Menopause and Hormonal Change

Menopause is the stage reached when ovarian activity has declined and menstrual periods have stopped permanently. The transition usually develops over several years, and hormone levels may fluctuate considerably before settling at lower levels.

Menopause is part of reproductive ageing The ovaries contain a finite number of immature eggs. As the remaining follicle pool declines, ovulation becomes less regular and ovarian hormone production changes. This process is called reproductive ageing. It does not happen suddenly on one birthday. The word menopause refers to a point identified retrospectively after 12 months without a menstrual period. This definition applies when the bleeding has stopped naturally and hormonal contraception is not masking the cycle. Perimenopause comes before menopause Perimenopause is the transition leading up to menopause. During perimenopause, ovulation becomes less predictable. Oestrogen and progesterone production may rise and fall unevenly. Hormone levels therefore do not simply decline in a smooth straight line. Periods may become closer together, further apart, lighter, heavier or less predictable. Pregnancy can still occur because occasional ovulation continues. Postmenopause follows the final period Postmenopause describes the time after menopause has been reached. Ovarian oestrogen and progesterone production remain lower than during the main reproductive years. Some symptoms improve after the transition. Others, particularly vaginal and urinary symptoms, may persist or develop later. Lower oestrogen also affects bones, blood vessels, skin, muscles and connective tissues. Ageing itself affects the same systems, so not every change occurring at midlife is caused by menopause. When menopause usually happens Natural menopause most often occurs between ages 45 and 55. The exact age varies between individuals and populations. Surgery removing both ovaries causes an immediate surgical menopause. Chemotherapy, radiotherapy and some medical treatments can also reduce or stop ovarian function. Menopause occurring between ages 40 and 44 is called early menopause. Loss of normal ovarian function before age 40 is called premature ovarian insufficiency, or POI. POI is not always identical to permanent natural menopause. Occasional ovarian activity can still occur in some people. Menstrual changes Changes in menstrual bleeding are often the first noticeable sign of perimenopause. Cycles may become longer or shorter. Bleeding may become lighter, heavier or more variable. Hormonal contraception can also alter or stop bleeding. This can make the natural transition harder to identify. Bleeding changes should not automatically be attributed to menopause. Pregnancy, fibroids, polyps, thyroid disease, medicines and other conditions may create similar changes. Heavy, persistent, post coital or otherwise concerning bleeding requires appropriate assessment. Vasomotor symptoms Vasomotor symptoms include hot flushes and night sweats. They are linked to changes in the brain's temperature regulation system during ovarian hormone fluctuation. A hot flush may involve sudden heat, sweating, facial or upper body redness and sometimes palpitations. Night sweats can disturb sleep and contribute to daytime tiredness. Not every episode of sweating is menopausal. Infection, medicines, anxiety and other conditions can also cause sweating. Sleep, mood and cognition Sleep can be disrupted directly by night sweats or by changes in sleep regulation. Some people experience low mood, anxiety, irritability or reduced confidence. Memory lapses and difficulty concentrating are sometimes described as brain fog. These symptoms are real, but they are not specific to menopause. Depression, thyroid disease, anaemia, sleep apnoea, medicines and major life stress may cause similar experiences. Clinical assessment considers the whole pattern rather than assuming that age explains every symptom. Muscles, joints and body composition Joint and muscle discomfort can become more noticeable during the menopause transition. Muscle mass and strength naturally decline with age unless supported by physical activity. Body fat distribution may change, with more fat tending to accumulate around the abdomen. Weight change is influenced by ageing, activity, sleep, diet, medicines and health conditions. Menopause does not make weight gain inevitable, and HRT is also not proven to cause substantial weight gain in most users. Genitourinary symptoms Lower oestrogen affects the vagina, vulva, bladder and urethra. These are called genitourinary symptoms associated with menopause. The vaginal tissues may become thinner, drier and less elastic. This can cause soreness, itching or pain during sex. Urinary urgency, discomfort and recurrent urinary infections may also become more common. Unlike many hot flushes, genitourinary symptoms often persist without treatment. These symptoms are common but should not be accepted as unavoidable. Bleeding, persistent discharge, ulcers or a new lump require assessment rather than treatment based on assumption. Sexual wellbeing Menopause may affect sexual wellbeing through vaginal discomfort, sleep disruption, mood, relationship changes or altered desire. Some people experience reduced sexual desire. Others notice no change or feel more comfortable after pregnancy concerns reduce. Sexual difficulties are not explained by hormones alone. Pain, medicines, health conditions, relationship factors and previous experiences may all contribute. Care should focus on the person's concerns and goals rather than assuming that sexual activity is expected. How menopause is identified In otherwise healthy people aged 45 or over, perimenopause is usually identified from symptoms and menstrual change. Menopause can usually be identified after 12 months without periods when hormonal contraception is not being used. Routine hormone testing is not required in this typical