Menopause

The menopause is when your ovaries stop working and your periods stop. For most women, the menopause is a natural stage of life. Menopause symptoms include hot flushes, night sweats and mood changes. The average age that women in the UK reach the menopause is 51, but this can vary widely.

About the menopause

The menopause is the time in a woman’s life when her periods stop completely. It can also affect some intersex, trans and non-binary people. You’re said to have reached the menopause if you haven’t had a period for at least a year. This is usually between the ages of 45 and 55. The time leading up to the menopause is called the perimenopause (or menopausal transition). This can last for a few months to several years. During the perimenopause, you may notice several symptoms. Your periods may also change. They may:

• happen less often than they used to
• happen more often
• be heavier or lighter
• stop completely

If you keep getting periods more often than usual, contact your GP for advice.

You may still be able to get pregnant while going through the perimenopause, so you need to keep using contraception. Doctors usually suggest you can stop contraception:

• when you’re 55
• if you’re over 50, aren’t using other hormonal treatments, and haven’t had a period for a year
• if you’re between 40 and 50, aren’t using other hormonal treatments, and haven’t had a period for two years

Premature and early menopause

If you reach the menopause before you’re 40, this is called premature menopause or premature ovarian insufficiency. When the menopause happens between 40 and 44, it’s called an early menopause.

Causes of the menopause

For most women, the menopause is a natural part of ageing. It happens when your ovaries run out of eggs. Your ovaries also make the hormone oestrogen. So, when they stop working, your blood levels of oestrogen fall. This change disrupts your periods and causes the symptoms of the menopause. Some things can cause a premature or early menopause. These include:

• surgery to remove your ovaries (oophorectomy), which may be done during a hysterectomy
• some types of medicine, including chemotherapy
• radiotherapy to your pelvic area

You may also go through the menopause at an earlier age if you’re:

• from certain ethnic backgrounds – for example, South Asian (from India, Pakistan or Bangladesh backgrounds)
• have certain medical conditions –for example, thyroid problems

In around 9 in 10 women who have an early menopause, doctors can’t find a specific medical cause. Premature ovarian insufficiency can run in families. It may not always be permanent.

Signs and symptoms of the menopause

The menopause affects everyone differently. Your symptoms may not cause you much trouble. Or they may significantly affect your daily life. Around 1 in 4 women and some non-binary people and trans men will have more severe menopausal symptoms. The timing of menopausal signs and symptoms can vary widely. Your symptoms may begin while you’re still having periods or they may start a year or more after your last period. You may not have any vaginal or urinary symptoms until 10 years after your last period. Hot flushes and night sweats may go on for seven years or more after your periods stop. But everyone is different.

During the perimenopause, you may have irregular periods. Your periods may happen more or less often before they stop completely. You may bleed more or less heavily than usual. Speak to your GP if your periods are longer, heavier or more frequent than usual.

Other possible signs and symptoms of the perimenopause and postmenopause include the following.

• Hot flushes and night sweats. During a hot flush, your head, face and neck can become very hot for several minutes. At the same time, you may have heart palpitations and feel anxious.
• Mood changes. You may get anxious or irritable or have mood swings. These symptoms can be worse if you’re not sleeping properly.
• Joint and muscle pain or stiffness.
• Difficulty sleeping (insomnia). You may find it hard to sleep because of night sweats. But the menopause can affect your sleep, even if you don’t have night sweats.
• Vaginal symptoms (such as vaginal dryness and pain during sex). These symptoms are due to your vaginal tissue becoming fragile and thinner. You may also have some itching and irritation.
• Loss of interest in sex (reduced libido). The hormonal changes of the menopause can affect your sex drive. You may also have less interest in sex if you have uncomfortable vaginal symptoms.
• Urinary problems. These symptoms include repeated urinary tract infections, leaking urine (incontinence) and needing to go to the toilet more often.
• Memory problems. You may also have difficulty concentrating.

If you’re going through the menopause, you may have an increased chance of developing depression. This is more serious than mood swings. If you find your mood stays low for two weeks or more, contact your GP.

Vaginal bleeding after the menopause

If you start to have vaginal bleeding after you’ve reached the menopause (when you haven’t had a period for a year or more), contact your GP. This is quite common, and there may be a simple explanation. Postmenopausal bleeding may be caused by hormonal changes affecting your vagina. But it can also be a symptom of certain cancers, including womb cancer. So many bleeding from your vagina after the menopause needs to be checked out by your GP.

When to seek help for the menopause

If you can manage your symptoms yourself, you may not need to see a doctor. But you may wish to see your doctor if your symptoms are hard to deal with or happen before you’re 40.

You may find it difficult to talk about some of the symptoms you’re having. But remember, your GP is there to help and will have helped many others in your situation. Your GP can support you with lifestyle changes and medicines.

Blood tests

If you’re over 45, your GP will usually diagnose the perimenopause and menopause from your symptoms without doing any tests. If you’re between 40 and 45, your GP may wish to do some blood tests to rule out other causes for your symptoms. If you’re under 40, your GP will do a thorough investigation to determine if you’re having a premature menopause because this can cause long-term health problems. Sometimes, doctors may offer you blood tests to check your levels of follicle-stimulating hormone (FSH). FSH helps to control egg production and oestrogen production in the ovaries. But hormone tests aren’t usually reliable. This is because FSH levels vary naturally during the perimenopause. Your hormone levels can change hour by hour, day by day. So a blood test just shows your hormone levels at that particular moment. There’s also a wide range of normal hormone levels. So you could be getting menopausal symptoms but a blood test may still show your changing hormone levels are normal.

