Menopause: Symptoms, Treatment Options and What HRT Really Does

Menopause is defined as twelve consecutive months without a period, marking the end of ovarian function. In India it occurs on average around 46-48 years, somewhat earlier than in Western populations. The transition leading up to it — perimenopause — can last four to eight years and is when most symptoms occur.

Because periods are still happening during perimenopause, symptoms are frequently attributed to stress, thyroid problems or ageing rather than recognised for what they are.

Symptoms

Vasomotor:

• Hot flushes: sudden heat in the face, neck and chest, often with flushing and sweating, lasting a few minutes
• Night sweats, which disrupt sleep badly

Genitourinary:

• Vaginal dryness, itching and pain during intercourse
• Urinary urgency and recurrent urinary infections
• These symptoms, unlike hot flushes, do not improve on their own and tend to worsen with time

Sleep and mood:

• Insomnia, often from night sweats but also independently
• Low mood, irritability, anxiety
• Difficulty with concentration and word-finding, commonly described as brain fog

Other:

• Joint and muscle aches
• Palpitations
• Changes in skin and hair
• Weight gain, particularly around the abdomen, driven partly by hormonal change and partly by ageing muscle loss

What changes in the body

Falling oestrogen accelerates bone loss, with the fastest rate in the first five to seven years after menopause. Cardiovascular risk rises, partly through changes in lipids and fat distribution. These are the reasons menopause matters beyond symptom relief.

Hormone therapy: where the fear came from

In 2002, early reporting of the Women’s Health Initiative trial led to headlines about breast cancer and heart disease, and hormone therapy use collapsed worldwide. Subsequent reanalysis changed the picture substantially. The trial studied mainly women well past menopause, at an average age of 63, using one specific formulation.

Current understanding:

• For women under 60, or within 10 years of menopause, with troublesome symptoms, the benefits of hormone therapy generally outweigh the risks
• Oestrogen alone, in women who have had a hysterectomy, does not appear to increase breast cancer risk and may reduce it
• Combined oestrogen and progestogen carries a small absolute increase in breast cancer risk with longer use — smaller than the risk attributable to obesity or to drinking alcohol daily
• Transdermal oestrogen (patch or gel) does not carry the clot risk that oral oestrogen does, which makes it preferable for many women
• Hormone therapy is the most effective treatment for hot flushes and night sweats, and it protects bone

It is not suitable for everyone: previous breast cancer, unexplained vaginal bleeding, active liver disease, previous venous thrombosis and some other conditions require alternatives.

Vaginal oestrogen is a separate matter. Low-dose local treatment for dryness and urinary symptoms has minimal systemic absorption and is safe for the large majority of women, including many who cannot take systemic therapy. It is greatly underused.

Non-hormonal options

• SSRIs and SNRIs reduce hot flushes and help mood
• Gabapentin, particularly for night-time flushes
• Clonidine, modestly effective
• Cognitive behavioural therapy has good evidence for flushes, sleep and mood
• Vaginal moisturisers and lubricants for dryness
• Newer non-hormonal drugs targeting the brain pathway behind flushes are becoming available

Black cohosh, evening primrose oil and most herbal products have weak or inconsistent evidence. Soy isoflavones may help slightly.

What matters regardless of treatment

• Bone: weight-bearing and resistance exercise, adequate calcium (about 1000-1200 mg daily) and vitamin D, stopping smoking, limiting alcohol. Bone density testing where risk factors exist.
• Heart: blood pressure, lipids and glucose checked regularly; this is the period when cardiovascular risk starts to climb
• Muscle: resistance training twice weekly, which counters the muscle loss that drives weight gain
• Sleep: consistent timing, a cool bedroom, limiting alcohol and caffeine
• Screening: continue cervical and breast screening on schedule

When to see a doctor

• Symptoms interfering with work, sleep or relationships
• Any bleeding after twelve months without a period
• Periods stopping before age 40, which is premature ovarian insufficiency and needs treatment to protect bone and heart
• Painful intercourse or recurrent urinary infections
• Low mood that persists

This article is general health information. Decisions about hormone therapy should be individualised with a doctor who knows your medical and family history.