What is the menopause?
The menopause refers to a woman’s last menstrual period. This happens when your ovaries stop releasing eggs and, as a result, the levels of your hormones (oestrogen, progesterone and testosterone) fall.
A woman’s menopause is said to have occurred when her last menstrual period was one year ago. After this date, she is considered post-menopausal. Menopausal symptoms often occur in the months or years leading up to a woman’s final period. This time is often referred to as the perimenopause.
The average age of menopause in the UK is 51 years of age, but any time after 45 is considered normal. If menopause occurs between the ages of 40 and 45 this is called an early menopause. One in a hundred women will experience menopause below the age of 40 – this is referred to as premature menopause or Premature Ovarian Insufficiency (POI).
Menopause is natural process, but can also occur as a result of surgery to remove the ovaries (called a bilateral oophorectomy), medical treatment (e.g. following radio- or chemotherapy), infection, auto-immune conditions (e.g. type 1 diabetes) and genetic causes (e.g. Turner Syndrome). Although a cause for early or premature menopause is not always found, it can sometimes run in families. Some women may experience an early menopause as a result of having a hysterectomy (removal of the womb), even if they do not have their ovaries removed at the same time.
How is the menopause diagnosed?
If you are over 45 years of age and are experiencing menopausal symptoms, together with a change in your menstrual cycle (your periods may have become irregular or more frequent, may be lighter or heavier), then no tests are needed to diagnose the menopause. If you are using contraception that stops your periods (e.g. the progesterone-only pill or a hormone containing coil such as the Mirena IUS) or have had a hysterectomy, then it would be a good idea to write down your symptoms, or record them using an electronic app, and discuss these with your GP.
If you are under 45 years of age and believe you are experiencing menopausal symptoms, you will need to have a blood test to measure the level of a hormone called
What are the symptoms of the menopause?
Pre-menopause, the hormones oestrogen and progesterone work together to release eggs from the ovaries and regulate your menstrual cycle. During the perimenopause, the levels of oestrogen and progesterone fluctuate widely and the imbalance in these hormones can lead to menopausal symptoms. Other symptoms are often a result of an overall low level of oestrogen in the body. Many different parts of the body can be affected, including the bones, joints, heart, brain, skin and vagina.
Most women will experience some menopausal symptoms, but the severity of symptoms can vary hugely. Symptoms can start several years before a woman’s final period and may continue for months to years after her menopause. However, the average length of time for women to experience symptoms is 7 years.
Hot flushes are one of the most common menopausal symptoms and affect three out of four women. These are often felt as a sudden sensation of warmth which spreads throughout the body. They may be associated with sweating, dizziness, anxiety and feeling sick or light-headed. Hot flushes often come on suddenly, but certain things can also trigger them e.g. after drinking alcohol, coffee or eating spicy food, smoking cigarettes.
Other symptoms include: irregular or heavy periods, night sweats, joint pains, poor sleep (insomnia), heart palpitations, low mood (depression), anxiety, mood swings, poor memory, tiredness, headaches, vaginal dryness, hair and skin changes, urinary symptoms (needing to pass urine more frequently), painful sex, and low sex drive (libido).
Are there any long-term health problems associated with the menopause?
After menopause, women have an increased risk of osteoporosis (thinning of the bones), heart disease and dementia. This is believed to be as a result of the falling levels of oestrogen, as this hormone protects our bones, heart and our brain.
Hormone replacement therapy (HRT) may help reduce these risks. For this reason, it is very important, if possible, for women who experience an early or premature menopause to take HRT until at least the age of 51.
There are also things you can do to help yourself to reduce your risk of long-term health problems after the menopause, including eating a well-balanced diet, exercising regularly and reducing stress (see below)
What can I do to help myself during menopause?
Diet and lifestyle are very important in helping to manage menopausal symptoms and in protecting long-term health.
Stopping smoking, if this is relevant to you, is one of the best things you can do to reduce your symptoms and improve long term health. Consider seeking support/smoking-cessation therapy if you feel you will struggle to do this alone.
There is some evidence that women who follow a plant-based diet have fewer menopausal symptoms. They also have lower rates of heart disease and cancer. Even if you do not follow a fully plant-based diet, aim to focus your meals around fruits, vegetables, whole-grains, beans/legumes and nuts/seeds. Include foods rich in phyto-oestrogens (plant-based oestrogens) in your daily diet e.g. soya beans, chickpeas/hummus, and lentils. Minimise processed and refined foods, including sugar and junk food, animal products (meat, dairy, eggs) and alcohol.
