Menopause
HRT, symptom management and long-term health in the perimenopause and beyond
Menopause is a natural biological transition marking the end of menstrual cycles, defined as 12 consecutive months without a period. It typically occurs between the ages of 45 and 55 in the UK, with an average age of 51. The perimenopause — the years leading up to menopause — can cause significant symptoms due to declining oestrogen levels. Hormone replacement therapy (HRT) is the most effective treatment for menopausal symptoms and has been reassessed in recent years following updated evidence and NICE guidance.
What is Menopause?
Menopause occurs when the ovaries stop producing oestrogen and progesterone, and menstrual periods cease permanently. The perimenopause begins with hormonal fluctuations — often years before the final period — and may last several years. Common symptoms include vasomotor symptoms (hot flushes and night sweats), sleep disturbance, mood changes (anxiety, low mood, irritability), brain fog, vaginal dryness, reduced libido, joint pains, and urinary symptoms. Not all women experience significant symptoms, but around 75% have hot flushes and for a quarter of women, symptoms are severe enough to significantly affect quality of life and ability to work.
Hormone Replacement Therapy (HRT)
HRT replaces the oestrogen (and progesterone for women with a uterus) that the ovaries stop producing. It is the most effective treatment for vasomotor symptoms and also reduces the risk of osteoporosis. NICE guideline NG23 (updated 2024) recommends that HRT should be offered to women with menopausal symptoms, and that the benefits generally outweigh the risks for most healthy women under 60 or within 10 years of menopause. Transdermal oestrogen (patches, gels, spray) has a lower risk of venous thromboembolism and stroke compared to oral oestrogen. Women with a uterus must take a progestogen alongside oestrogen to protect the endometrium — the combined preparation can be cyclical (for women in perimenopause or less than one year post-menopause) or continuous (for women more than one year post-menopause). Progestogen-only options include the Mirena IUS (52 mg levonorgestrel) which also provides endometrial protection.
Long-Term Health and Non-HRT Options
Beyond symptom management, the perimenopause and menopause have long-term health implications. Oestrogen deficiency accelerates bone loss — all women should be assessed for fracture risk and encouraged to maintain adequate calcium and vitamin D intake and weight-bearing exercise. Cardiovascular risk increases after menopause due to loss of the cardioprotective effects of oestrogen. Genitourinary syndrome of menopause (GSM — previously called vaginal atrophy) causes vaginal dryness, irritation, and urinary symptoms; local vaginal oestrogen is safe and effective even when systemic HRT is not appropriate. Women who cannot or choose not to take HRT may benefit from non-hormonal options: clonidine for hot flushes, SSRIs or SNRIs (particularly venlafaxine), and CBT for mood and psychological symptoms. This article has been prepared following careful evaluation of NICE NG23 (Menopause, 2024), NICE CG146, and current BNF guidance.