Menopause: Symptoms, Treatment and the Truth About HRT
Menopause is a normal transition that is frequently endured rather than treated, partly because of a twenty-year scare about hormone therapy that has since been substantially revised.
The stages
Perimenopause begins several years before periods stop, often in the mid-forties. Cycles become irregular, and symptoms frequently start here while periods are still occurring. This is the phase most often missed and misattributed to stress.
Menopause is defined retrospectively, as 12 consecutive months without a period. Average age in India is around 46 to 48, earlier than in Western populations.
Premature ovarian insufficiency means menopause before 40 and needs treatment, since the long-term consequences for bone and heart health are significant.
Symptoms
Vasomotor: hot flushes and night sweats, the best-known symptoms, affecting the majority and sometimes lasting years.
Genitourinary syndrome of menopause: vaginal dryness, burning, pain during sex, urinary urgency and recurrent urinary infections. Unlike flushes, this does not improve with time and progresses without treatment. It is massively under-reported because people assume it is unavoidable.
Sleep: insomnia, frequent waking, often but not only due to night sweats.
Mood and cognition: low mood, irritability, anxiety, poor concentration and word-finding difficulty, which many women find more distressing than the physical symptoms.
Musculoskeletal: joint and muscle aches, which are common and rarely connected to menopause by the person experiencing them.
Other: palpitations, headaches, changes in skin and hair, weight redistribution to the abdomen, reduced libido.
Silent changes: accelerated bone loss, with the fastest rate in the first years after menopause, and rising cardiovascular risk as oestrogen’s protective effect is lost.
Diagnosis
In women over 45 with typical symptoms, menopause is a clinical diagnosis and blood tests are not needed. FSH levels fluctuate wildly in perimenopause and a normal result does not exclude it. Testing is appropriate under 45, and especially under 40, and to exclude thyroid disease or other causes.
Hormone therapy, and what the scare got wrong
In 2002 the Women’s Health Initiative trial was reported in a way that caused a global collapse in HRT use. The problems with that interpretation are now well established:
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- The average participant was 63 years old, more than a decade past menopause, and many had existing cardiovascular disease. This is not the population that typically starts HRT
- The absolute risks were small and were presented as relative increases
- Only one formulation and route was studied
- Later analysis showed that women starting within ten years of menopause and under 60 had a different and more favourable risk profile, including reduced mortality in some analyses
Current position in broad terms: for healthy women under 60 or within 10 years of menopause with troublesome symptoms, the benefits generally outweigh the risks.
Benefits: highly effective for hot flushes and night sweats, improves genitourinary symptoms, sleep, mood and joint pains, and prevents osteoporotic fracture.
Risks, in context: a small increase in breast cancer risk with combined HRT, related to duration, and smaller than the risk associated with obesity or regular alcohol; oestrogen-only HRT in women without a uterus does not show this increase in the same way. Oral oestrogen slightly increases clot and stroke risk; transdermal oestrogen, patches or gel, does not carry the same clot risk and is preferred for women with risk factors. Women with a uterus must take a progestogen alongside oestrogen to protect the endometrium.
Not suitable with current or past breast cancer, oestrogen-dependent cancer, unexplained vaginal bleeding, active liver disease, or previous unprovoked clot without specialist advice.
Vaginal oestrogen is a separate matter: low-dose local treatment for genitourinary symptoms has minimal systemic absorption, can be used long term, and is suitable for many women who cannot take systemic HRT. It is one of the most under-prescribed effective treatments in medicine.
Non-hormonal options
For flushes: SSRIs and SNRIs, gabapentin, clonidine, and newer non-hormonal agents targeting the brain pathway responsible. Cognitive behavioural therapy has good evidence for flushes and sleep.
For vaginal symptoms: moisturisers used regularly and lubricants used for intercourse, which are different products with different purposes.
For everything: regular exercise including weight-bearing and resistance work, maintaining a healthy weight, limiting alcohol and caffeine and spicy food if they trigger flushes, layered clothing, a cool bedroom, stopping smoking which brings menopause earlier and worsens flushes, adequate calcium and vitamin D, and attention to blood pressure, lipids and glucose, because cardiovascular risk is now rising.
Black cohosh, evening primrose oil and most herbal remedies have weak and inconsistent evidence. Phytoestrogens have modest effects at best. Compounded “bioidentical” hormones from unregulated sources are not recommended; regulated body-identical preparations are available.
Contraception in perimenopause
Fertility is reduced but not zero. Contraception is generally advised until 12 months after the last period over 50, or 24 months under 50.
See a doctor for
Bleeding after 12 months without periods, very heavy or prolonged bleeding, bleeding between periods or after sex, symptoms severe enough to affect work or relationships, menopause before 45, or if you want to discuss HRT. Being told to simply tolerate it is not an adequate answer in 2026.
This is general information. HRT suitability depends on your personal and family history, and the choice of preparation and route should be made with a doctor.