Some women find that spicy food, caffeinated drinks (coffee and tea) and alcohol worsen their symptoms (especially hot flushes and night sweats). Alcohol and caffeine can also exacerbate psychological symptoms (e.g. anxiety and low mood) and can be detrimental to bone health, so aim to keep these to a minimum (or eliminate completely).
Ensuring you have adequate sleep (7-8 hours a night) is paramount, but menopausal symptoms (especially night sweats) can make this difficult. Make sure your bedroom is well-ventilated, wear light natural clothing e.g. cotton pyjamas, and consider investing in a fan.
To minimise sleep disruption, switch off electronic devices at least one hour before bed and/or wear blue light blocking glasses in the evening. Aim to get up at approximately the same time each day and get outside in the morning daylight (whatever the weather) for at least 20 minutes. If this is not possible, try to have your breakfast/morning drink close to a window/in a naturally lit area. This will help to regulate your sleep cycle (and hormones).
Exercise is very important for physical and mental well-being, symptom reduction and bone, brain and heart health. Aim to move your body daily. If you are able to hike, run, or dance, for example, these are fantastic for improving bone density; if not, Pilates and yoga can provide similar benefits and are also important for developing strength and improving balance. Both cardiovascular exercise (activity that raises your heart rate for a sustained period of time) and weight-bearing exercise (activity that increases lean muscle mass, reduces body fat and increases strength) are equally important.
Stress reduction can have a hugely positively impact on menopausal symptoms. 5-10 minutes of mindfulness meditation and/or breathing exercises, for example, can be incredibly beneficial. Overall, be kind to yourself and allow yourself at least 30 minutes a day to do something just for you e.g. reading a novel, listening to your favourite music/podcast, walking in nature.
Are there any supplements I should consider taking during menopause?
Everybody over the age of 50, regardless of dietary choices, should take a regular vitamin B12 supplement. Aim for 10 micrograms daily, or at least 2000 micrograms once a week.
Vitamin D3 is important for everyone in the UK between the months of October and April. This is because we do not have enough sunlight in the northern hemisphere at this point in the year to make this vitamin (which is technically a hormone itself). Aim for 10 micrograms/400 IU daily. In spring/summer, try and get at least 20 minutes’ exposure to sun on your arms/legs/back (no sunscreen); if this is not possible, then continue to supplement. Vitamin D3 is particularly important for bone health.
Consider taking an algae-derived EPA/DHA omega-3 supplement (250 milligrams daily) or add 1 tablespoon of ground flaxseed and 6 walnut halves to your daily diet. Omega-3 fatty acids are essential for good heart and brain health.
Iodine is important when it comes to hormonal health and many people are deficient in this mineral (in many countries salt is iodised to guard against this, but this is not the case in the UK). Adults require 140 micrograms daily (
What medical treatments are available to help with the symptoms of menopause?
Some women will only experience mild symptoms of the menopause and may not need any treatment at all. Others may be able to manage their symptoms with lifestyle changes (see above). However, some women experience difficult symptoms and will require further help and support.
Hormone replacement therapy (HRT) is the most effective medical treatment for symptoms of the menopause, and also helps protect your brain, heart and bones. All HRT contains the hormone oestrogen and, for women who have not had a hysterectomy, a progestogen (a synthetic form of progesterone).
HRT is available as tablets, gel or patches to be placed on the skin. Tablets and gels are taken/applied daily and skin patches are usually changed twice weekly.
If you are prescribed HRT when you are still having periods, you will be given a type that still gives you monthly bleeds. If you have not had your period for at least one year you will be given a type of HRT that does not give you a bleed.
Some women only need to take HRT for vaginal symptoms (such as dryness, soreness or painful sex). In this case, they may require only topical treatment – a low dose oestrogen in the form of a pessary, cream or a silicone ring (inserted into the vagina). The ring (called Estring in the UK) may be the best option for you if it is difficult or not possible for you to insert the pessaries or cream into your vagina yourself. Topical vaginal treatment can be taken in conjunction with systemic HRT (as above) or used alone. A new non-oestrogen based treatment – a daily pessary containing dehydroepiandrosterone (DHEA) – has recently become available for vaginal symptoms.
