PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
The menopause is a natural phenomenon which occurs in all women when their finite number of ovarian follicles are depleted. As a result, oestrogen and progesterone hormone levels fall, and luteinising hormone (LH) and follicle stimulating hormone (FSH) increase in response. Menstruation becomes erratic and eventually stops and there are a number of secondary effects described as 'menopausal symptoms' - see under 'Presentation', below.
The climacteric, menopausal transition stage, or perimenopause, is the period of change leading up to the last period. The menopause itself is a retrospective diagnosis of the time when menstruation permanently ceases. It can only be defined with certainty after twelve months' spontaneous amenorrhoea.
Premature menopause (occurring before the age of 40) can occur in primary ovarian failure, surgically-induced menopause (hysterectomy with or without bilateral oophorectomy), radiation-induced menopause and chemotherapy-induced menopause.
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Menopausal transition stage usually begins when women are in their mid-to-late 40s. The final menstrual period (FMP) usually occurs between the ages of 40 and 58. Average age of menopause in the UK is 51 years.
The menopause can be 'induced' by surgical removal of the ovaries or by iatrogenic ablation of ovarian function by chemotherapy, radiotherapy or by treatment with gonadotrophin-releasing (GnRH) analogues.
Population studies identify smoking and low socio-economic factors as being associated with premature menopause. Other factors that can affect the age at which women have their final period include age at menarche, parity, previous oral contraceptive history, BMI, ethnicity, family history, and a history of breast surgery.
Most women do not seek medical advice for menopausal symptoms. Variations in consultation patterns for menopause depend on many factors, including cultural and educational differences as well as psychosocial difficulties.
Menopausal symptoms are attributed to tissue sensitivity to lower oestrogen levels. This primarily affects the oestrogen receptors in the brain. The experience of women varies widely, with some being debilitated and others unaffected by their symptoms. Some women experience symptoms while still menstruating and others not until a year or more after their last period.
- The majority of women notice irregularities to the menstrual cycle, which may last for up to four years.
- The cycle may lengthen to many months or shorten to 2-3 weeks.
- A slight increase in the amount of menstrual blood loss is common.
- Approximately 10% of women have an abrupt cessation of periods.
Hot flushes and sweats
- These are hallmark symptoms. Hot flushes commonly affect the face, head, neck and chest, and last for a few minutes.
- Vasomotor symptoms affect around 80% of women during the menopause transition and are severe in about 20% of these women .
- The duration of these symptoms varies, with a median of four years, but may continue for as many as 12 years in about 10% of women.
- They are caused by a loss of homeostasis by the central thermoregulatory centre.
Urinary and vaginal symptoms
- Urogenital symptoms arise directly from loss of the trophic effect of oestrogen.
- These may include dyspareunia, vaginal discomfort and dryness, recurrent lower urinary tract infection and urinary incontinence.
- Urinary symptoms may not actually be manifest until five to ten years after the menopause.
- This is a common subjective symptom reported by women but not confirmed by polysomnography.
- Symptoms may be secondary to vasomotor symptoms, are affected by psychosocial factors, and may contribute to depression, irritability and poor concentration.
- These may include anxiety, nervousness, irritability, memory loss, depression and difficulty concentrating.
Loss of libido
- This can be caused by a number of hormonal factors, and oestrogen, progesterone and testosterone have all been implicated.
- Vaginal dryness, loss of self-image and other psychosocial factors also play a part.
These may include brittle nails, thinning of the skin, hair loss and generalised aches and pains. These are likely to be due to falling oestrogen levels.
The diagnosis will usually be obvious from the clinical picture but may be difficult in younger women in the early stages of the menopause.
Other causes of secondary amenorrhoea, such as pregnancy and hypogonadotrophic hypogonadism, may need to be considered.
Investigations are often of limited value.
- FSH levels:
- These vary markedly during the perimenopause and single measures are unreliable. FSH levels may be helpful in confirming the menopause in later stages.
- FSH level should be taken on days 2-5 in those women who are still menstruating.
- Women with suspected premature menopause (symptoms under the age of 40) or following a hysterectomy with ovarian conservation, should have more than one FSH level taken because of the implications of premature ovarian failure.
- Levels should be tested when the woman is not taking oestrogen-based contraception or hormone replacement therapy (HRT).
- FSH levels of greater than 30 IU/L are generally considered to be in the postmenopausal range.
- There is often no need for FSH level to be undertaken if the woman's symptoms are very suggestive of the menopause.
- TFTs - can help differentiate thyroid disease symptoms from menopausal symptoms.
- Blood glucose - may be considered in some women as diabetes can cause similar symptoms.
- Blood cholesterol and trigylcerides - consider if the woman has any cardiovascular risk factors.
