Menopause is when you stop having periods, which usually happens between the ages of 45 and 55. For a small number of women menopause occurs earlier. If it happens before you are 40 it’s called premature menopause (or premature ovarian insufficiency). Menopause happens when your ovaries stop producing a hormone called oestrogen and no longer release eggs. For some time before this – it could be for a few months or for several years – your periods may become less regular as your oestrogen levels fall. This is called perimenopause.
During perimenopause you might have symptoms such as hot flushes, night sweats, joint and muscle pain, vaginal dryness, mood changes and a lack of interest in sex.
Menopause affects every woman differently. You may have no symptoms at all, or they might be brief and short-lived. For some women they are severe and distressing.
You can still get menopause symptoms if you have had a hysterectomy (an operation to remove your womb).
Other natural changes as you age can be intensified by menopause. For example, you may lose some muscle strength and have a higher risk of conditions such as osteoporosis and heart disease.
Working with you
Your healthcare professionals should talk with you about menopause. They should explain any tests, treatments or support you should be offered so that you can decide together what is best for you. Your family or career can be involved in helping to make decisions, but only if you agree.
Some treatments or care described here may not be suitable for you. If you think that your treatment does not match this advice, talk to your healthcare professional.
If menopausal symptoms are affecting your day-to-day life you should see your gynecologist. Your doctor should be able to tell if you are in perimenopause or menopause based on your age, symptoms and how often you have periods, so you are unlikely to need tests. If you are taking any hormonal treatments (for example, to treat heavy periods) it can be more difficult to know when you have reached menopause.
You may be offered a blood test but only if: you are between 40 and 45 and have menopausal symptoms, including changes in your menstrual cycle (how often you have periods) you are under 40 and your doctor suspects you are in menopause (also see premature menopause).
The blood test measures a hormone called FSH (follicle-stimulating hormone). FSH is found in higher levels in menopause. You should not be offered this test if you are taking a contraceptive containing oestrogen and progestogen or high-dose progestogen because the contraceptive changes your natural FSH levels.
Is there a cure?
There is no cure for polycystic ovary syndrome. Treatments aim at treating and reducing the symptoms or consequences of the syndrome. Medication alone has not been proven to be better than healthy lifestyle changes (weight loss and exercise).
Many women with polycystic ovarian syndrome have successfully managed their symptoms and their long-term health risks without medical intervention simply by making a healthy diet and regular exercise.
Menopause as a result of medical treatment
Some medical treatments and procedures can cause menopause, such as chemotherapy and radiotherapy to treat cancer, and surgery that involves the ovaries.
If you are about to have treatment likely to cause menopause, your doctor should explain to you what to expect and how it will affect your fertility. They should offer you support and also refer you to a healthcare professional who specializes in menopause.
Treating menopausal symptoms
For women who seek help for their menopausal symptoms, HRT (hormone replacement therapy) is the most commonly prescribed treatment. HRT helps to relieve symptoms by replacing oestrogen levels that naturally fall in menopause. You can take HRT as tablets or through a patch or gel on your skin.
If HRT is suitable for you and you are interested in taking it, your doctor should discuss the benefits and risks with you, both in the short term (the next 5 years) and in the future, before you decide to start it.
You should also be given information about:
non-hormonal treatments, for example a drug called clonidine
other types of treatments, such as cognitive behavioral therapy (CBT), a type of psychological therapy that helps people to manage the way they think and feel.
You can get many different treatments for menopausal symptoms without a prescription. Some women find that complementary therapies help. If you wish to try these, your doctor should explain that their quality and ingredients may be unknown. Another type of treatment is called bioidentical or compounded hormones, but these are unregulated and it is not known whether they are safe or effective.
Managing your symptoms
Hot flushes and night sweats
Hot flushes and night sweats are common in menopause. If you are finding them a problem, you should be offered HRT after discussing the benefits and risks with your doctor. If you have a womb you should be offered HRT that contains oestrogen and progestogen. This is because oestrogen-only HRT can be harmful to the lining of the womb. If you don’t have a womb you should be offered oestrogen-only HRT.
Some women find that the dietary supplements black cohosh and isoflavones can reduce their hot flushes and night sweats. However, the ingredients of these products may vary and their safety is unknown. They may also interfere with any other medicines you are taking.
Low mood is a common symptom of menopause – it is different from depression.
If you’re feeling low as a result of menopause you may be offered HRT. Another possible treatment is CBT (cognitive behavioural therapy) and you may be offered this if you have low mood or anxiety as a result of menopause.
It has not been shown that antidepressant drugs called SSRIs and SNRIs can help with low mood during menopause if you haven’t been diagnosed with depression.