Some women are unable to take HRT for medical reasons (e.g. a
Is HRT safe?
You may have heard, or read about, scare stories relating to the safety of HRT. Most of these came about following the results of some large studies, published more than 15 years ago. These studies raised concerns over the safety of HRT (in particular relating to heart disease and breast cancer). However, following their publication, several of these studies have been showed to be flawed; the results were misinterpreted and inaccurate.
More up to date studies have shown numerous benefits of taking HRT and that any associated risks are very small.
For most women, if started within ten years of menopause, below the age of 60, HRT has more benefits than risks and is generally safe and effective.
What are the benefits of taking HRT?
HRT helps reduce symptoms of the menopause, and many women who choose to take HRT feel that they have regained their quality of life.
HRT also reduces your risk of osteoporosis, heart disease (if started within ten years of menopause) and colorectal (bowel) cancer (if taking combined HRT).
HRT is also very important for brain health in women who experience
What are the risks of taking HRT?
If HRT is started within ten years of menopause, below the age of 60, then there is no increased risk of heart disease (e.g. experiencing a heart attack or stroke); in fact, as mentioned above, there is evidence that HRT appears to reduce this risk.
However, if started after the age of 60, there is possibly a very small increased risk (although we are not entirely clear why, and more research is needed). Nevertheless, a woman’s actual risk of developing heart disease depends on many things, such as family history, lifestyle and general health. Some women do choose to start HRT after the age of 60 if their menopausal symptoms are severe and, in these cases, tend to experience far more benefit than harm.
Many women worry about the risk of developing breast cancer on HRT. This is a complex subject, as breast cancer is a complex disease. If you are taking certain forms of combined HRT (both oestrogen and a progestogen), then you may have a small increased risk of breast cancer if you take it for more than 5 years. However, the overall increase in risk is very small, and taking HRT does not appear to increase a woman’s risk of dying from breast cancer.
Women who are overweight, who smoke, regularly drink alcohol, or do little to no exercise have a higher risk of developing breast cancer than those who choose to take HRT, so it is important to put this into perspective if you feel you may benefit from HRT.
When you stop taking HRT, any associated increased risk of breast cancer returns to normal.
Women who have had a hysterectomy and are on oestrogen-only HRT have no increased risk of breast cancer. Likewise, there is no increased risk of breast cancer in women who take HRT under the age of 51.
For women who take a tablet form of HRT, there is a small increased risk of developing a blood clot. This risk is greater for women who are overweight, who smoke, who have had a clot in the past, or who have a medical history of diabetes or migraine. However, there is no increased risk of developing a blood clot if HRT is taken in the form of a gel or patch (which means that women who do suffer with migraine, or have diabetes, for example, can take this form safely).
What are the side effects of HRT?
As with any new medication, there may be a few side effects when you first start HRT (although not everyone will experience these by any means).
The most common side effects are nausea (feeling sick), breast tenderness and leg cramps. These usually settle within the first month (and usually within a few days).
Some women experience some vaginal spotting or irregular bleeding when they first start HRT. This usually happens in the first 3-6 months of treatment as your body gets used to the hormones. If any unscheduled bleeding happens after this time it is very important that you see your doctor. Most of the time, all that will be required will be a change in medication. In some cases, you may be referred for an ultra-sound scan to check the thickness of the lining of your womb (again, this is rarely anything to worry about but may be important to rule out a more serious cause for your bleeding).
Are there any non-medical alternatives to HRT?
Some women choose not to take
There is some evidence that
Herbal preparations, e.g. black cohosh and sage, may also be helpful. However, if you choose to go down the herbal route it is important to understand that these may interact with other medications you may be taking. As such, always discuss this with your doctor or a pharmacist before starting a herbal medication.
If you buy herbal medicine over the counter, ensure that it has the THR registration (for quality standard and safety). You may wish to consult with a trained medical herbalist e.g. someone who is registered withThe National Institute of Medical Herbalists. They will be able to advise you on all your options and will be aware of possible interactions between herbs and prescribed medications.
In some cases, women have found cognitive-behavioural therapy (CBT), acupuncture and magnet therapy (e.g. the LadyCare magnet) helpful in managing their symptoms.