Menopause: Symptoms, the HRT Confusion, and What the Evidence Says Now
Menopause is a single day, the point twelve months after the final period. Everything leading up to it is perimenopause, and that is where most of the symptoms live, often for years before periods become irregular enough to make the connection.
The stages
Perimenopause. Begins with fluctuating hormones, often in the mid-forties, sometimes earlier. Cycles may shorten, then lengthen, and become unpredictable. Symptoms frequently begin while periods are still regular, which is why many women do not recognise what is happening.
Menopause. The retrospective marker: twelve consecutive months with no period. The average age is around 51.
Postmenopause. Everything afterwards. Hot flushes often settle over years; genital and urinary symptoms do not improve on their own and tend to worsen.
Premature ovarian insufficiency is menopause before 40, affecting around one per cent of women, and it needs hormone treatment until the usual age of menopause for bone and cardiovascular protection, rather than being treated as ordinary menopause.
Symptoms beyond hot flushes
Vasomotor: hot flushes, night sweats, palpitations.
Sleep: insomnia, early waking, fragmented sleep, partly from night sweats and partly independent of them.
Mood and cognition: low mood, anxiety, irritability, loss of confidence, word-finding difficulty and poor concentration, frequently described as brain fog. Perimenopause carries an increased risk of depressive episodes, including in women with no previous history.
Genitourinary syndrome of menopause: vaginal dryness, discomfort, pain with sex, urinary urgency and frequency, recurrent urinary infections. This affects a large proportion of women, is persistent and progressive, and is massively undertreated because it is rarely raised in consultations.
Musculoskeletal: joint and muscle aches, frozen shoulder, which is notably more common around menopause.
Other: migraine change, skin dryness, hair thinning, weight redistribution to the abdomen, palpitations.
Diagnosis
In a woman over 45 with typical symptoms, menopause is a clinical diagnosis. Hormone blood tests are generally unhelpful because levels fluctuate wildly in perimenopause and a normal FSH does not exclude it.
Testing is appropriate under 45, and particularly under 40, and where the picture is unclear or there has been a hysterectomy.
The HRT confusion, explained
In 2002 the Women’s Health Initiative trial reported increased risks and triggered a collapse in HRT use worldwide. Subsequent re-analysis changed the picture substantially, and the key points are these.
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Age matters enormously. The average participant was 63, more than a decade past menopause. Starting hormone therapy within ten years of menopause, or before 60, carries a different and considerably more favourable risk-benefit balance than starting much later.
Type and route matter. Transdermal oestrogen, through a patch or gel, does not carry the increased clot and stroke risk associated with oral oestrogen, because it bypasses first-pass liver metabolism. Micronised progesterone appears to carry a lower breast risk than older synthetic progestogens.
Breast cancer risk is real but modest and often misrepresented. Combined HRT is associated with a small increase in risk, which rises with duration of use and declines after stopping. In absolute terms the increase is comparable to or smaller than that associated with drinking a couple of units of alcohol daily or being physically inactive. Oestrogen-only HRT, used by women who have had a hysterectomy, has not shown the same increase and in the WHI was associated with slightly lower breast cancer incidence.
Benefits are substantial for symptom relief, and HRT reduces fracture risk meaningfully.
The practical consequence is that a generation of women avoided effective treatment on the basis of a risk profile that applied to a different population using different preparations.
That said, HRT is not for everyone. Contraindications include current or past breast cancer, oestrogen-dependent cancers, unexplained vaginal bleeding, active liver disease, and current or recent clots or stroke, though some of these are nuanced and worth specialist discussion rather than blanket exclusion.
Vaginal oestrogen is a separate matter
Low-dose vaginal oestrogen, as a cream, pessary or ring, treats genitourinary symptoms effectively. Systemic absorption is minimal, it does not require added progestogen, and it can usually be used long term, including by many women who cannot take systemic HRT. For recurrent urinary infections after menopause, it is one of the most effective preventive measures available.
It is dramatically underused, largely because the symptoms go unmentioned.
Non-hormonal options
- Cognitive behavioural therapy for hot flushes and sleep, with good evidence
- SSRIs and SNRIs, which reduce flush frequency, and are useful where HRT is unsuitable
- Gabapentin for night sweats
- Clonidine, modestly effective
- Fezolinetant and newer neurokinin receptor antagonists, a genuinely new non-hormonal class targeting the brain pathway behind flushes
- Vaginal moisturisers and lubricants, which are different things: moisturisers used regularly, lubricants used for sex
- Layered clothing, cool rooms, reduced alcohol and spicy food, and stopping smoking
- Regular exercise and strength training, which help mood, sleep, bone and body composition
- Over-the-counter herbal products have limited and inconsistent evidence, and some interact with other medicines
Long-term health after menopause
Oestrogen loss accelerates bone loss and alters cardiovascular risk. Worth attending to:
- Weight-bearing and resistance exercise
- Adequate calcium and vitamin D
- Bone density scanning where risk factors exist
- Blood pressure, lipids and glucose monitoring
- Continuing cancer screening programmes
The short version
Perimenopause often starts while periods are still regular, which is why symptoms get attributed to everything else. HRT risk was overstated for a generation, and for most women starting within ten years of menopause the balance favours treatment, particularly with transdermal oestrogen. Vaginal symptoms will not resolve on their own, and low-dose vaginal oestrogen is safe, effective and rarely offered unless you raise it.