Self-help for symptoms of the menopause

Many people cope with their symptoms without any specific medical treatment. There’s a lot you can do to help yourself.

Low oestrogen levels during and after the menopause can increase your risk of getting certain diseases. These include osteoporosis (thinning of the bones) and heart and vascular (blood vessel) problems. So, it’s more important than ever to try to stay healthy during and after the menopause.

Keeping active

Exercise that puts pressure on your bones – for example, running and walking – can help to strengthen them and reduce your risk of osteoporosis. Being physically active can also:

• help to protect against heart disease and stroke
• lift your mood
• improve your general wellbeing
• ease hot flushes

Eating well

Aim to eat a healthy diet – low in saturated fat and high in fibre and protein. Reducing your intake of caffeine may help to ease hot flushes. The menopause increases bone loss. Calcium helps to build and maintain healthy bones. So it’s important to include two or three portions of calcium-rich foods such as dairy products in your daily diet. It’s also important to get enough vitamin D because it’s vital for bone health. The UK government recommends that all adults take a 10-microgram vitamin D supplement every day during the autumn and winter months.

Losing excess weight

You may put on weight during the menopause, especially around your tummy. This may be linked to lowered oestrogen levels but also to getting older and to lifestyle changes. Losing weight will help to reduce your risk of heart disease and improve your overall health. It may also help to ease hot flushes.

Stopping smoking

Smoking can cause an earlier menopause and trigger hot flushes. It can also affect your general health. Ask your GP or practice nurse for advice and support on how to quit.

Limiting alcohol

Alcohol may trigger hot flushes. It can also affect your sleep quality and your mood. So it may help to limit how much alcohol you drink.

Easing mood changes

If your mood is low or you’re feeling anxious, relaxation therapies and yoga may help.

Cognitive behavioural therapy (CBT) is recommended for anxiety and depression at the menopause. It can help to change the way you think, feel and behave. CBT may also help with:

• hot flushes and night sweats
• sleep problems due to night sweats

You can have CBT sessions with a professional therapist on your own or in a group – face-to-face or online. Or you can learn how to do CBT yourself using self-help books or an online programme.

Managing hot flushes

If you’re prone to hot flushes, you may be able to ease them by:

• avoiding possible triggers –for example, spicy foods
• keeping cool by turning down the central heating and using a fan
• dressing in layers so you can take off some clothes when you feel too warm
• reducing stress with relaxation therapies or cognitive behavioural therapies

Improving your pelvic floor health

Pelvic floor exercises can help to strengthen your pelvic floor muscles. These involve squeezing and releasing the muscles that support your bowel, bladder and vagina. This may improve your bladder control. It may also help to ease other symptoms such as long-term pelvic pain or constipation. A specialist physiotherapist can give you advice on pelvic floor exercises. You can also download pelvic floor exercise apps on your phone.

Treatment of the menopause

Hormone replacement therapy (HRT)

If you’re finding it hard to manage your menopausal symptoms, your GP may suggest you try hormone replacement therapy (HRT). HRT may help many menopausal symptoms including night sweats and hot flushes, mood swings and vaginal dryness. It can also help to reduce your risk of osteoporosis. Most menopausal symptoms should start to improve within three months of starting HRT.HRT works by helping to restore your blood levels of oestrogen. Sometimes you may need to use the hormone progesterone too. You may be offered:

• oestrogen on its own (called oestrogen-only HRT) if you’ve had a hysterectomy and your womb (uterus) has been removed
• a combination of oestrogen and progesterone (called combined HRT) if you still have your womb – you may have both hormones every day (continuous combined HRT) or have only the progesterone part for 10 to 14 days of each month (sequential combined HRT)

HRT comes in lots of different forms, including oral tablets, skin patches, skin gels, spray, vaginal rings, vaginal creams and pessaries. You and your doctor can discuss which form is the best one for you.

Using HRT has some potential risks. These risks depend on your age, which HRT you’re using and how long you’re using it for. Whether you wish to use HRT is an individual decision. Your GP can talk with you about the possible risks and benefits of using HRT and the safest option for you. You may need to use HRT for between 2 and 5 years to treat your symptoms. But you may also need to use it for longer – for most people, this is safe to do. Your symptoms may come back for a short time after you stop using it. Gradually reducing HRT, rather than stopping suddenly, will help to prevent this. Testosterone is also used with HRT by some women if they have a low sex drive.

Body-identical and bioidentical hormones

Your doctor can prescribe licensed body-identical hormones in the form of oestradiol and micronised progesterone’s on the NHS. Body-identical hormones are strictly regulated. They are different from bioidentical hormones.

Bioidentical hormone preparations are often custom-made (compounded) and are not recommended. They are often promoted as being more ‘natural’ than standard HRT but can’t be prescribed on the NHS. This is because these hormones are unregulated, which means doctors can’t be sure they’re safe and effective.

Other treatments

If you can’t or don’t want to take HRT, your GP may suggest other treatments. These may include the following.

• Talking therapies, such as cognitive behavioural therapy (CBT) to help with low mood and mood changes. Your GP may offer you antidepressant medicines if they think you have depression.
• Vaginal moisturisers or lubricants to help with vaginal dryness.
• Non-hormonal medicines such as antidepressants, fezolinetant or clonidine, for hot flushes and sweats.

Complementary therapies

There’s no evidence that complementary therapies such as aromatherapy, acupuncture and reflexology can help menopausal symptoms. Herbal remedies, such as black cohosh and soya-based foods, may help hot flushes. But these can have side-effects and interact with other medicines. Ask your pharmacist for advice if you plan to try any herbal products.