Menopause: Symptoms and Treatment Options
Menopause is defined as twelve months after the final menstrual period. The perimenopausal transition preceding it frequently lasts several years and is when symptoms are often most disruptive.
The range of symptoms
Vasomotor symptoms — hot flushes and night sweats — are the most recognised and affect a large majority of women to some degree.
Sleep disturbance, which may be independent of night sweats and has knock-on effects on mood and cognition.
Mood changes, anxiety and low mood, which are frequently attributed to other causes.
Cognitive symptoms, commonly described as brain fog, affecting concentration and word finding.
Genitourinary symptoms — vaginal dryness, discomfort, urinary frequency and recurrent urinary infections — which are progressive, do not resolve without treatment, and are substantially under-reported.
Joint aches, palpitations, changes in skin and hair, and altered libido.
Hormone therapy
Understanding of risk and benefit has been substantially revised since the early 2000s, when initial reporting of a large trial led to a sharp decline in prescribing.
Subsequent analysis clarified that risk profiles differ considerably by age at initiation, time since menopause, type of preparation and route of administration.
Current guidance in many countries supports hormone therapy as effective for vasomotor symptoms, with individualised discussion of risks and benefits rather than blanket avoidance.
Transdermal preparations — patches and gels — carry a different risk profile from oral preparations regarding blood clots, which is relevant to the choice.
Women with a uterus require progestogen alongside oestrogen to protect the endometrium.
Local treatment for genitourinary symptoms
Vaginal oestrogen is applied locally, with very low systemic absorption, and is effective for genitourinary symptoms.
It is generally considered appropriate for many women who cannot or choose not to take systemic hormone therapy, and it can be continued long term.
These symptoms are progressive and respond well to treatment, yet frequently go unmentioned in consultations.
Non-hormonal options
Certain antidepressants have evidence for reducing vasomotor symptoms and suit women who cannot take hormones.
Newer non-hormonal treatments targeting the neural pathway involved in flushing have become available in some markets.
Cognitive behavioural therapy has evidence for vasomotor symptoms, sleep and mood.
Regular exercise, limiting alcohol and caffeine, and managing weight all help, though they are adjuncts rather than replacements for treatment where symptoms are severe.
Practical points
Keep a symptom diary before appointments, since the breadth of symptoms is easy to under-report.
Blood tests are generally unnecessary for diagnosis in women over a certain age with typical symptoms, and can be misleading during perimenopause because hormone levels fluctuate.
This article is general information and not medical advice. Discuss your own circumstances with a qualified healthcare professional.
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