 years. If osteoporosis or reduced bone mass has been found, it is checked every 1–3 years; in women taking bone-losing medicines who are not on hormone therapy, every 2 years is advised.

Current advice for women at average risk of breast cancer is to begin screening with mammography every two years from the age of 40. In women on hormone therapy follow-up is closer; clinical protocols include breast imaging together with a gynaecological examination once a year.

Yes. After the menopause the protective effect of oestrogen is lost, so risks relating to the heart and metabolism increase. In natural menopause a baseline risk profile is established during the transition, lifestyle changes are supported, and regular cholesterol and blood pressure monitoring follows according to risk. In early menopause this monitoring should be annual.

In those at high risk of bone loss, measuring the vitamin D level at the outset, or considering supplementation directly, is advised. The amount of supplement is decided individually, so no dose is given on this page.

If 12 consecutive months have passed since your periods stopped, you are considered to have reached the menopause; the date of your last period is taken retrospectively as the moment of menopause. The stage before those 12 months are complete, when periods become irregular and symptoms can begin, is called perimenopause.

Usually not, if you are over 45 — an FSH test is not useful for diagnosis in that age group, because the level fluctuates from month to month. The diagnosis is made from your symptoms and the change in your periods. Under 40, FSH is measured if ovarian insufficiency is suspected; between 40 and 45 it may help. A single test may not give the diagnosis.

No. About one in four women has no symptoms at all. Hot flushes and night sweats are the most common symptoms and occur in 70–80% of women. Of those who do have symptoms, 25% describe them as severe and disruptive to daily life.

On average more than 7 years. More than a third of women have long-lasting symptoms that can continue for years. During perimenopause symptoms may come and go; some ease while others become more noticeable.

Yes. Because hormone receptors are found throughout the body, symptoms can look unrelated to each other. Disturbed sleep, fatigue, anxiety, difficulty with memory and concentration ("brain fog"), joint pains, palpitations and headaches are all recognised. In perimenopause the first hormone to fall is usually progesterone; because it has a calming, sleep-promoting effect, sleep can suffer as it declines.

Yes. Menopause under the age of 40 is called premature ovarian insufficiency (POI) and affects about 1 in 100 women under 40 (1 in 1,000 under 30, 1 in 10,000 under 20). Periods stopping permanently between 40 and 45 is described as early menopause.

Removing both ovaries at operation is called surgical menopause; loss of ovarian function through radiotherapy or chemotherapy is called medical menopause. In these situations the menopause begins abruptly. You should be told about the effects in detail before the operation or treatment, and have access to continuing support afterwards.

Falling oestrogen has long-term effects in two areas: an increased risk of osteoporosis and of heart disease. Osteoporosis has no clear symptom — the first sign may be a fracture. The menopause is therefore a good time to review lifestyle and health screening.

Current guidelines set no arbitrary time limit; the rule "it must be stopped after 5 years" does not apply. The decision whether to continue is made individually each year, by reviewing benefit and risk together.

According to guidelines the balance of benefit and risk is most favourable when it is started before the age of 60 or within the first 10 years of the menopause. If it is to be started later, an individual assessment of the risk of clots and of heart and blood vessel disease is needed.

Very little of the low-dose oestrogen applied inside the vagina passes into the blood. According to guidelines it does not create a whole-body risk in terms of breast cancer, clots or the heart and blood vessels, and it does not need a progestogen in women who have a womb. For those with a history of breast cancer, the decision needs to be made together with the relevant specialist.

Yes. In women who lose ovarian function before 40 and in those who enter the menopause before 45, hormone therapy is strongly recommended, and it is advised to continue it at least until the age of natural menopause (on average 51).

No. Guidelines describe several non-hormonal options: neurokinin receptor blockers, antidepressant-group medicines (SSRIs/SNRIs), gabapentin and pregabalin, oxybutynin and clonidine. Cognitive behavioural therapy is also recommended with the strongest level of evidence. None is as effective as hormone therapy, but they can reduce symptoms appreciably.

Past or active breast cancer, hormone-sensitive gynaecological tumours, vaginal bleeding of unexplained cause, active or past blood clot, active liver disease, a recent heart attack or coronary heart disease, past stroke, and high blood pressure that is not under control.

If you take tamoxifen, paroxetine and fluoxetine must not be used — they block the enzyme that activates tamoxifen in the body. The preferred option is venlafaxine. St John's wort is also not recommended because it interacts seriously with chemotherapy, and phytoestrogen supplements are not suitable with a history of a hormone-sensitive tumour.

It is important to set the right expectation: CBT does not remove the number of hot flushes. It changes how you perceive them, strengthens your belief that you can cope, and lessens the sense of being overwhelmed. In studies, 4–6 weekly sessions clearly improved distress, sleep problems and anxiety, and the effect persisted at 26 weeks.

In a randomised controlled trial aerobic exercise, yoga and omega-3 supplements could not be shown to be superior to placebo for the frequency of hot flushes. That does not make exercise unnecessary — it is always recommended for muscle mass, mood and bone health. It should just not be done with the sole expectation of reducing hot flushes.

