Overview
Menopause is the natural biological process marking the end of menstrual cycles, defined as 12 consecutive months without a period. In the UK the average age is 51. The perimenopause (transition phase, usually 4 to 8 years before the final period) is when symptoms typically begin. Symptoms vary enormously in severity and duration. Effective treatments exist.
How common is it?
Every woman who lives long enough will experience menopause. Approximately 13 million women in the UK are currently peri or postmenopausal. About 25% experience severe symptoms significantly affecting quality of life.
Causes and risk factors
The ovaries produce progressively less oestrogen and progesterone as egg supply declines, causing the hypothalamic-pituitary axis to register an absence of negative feedback and FSH to rise.
Common risk factors
- Natural menopause: age-related follicular depletion (average age 51)
- Premature ovarian insufficiency (POI): before age 40, affecting 1 in 100 women
- Surgical menopause: bilateral oophorectomy (most abrupt onset)
- Medical: chemotherapy, radiotherapy, certain GnRH agonists
- Genetic: Turner syndrome, Fragile X premutation
Symptoms
- Hot flushes and night sweats (vasomotor symptoms — most common, affecting 80%)
- Sleep disturbance
- Mood changes: anxiety, low mood, irritability
- Brain fog and memory difficulties
- Vaginal dryness and dyspareunia (genitourinary syndrome of menopause)
- Reduced libido
- Urinary symptoms: urgency, frequency, recurrent UTIs
- Joint aches
- Irregular periods (perimenopause)
- Long-term: increased cardiovascular risk, osteoporosis
When to see a doctor
Consult a GP or menopause specialist for any symptoms affecting quality of life. All women under 45 with possible perimenopausal symptoms need prompt assessment and should be considered for HRT. Premature ovarian insufficiency requires specialist management.
Diagnosis
Clinical diagnosis in women over 45 with typical symptoms. FSH levels are not required for diagnosis over 45 (too variable to be reliable). FSH and oestradiol useful under 45 to confirm premature ovarian insufficiency.
Treatments
Hormone replacement therapy (HRT)
The most effective treatment for vasomotor and other menopausal symptoms. Modern body-identical HRT (oestradiol gel/patch with micronised progesterone) has a more favourable risk profile than older formulations. The benefits for symptoms and bone health outweigh risks for most women under 60 or within 10 years of menopause.
Vaginal oestrogen
Low-dose topical oestrogen cream, pessary, or ring for genitourinary syndrome of menopause (vaginal dryness, UTIs). Safe for almost all women including breast cancer survivors. Can be used long-term with negligible systemic absorption.
Non-hormonal pharmacological options
SSRIs/SNRIs (venlafaxine, paroxetine), gabapentin, or oxybutynin reduce vasomotor symptoms in women who cannot use HRT. Fezolinetant (a neurokinin 3 receptor antagonist) is newly licensed specifically for hot flushes.
CBT for menopause
Cognitive behavioural therapy adapted for menopause (CBT-M) is evidence-based for mood, sleep, and hot flush perception. Recommended in NICE guidelines.
Self-care and lifestyle
- Regular weight-bearing exercise for bone density; aerobic exercise for cardiovascular protection
- Reduce alcohol and caffeine (triggers hot flushes)
- Avoid triggers: spicy food, hot drinks, hot environment
- Maintain healthy weight (overweight worsens hot flushes)
- Mindfulness and CBT-based approaches help with mood and sleep
Prevention
Menopause cannot be prevented. Early HRT use prevents long-term effects on bone and cardiovascular system. Premature ovarian insufficiency should be treated with HRT until at least age 51.