Lack of interest in sex
If you have vaginal dryness you should be offered vaginal oestrogen, which is put directly into the vagina as a pessary, cream or a vaginal ring. You can use vaginal oestrogen for as long as you need to, even if you are already using HRT. Moisturizers and lubricants can also help. If vaginal oestrogen doesn’t help to start with you may be offered a higher dose.
It’s rare for vaginal oestrogen to cause problems, but if you have any unexpected vaginal bleeding you should tell your doctor. Your doctor should explain that your symptoms may come back when you stop using it.
Vaginal oestrogen might be suitable for you if you can’t take HRT for medical reasons.
Benefits and risks of HRT
When your ovaries stop producing estrogen, your bones become thinner and have a higher risk of osteoporosis, so they break more easily. Your doctor should tell you that for women around the age of menopause the risk of suffering a woman’s fracture is low, and OSH further reduces this risk in the future. This benefit lasts only while you are being treated, but it can last longer if you have been treated for a long time.
Blood clots (venous thromboembolism)
HRT tablets (but not patches or gels) are linked with a higher risk of developing a blood clot. If you are already at higher risk of blood clots (for example, you are obese) and you are considering HRT, you may be offered patches or gel rather than tablets.
If you have a strong family history of blood clots or if there’s another reason why you are at high risk of blood clots, you may be referred to a haematologist (a doctor who specialises in blood conditions) before considering HRT.
Heart disease and stroke (cardiovascular disease)
Studies show that:
If you start HRT before you’re 60 it does not increase your risk of cardiovascular disease.
HRT does not affect your risk of dying from cardiovascular disease.
HRT tablets (but not patches or gels) slightly raise the risk of stroke. However, it is important to remember that the risk of stroke in women under 60 is very low. If you’re already at higher risk of cardiovascular disease it may still be possible for you to take HRT but it will depend on your individual circumstances.
Studies show that for women around menopausal age: Oestrogen-only HRT causes little or no change in the risk of breast cancer. HRT that contains oestrogen and progestogen may increase breast cancer risk. This risk may be higher if you take HRT for longer but falls again when you stop taking HRT.
Type 2 diabetes
HRT does not increase your risk of developing type 2 diabetes.
If you already have type 2 diabetes, HRT is unlikely to have a negative effect on your blood sugar control. When deciding if HRT is suitable for you, your GP should take into account any health problems related to your diabetes and may ask a specialist for advice before offering you HRT.
When your ovaries stop making oestrogen your bones become thinner and you have a higher risk of osteoporosis, where your bones break more easily.
You should be given advice about bone health and osteoporosis at your first appointment and again when reviewing your treatment. Your doctor should explain that for women around menopausal age the risk of breaking a bone is low, and HRT reduces this risk further. This benefit only lasts while you are taking HRT but it may last longer if you have taken HRT for a long time.
Loss of muscle strength
It is currently unknown whether HRT affects the risk of developing dementia.
Starting and stopping HRT
Your doctor should tell you what to expect when you start taking HRT. It’s common to have some vaginal bleeding in the first 3 months (for women who have a womb). If you have any unexpected bleeding in the first 3 months, tell your doctor at your first review appointment. If it happens after the first 3 months tell your doctor straightaway.
When you are thinking about stopping HRT you can either stop immediately or gradually reduce your dose. Your doctor should give you more advice about this. You may have some menopausal symptoms again after stopping HRT, although they may return less quickly if you stop gradually.
Premature menopause (premature ovarian insufficiency)
Premature menopause is diagnosed using your age and symptoms, as well as information about your family history and medical history (for example, whether you have had medical treatment that is known to trigger menopause). If you are under 40 and having no or very few periods, you should be offered blood tests to measure your levels of FSH (follicle-stimulating hormone). You should be offered 2 blood tests for FSH, which should be done 4–6 weeks apart (this is because your FSH levels change at different times during your menstrual cycle).
If it is not clear whether you are in premature menopause, you should be referred to a healthcare professional who specializes in menopause or reproductive medicine to confirm your diagnosis.
Treating premature menopause
Treatment for premature menopause usually involves HRT or a combined hormonal contraceptive.
Your doctor should explain that:
it is important to continue treatment until at least the age of natural menopause, to give you some protection from osteoporosis and other conditions that can develop after menopause the risk of conditions such as cardiovascular disease and breast cancer rises with age and is very low in women under 40 both. HRT and the combined contraceptive pill are good for bone health. HRT may be better for your blood pressure than the combined contraceptive pill
HRT is not a contraceptive. Hormonal treatment is not suitable for some women, for example if you have a history of breast cancer or another type of cancer stimulated by the hormone oestrogen. If hormonal treatment is not suitable, your doctor should discuss other possible treatments with you and should give you information about bone and cardiovascular health.