Being “natural” does not mean being safe. For black cohosh a Cochrane review found no clear superiority over placebo, and cases of serious liver toxicity have been reported. St John's wort interacts seriously with many medicines. Phytoestrogen supplements are not recommended with a history of a hormone-sensitive tumour.

Neurokinin receptor blockers are the newest group; they have been reported to reduce the frequency of hot flushes by more than 50%, with the effect beginning within the first week. However licensing and availability differ from country to country. These medicines also require regular liver function tests before and during treatment.

If non-hormonal treatments do not relieve your symptoms, or troublesome side effects persist, guidelines recommend referral to a health professional experienced in the menopause. The treatment options are then reassessed individually.

Earlier than most people think: loss begins 1–2 years before the last period and continues for a further 3–4 years. The fastest loss is in the three-year window from one year before to two years after the last period — in that short time an average of 10.6% of bone mass is lost from the lumbar spine and 9.1% from the femoral neck.

No, and this is the most common mistake in assessment. The great majority of fractures after the menopause occur not at the “osteoporosis” threshold but one step above it, in people whose bone mass is only mildly reduced. Bone health should therefore be judged with whole-person risk assessment tools, not the score alone.

Oestrogen keeps blood vessels flexible and supports the healthy working of the vessel lining; when it is withdrawn the vascular bed is left unprotected. In the same period total cholesterol, “bad” cholesterol and triglycerides rise while “good” cholesterol falls. This increases arterial stiffness and the risk of heart disease.

Because the benefit depends on it. When treatment is started within the first 10 years of the menopause or before the age of 60, coronary heart disease, heart failure and cardiovascular deaths are reported to fall by roughly half. The same treatment started later does not show this benefit.

Yes, and it has a measurable basis. Oestrogen governs how the brain uses glucose, its main fuel; with the menopause the brain's use of glucose falls temporarily by 20–25% and the brain shifts to a different fuel arrangement. Difficulty finding words and trouble concentrating follow from that shift — they are not imagined.

No. Although protective effects of oestrogen in the brain have been described, guidelines do not recommend starting hormone therapy solely to prevent dementia in women going through a natural menopause. The decision to treat is made on other grounds and individually.

With the menopause the distribution of fat changes permanently: fat collects around the abdomen and the internal organs rather than at the hips. Muscle mass and strength also decline. Where the weight sits matters more than the weight itself — fat inside the abdomen drives insulin resistance and the risk of type 2 diabetes.

Yes, markedly. In women with early menopause who do not use hormone therapy, life expectancy is reported to be shortened; the main reason is rapidly progressing cardiovascular disease. Each year spent without oestrogen independently increases cardiovascular risk. Menopause caused by surgery takes a faster and more severe course than spontaneous early menopause.

If this is early menopause or ovarian insufficiency, yes. The strongest recommendation in the guidelines is that these women take hormone therapy even if they have no symptoms at all, at least until the age of natural menopause (on average 50–51), to protect heart, bone and brain health. In this age group the benefits are far greater and the risks far lower than in older women.

It depends on the cause. For mild dryness, vaginal moisturisers used regularly several times a week and lubricants during intercourse are often enough. If menopause-related dryness does not improve with these, the first-line medical treatment in guidelines is low-dose oestrogen applied in the vagina. Dryness linked to breastfeeding usually settles on its own as breastfeeding decreases.

The most common cause is the fall in oestrogen (the main female hormone) at the menopause. Breastfeeding, anti-oestrogen medicines used in breast cancer treatment, some contraceptives, chemotherapy and radiotherapy, Sjögren's syndrome (an immune condition that affects the body's glands), smoking, not enough arousal, and scented soaps or vaginal douching can also cause dryness.

Usually not. While hot flushes may ease over the years, menopause-related vaginal dryness often persists and tends to increase if untreated. So if you have symptoms, it is better to have them assessed than to wait.

Yes. Dryness and thinning of the tissue cause burning and pain from friction during intercourse, and sometimes light bleeding afterwards. However, pain during intercourse has other causes too; infection, skin conditions and involuntary tightening of the muscles around the vagina can also cause pain. The distinction is made at the examination.

Very little of low-dose oestrogen applied in the vagina reaches the bloodstream. According to guidelines it does not carry the risks of hormone therapy acting on the whole body, and women with a womb do not need an additional hormone. Any unexpected bleeding after the menopause must be assessed. For women who have had breast cancer, the decision is made together with the oncologist.

The first choice is hormone-free moisturisers and lubricants; if intercourse is painful, pelvic floor physiotherapy (exercises to relax the muscles at the base of the pelvis) can help. If these are not enough, vaginal oestrogen or other options are assessed together with your oncologist, taking into account the cancer medicine you use.

Some studies have reported improvement; however, the evidence is still limited and long-term results are not well known. In 2018 the U.S. Food and Drug Administration (FDA) stated that the safety and effectiveness of these devices for menopausal symptoms have not been established. These methods do not replace moisturisers or vaginal oestrogen.

Yes, it is common. Oestrogen levels stay low during breastfeeding. Moisturisers and lubricants are usually enough in this period; dryness often settles as breastfeeding decreases and periods return to normal. If it is very marked, or if there are other signs such as bleeding or unpleasant-smelling discharge, an examination is needed.