Menopause Symptoms: Signs, Age, Hot Flushes, HRT and Staying Healthy

Menopause is the natural end of menstrual periods, which happens when the ovaries stop releasing eggs and produce much less oestrogen. It is a normal stage of life, not a disease, but the hormonal changes can cause symptoms that affect sleep, mood, work and relationships. Understanding what is happening can help you manage it well.

The stages

• Perimenopause: the transition, starting on average in the mid-40s and lasting 4-8 years. Periods become irregular, and symptoms begin while hormone levels fluctuate.
• Menopause: the point, confirmed after 12 months without a period. The average age is about 51.
• Postmenopause: all the years after menopause.
• Premature menopause (before age 40) and early menopause (40-45) can be due to genetics, surgery to remove the ovaries, chemotherapy or radiotherapy, or autoimmune disease, and need medical assessment.

Common symptoms

• Changes in periods: shorter or longer cycles, lighter or heavier bleeding, skipped periods
• Hot flushes and night sweats: sudden waves of heat, flushing and sweating, which affect up to 80% of women and may last several years
• Sleep problems, insomnia and waking at night
• Mood changes: irritability, low mood, anxiety, and loss of motivation
• Brain fog: memory lapses and difficulty concentrating
• Vaginal dryness, discomfort during sex and reduced libido
• Urinary symptoms: frequency, urgency and recurrent urine infections
• Joint and muscle aches
• Palpitations, headaches or migraines that change
• Skin and hair changes: dryness, thinning hair
• Weight gain around the abdomen

Symptoms vary greatly. Some women barely notice them, while others find them disabling.

Diagnosis

• Women over 45 with typical symptoms usually do not need tests.
• Under 45, or if the diagnosis is unclear, doctors may check FSH, oestradiol, thyroid function and a pregnancy test, since thyroid disease and other conditions mimic menopause.
• Irregular or heavy bleeding, bleeding after sex or bleeding after menopause must always be checked. See irregular periods.

Treatment options

Lifestyle changes

• Dress in layers, keep the bedroom cool, use a fan and avoid triggers such as hot drinks, spicy food, alcohol and smoking
• Exercise regularly, including walking and strength work
• Maintain a healthy weight. Hot flushes are often worse with obesity
• Practise relaxation, good sleep habits and cognitive behavioural therapy (CBT), which helps with hot flushes, sleep and mood

Menopausal hormone therapy (HRT)

• Oestrogen, with a progestogen if you have a womb, is the most effective treatment for hot flushes, night sweats, vaginal dryness and bone protection.
• It is available as tablets, patches, gels or sprays. Transdermal (skin) forms have a lower clot risk.
• Benefits usually outweigh risks for healthy women under 60 or within 10 years of menopause. Risks include a small increase in breast cancer risk with combined long-term use, and clots and stroke with tablets.
• Not suitable for some women, such as those with breast cancer, unexplained vaginal bleeding, active liver disease or previous clots, unless specialist-approved.

Non-hormonal options

• Fezolinetant, certain antidepressants (SSRIs, SNRIs), gabapentin or clonidine for hot flushes, prescribed by a doctor
• Vaginal oestrogen (cream, pessary or ring) or moisturisers and lubricants for vaginal dryness; it is safe for most women, including many who cannot take systemic HRT
• Herbal products such as black cohosh and soy isoflavones have limited and inconsistent evidence, and some can harm the liver or interact with medicines. Talk to your doctor first.

Protect your long-term health

Falling oestrogen raises risk of:

• Osteoporosis and fractures: bone loss speeds up in the years after menopause. Get enough calcium (about 1,000-1,200 mg a day from food, such as milk, curd, small fish with bones, leafy greens) and vitamin D (sunlight and supplements if low), do weight-bearing exercise and avoid smoking and heavy alcohol. Your doctor may advise a bone density scan.
• Heart disease: risk rises after menopause. Check blood pressure, cholesterol and blood sugar regularly. See how to lower high blood pressure and how to lower cholesterol.
• Diabetes and weight gain: metabolism slows, and abdominal fat increases. Use our TDEE calculator and waist-to-height calculator.
• Urinary and sexual health: pelvic floor exercises help with bladder control.
• Cancer screening: keep up with cervical screening and breast checks or mammograms as recommended.

Contraception in perimenopause

You can still become pregnant until menopause is confirmed. Continue contraception for 12 months after your last period if you are over 50, and 24 months if under 50, or as advised by your doctor.

Emotional well-being

Mood swings and low mood are common during perimenopause. If you feel persistently sad, hopeless or anxious, or have thoughts of self-harm, speak to a doctor promptly. Talking therapies, exercise, social support and medicines can help.

When to see a doctor

See a doctor if symptoms affect your daily life, if you are under 45 and your periods change or stop, if you have very heavy bleeding, bleeding between periods or after menopause, or if you want to discuss HRT or bone health.

References

• The North American Menopause Society: 2022 hormone therapy position statement
• NICE guideline NG23: menopause, diagnosis and management
• International Menopause Society: recommendations on women's midlife health
• World Health Organization: menopause fact sheet