- Cervical screening and mammograms - ensure the woman is up to date with her cervical screening and also mammograms (if appropriate).
- A pelvic scan - may be considered for those women with atypical symptoms.
NB: LH, estradiol and progesterone levels are generally unhelpful in clinical practice.
The relationship between the menopause and the development of associated conditions is sometimes difficult to differentiate from age-related morbidity, but is best demonstrated in cases of premature primary and secondary ovarian failure.
- Cardiovascular disease - including coronary artery disease, stroke and peripheral arterial disease. These all increase significantly after the menopause.
- Osteoporosis - the link of osteoporosis with oestrogen deficiency is well-documented.
- Urogenital atrophy - as outlined in 'Presentation', above.
- Redistribution of body fat - body fat tends to be redistributed around the abdomen with age. This is recognised as being an independent risk factor for cardiovascular disease and diabetes.
- Alzheimer's disease - this is two to three times more common in women than in men of the same age. Observational data have shown an improvement in cognitive function with HRT started in early menopause and a possible reduction in the long-term risk of Alzheimer’s disease and all-cause dementia. However, these observational findings have not been substantiated in adequately powered or long-term follow-up studies, and further evidence is needed to evaluate this.
Reassurance and support may be all that are needed (viewing menopause as a normal period of physiological adaptation). The patient's most troublesome symptoms should be identified and management possibilities should then be discussed.
Encourage a healthy lifestyle. Stopping smoking, losing weight and limiting alcohol are beneficial. Women should be encouraged to take regular aerobic exercise and ensure they have adequate calcium intake (around 700 mg/day). Avoidance or reduction of alcohol and caffeine may help.
Hormone replacement therapy (HRT)
HRT is undoubtedly the most effective treatment to completely relieve the symptoms caused by the menopause. It also prevents and reverses bone loss. See separate article Hormone Replacement Therapy for more detail.
HRT is extremely effective in the control of menopausal symptoms, particularly:
- Vasomotor symptoms (hot flushes/night sweats)
- Mood swings
- Vaginal and bladder symptoms
Vasomotor symptoms are usually improved within four weeks of starting treatment and maximal benefits will be gained by three months. Vasomotor symptoms may persist for many years and therefore treatment may need to be continued. Regular assessment of the risks versus the benefits of ongoing treatment should be undertaken at least annually. Vaginal symptoms tend to be slower to respond to treatment and to recur if treatment is stopped.
There is good evidence for the efficacy of topical HRT in the short-term treatment of menopausal atrophic vaginitis. Vaginal symptoms are improved, vaginal atrophy and pH decrease and there is improved epithelial maturation with topical oestrogen preparations compared to placebo or non-hormonal gels. However, vaginal lubricants can be effective to use as non-hormonal alternatives, especially if the main symptoms are pain on intercourse due to dryness.
Alternatives to HRT
Around 30% of women consider alternatives to HRT to combat climacteric symptoms.
There is only conflicting evidence at best to support alpha-2 agonists - eg, clonidine - and limited evidence for dihydroepiandrosterone and natural progesterones.
Herbal or complementary treatments
- Phyto-oestrogens are naturally occurring compounds found in plant sources, that are structurally related to estradiol.
- They appear to have both oestrogenic and anti-oestrogenic effects on human oestrogen receptors.
- The main types of phyto-oestrogen are isoflavones, including genistein, daidzein and glycitein, lignans and coumestans.
- Foods such as soy beans, as well as nuts, wholegrain cereals and oilseeds are the foods most rich in phyto-oestrogens.
- Phyto-oestrogens can be taken in the form of tablets containing concentrated isoflavones, such as red clover.
- Black cohosh can cause liver toxicity.
- The efficacy of vasomotor symptom relief with phyto-oestrogens is around 60% reduction compared with 90-100% reduction with HRT.
Many women choose to try these products, as they believe them to be more ‘natural’, and safer than prescribed medication. However, most herbal products available in the UK are not subject to the same regulatory requirements as licensed medications and, as such, are not subject to the same degree of standardisation. There may be variability between products or a lack of clarity as to what ingredients a particular product contains.
In addition, there is currently insufficient evidence to suggest that they are safe to be taken by women with oestrogen-dependent cancer - eg, breast cancer. There are no safety data available in relation to their risk of venous thromboembolism (VTE).
National Institute for Health and Care Excellence Clinical Knowledge Summaries currently state that if complementary or herbal products are being used, the woman should be advised that:
- The efficacy of these products has not yet been established.
- There is very little control over the quality of the products available, which may vary considerably.
- Some of these treatments (for example, ginseng, black cohosh, and red clover) have oestrogenic properties and should not be used by women with contra-indications to oestrogen (for example, women who have had breast cancer).
- The long-term safety of these products (for example, their effects on the breast and endometrium) have not been assessed.