situation. Hormone levels fluctuate during perimenopause, so one result may therefore be misleading. When FSH testing is useful Follicle stimulating hormone, or FSH, rises as ovarian responsiveness declines. NICE recommends considering FSH testing in people aged 40 to 45 with menopausal symptoms and cycle changes. FSH testing is also considered when menopause or POI is suspected before age 40. POI should not be diagnosed from one blood test. NICE recommends two elevated FSH results taken four to six weeks apart. FSH testing is not appropriate for identifying menopause while using combined hormonal contraception or high dose progestogen. AMH, oestradiol, ovarian scans and follicle counts should not routinely be used to diagnose menopause in people aged 45 or over. Other conditions may need consideration Menopause symptoms overlap with several medical conditions. Thyroid disease may cause sweating, palpitations, mood change and irregular periods. Anaemia can cause fatigue, breathlessness and poor concentration. Pregnancy remains possible during perimenopause and should be considered when relevant. Depression, anxiety and sleep disorders may coexist with menopause or provide an alternative explanation. Investigation should be guided by age, symptom pattern, examination and clinical uncertainty. Hormone replacement therapy Hormone replacement therapy, or HRT, replaces some of the hormones that decline during menopause. Oestrogen is the main hormone used to treat hot flushes and other systemic symptoms. Systemic HRT reaches the wider body and may be taken as tablets, patches, gel or spray. People who still have a uterus usually need a progestogen alongside systemic oestrogen. Unopposed systemic oestrogen can thicken the uterine lining and increase the risk of endometrial cancer. People who have had a total hysterectomy can usually use oestrogen only HRT. An appropriate hormonal IUS can sometimes provide the progestogen component of HRT. HRT is an individual decision NICE recommends offering HRT for vasomotor symptoms associated with menopause. The decision should consider symptom severity, age, past health problems, treatment route and personal preference. Benefits and risks differ between oestrogen only and combined HRT, and also between tablets and transdermal preparations such as patches or gel. Oral HRT increases blood clot risk more than transdermal HRT. The absolute risk remains influenced by the person's baseline risk. Combined HRT is associated with a duration related increase in breast cancer risk. Oestrogen only HRT has a different risk profile and is used after total hysterectomy. These are not reasons to label HRT as universally safe or unsafe. Shared decision making should use the person's actual risks and expected benefits. Vaginal oestrogen Vaginal oestrogen treats vaginal and urinary symptoms locally. It is available as creams, gels, tablets, pessaries or rings. Only a minimal amount is absorbed into the bloodstream compared with systemic HRT. Serious adverse effects are very rare, and treatment can be continued when benefits remain. Vaginal oestrogen does not usually require additional progestogen for uterine protection. People with a history of breast cancer need individual discussion using current specialist guidance. Non hormonal moisturisers and lubricants may be used alone or with vaginal oestrogen. Non hormonal management Not everyone wants or can use HRT. Menopause specific cognitive behavioural therapy, called CBT, can help some people manage hot flushes, sleep problems and their impact. Practical measures include layered clothing, a cooler sleep environment and identifying personal flush triggers. Regular weight bearing and resistance activity supports bones, muscles, sleep and cardiovascular health. Some prescription non hormonal treatments are available when HRT is unsuitable. The most appropriate option depends on symptoms, past health problems, interactions and availability. Unregulated hormone preparations should not be assumed to be safer than licensed medicines. Their dose, purity, effectiveness and safety may be uncertain. Bone and cardiovascular health Oestrogen helps maintain bone density. Bone loss accelerates around menopause, increasing later fracture risk in some people. Physical activity, adequate nutrition, avoiding smoking and addressing excess alcohol remain important. Early menopause and POI create a longer period of low oestrogen exposure. Hormonal treatment is therefore often recommended until around the usual age of menopause, unless contraindicated. Cardiovascular risk also changes with age. Blood pressure, smoking, diabetes, cholesterol and activity remain important modifiable factors. HRT should not be started solely to prevent cardiovascular disease. Menopause and contraception HRT does not reliably suppress ovulation and is not contraception. Pregnancy remains possible during perimenopause. People who do not wish to become pregnant need contraception until natural fertility is considered to have ended. The timing depends on age, bleeding pattern and the contraceptive method being used. Hormonal contraception can mask periods, so stopping decisions may require clinical advice. Bleeding after menopause Bleeding after 12 months without periods is called postmenopausal bleeding. It should be assessed even when it occurs once or involves only spotting or brown discharge. Most cases are not caused by cancer. However, assessment is important because womb or cervical disease can present this way. Unexpected bleeding can also occur after starting or changing HRT. Some bleeding is common during the first six months of systemic HRT or within three months of changing the preparation. Bleeding that continues beyond expected adjustment periods, becomes heavy or begins later requires prompt review.

Menopause is a gradual reproductive transition with variable symptoms, and management should match the individual rather than one universal rule.