- Some treatments may have serious adverse effects.
- Dong quai extracts and some species of red clover contain coumarins, which make them unsuitable for women taking anticoagulants.
Although hormone therapy is the gold standard treatment for hot flushes, concerns for the risks of hormone therapy have resulted in its decline and a demand for non-hormonal treatments with demonstrated efficacy for hot flushes. Two classes of non-hormonal medications have been demonstrated to effectively alleviate hot flushes, namely gamma-aminobutyric acid (GABA) analogues and selective serotonin reuptake inhibitors (SSRIs).
Gabapentin 600-2400 mg/day in divided doses has been shown to significantly decrease the frequency of hot flushes by 45-71% for short-term use. Adverse effects with gabapentin, including somnolence/drowsiness, unsteadiness and dizzines, can be common during the first 1-2 weeks of treatment.
SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) have been shown to reduce flushing symptoms in short-term studies although symptoms commonly return after stopping treatment. The studies involving these medications are short, however, lasting only a few weeks.
Premature and early menopause management
An early menopause is defined as a menopause between the ages of 40 and 45 years. This occurs in up to 20% of women. A premature menopause, due to premature ovarian failure (POF) is defined as a menopause occurring before the age of 40 years.
All women with a premature menopause have an increased risk of osteoporosis, cardivascular disease and dementia if they are not given HRT appropriately.
In essence, the principles of oestrogen replacement are the same as for women experiencing menopausal symptoms and problems at any age. However, the symptoms may be more severe in premature menopause, particularly after surgical menopause, often requiring higher doses of oestrogen than those needed following spontaneous menopause at a later age. In addition, the aetiology of the premature or early menopause needs to be considered, as this may change the treatment offered (eg, if it were following surgery for an oestrogen-sensitive cancer).
Women with a premature menopause should be offered HRT unless contra-indicated. It is normally continued until they reach at least 51 years. There is no evidence that there is any increased risk of breast cancer compared with normally menstruating women of the same age. They may need larger doses of HRT to control vasomotor symptoms.
Further reading & references
- Hickey M, Elliott J, Davison SL; Hormone replacement therapy. BMJ. 2012 Feb 16;344:e763. doi: 10.1136/bmj.e763.
- Lethaby A, Hogervorst E, Richards M, et al; Hormone replacement therapy for cognitive function in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003122.
- Lambrinoudaki I, Ceasu I, Depypere H, et al; EMAS position statement: Diet and health in midlife and beyond. Maturitas. 2013 Jan;74(1):99-104. doi: 10.1016/j.maturitas.2012.10.019. Epub 2012 Nov 28.
- Panay N, Hamoda H, Arya R, et al; The 2013 British Menopause Society & Women's Health Concern recommendations on hormone replacement therapy. Menopause Int. 2013 Jun;19(2):59-68. doi: 10.1177/1754045313489645. Epub 2013 May 23.
- Sturdee DW, Panay N; Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010 Dec;13(6):509-22. doi: 10.3109/13697137.2010.522875. Epub 2010 Sep 30.
- Pitkin J; Alternative and complementary therapies for the menopause. Menopause Int. 2012 Mar;18(1):20-7. doi: 10.1258/mi.2012.012001.
- Lim TY, Considine A, Quaglia A, et al; Subacute liver failure secondary to black cohosh leading to liver transplantation. BMJ Case Rep. 2013 Jul 5;2013. pii: bcr2013009325. doi: 10.1136/bcr-2013-009325.
- Menopause; NICE CKS, June 2013 (UK access only)
- Imai A, Matsunami K, Takagi H, et al; New generation nonhormonal management for hot flashes. Gynecol Endocrinol. 2013 Jan;29(1):63-6. doi: 10.3109/09513590.2012.705380. Epub 2012 Jul 19.
- Hayes LP, Carroll DG, Kelley KW; Use of gabapentin for the management of natural or surgical menopausal hot flashes. Ann Pharmacother. 2011 Mar;45(3):388-94. doi: 10.1345/aph.1P366. Epub 2011 Feb 22.
- Joffe H, Guthrie KA, Larson J, et al; Relapse of vasomotor symptoms after discontinuation of the selective serotonin reuptake inhibitor escitalopram: results from the menopause strategies: finding lasting answers for symptoms and health research network. Menopause. 2013 Mar;20(3):261-8. doi: 10.1097/GME.0b013e31826d3108.
- Alternatives to HRT for management of symptoms of menopause; Royal College of Obstetricians and Gynaecologists (September 2010)
- Okeke T, Anyaehie U, Ezenyeaku C; Premature menopause. Ann Med Health Sci Res. 2013 Jan;3(1):90-5. doi: 10.4103/2141-9248.109458.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Louise Newson
Prof Cathy Jackson