Menopause is defined as 12 consecutive months without a menstrual period, marking the end of the reproductive years. It typically occurs between ages 45–55 (average age 51 in Western countries). Perimenopause — the transition phase — can begin up to 10 years earlier and is when most symptoms are most pronounced. Both phases are driven by declining oestrogen and progesterone production from the ovaries.
The 34 recognised symptoms
Most people know about hot flushes and night sweats — but research has identified up to 34 symptoms associated with the menopausal transition. Some are so non-specific that neither the patient nor their doctor immediately connects them to menopause. Average time to diagnosis remains too long in most healthcare systems.
- Vasomotor symptoms: hot flushes (affecting up to 80% of women), night sweats, chills
- Sleep disruption — often secondary to night sweats, but also independent of them
- Mood changes: irritability, low mood, anxiety — oestrogen directly modulates serotonin pathways
- Cognitive symptoms: 'brain fog', difficulty concentrating, memory lapses
- Genitourinary syndrome: vaginal dryness, discomfort during intercourse, recurrent UTIs, urinary urgency
- Joint and muscle pain — often mistaken for early arthritis
- Palpitations — typically benign, but warrant ECG to rule out arrhythmia
- Headaches, migraines (often worsening in perimenopause, then improving post-menopause)
- Skin changes: dryness, thinning, reduced collagen
- Hair thinning
- Reduced libido
Blood tests and what they show
FSH (follicle-stimulating hormone) is the primary hormonal test. As ovarian function declines, the pituitary gland produces more FSH to try to stimulate the ovaries. An FSH above 30 IU/L in the context of symptoms and menstrual change suggests perimenopause or menopause — but levels fluctuate significantly, and a single measurement is not diagnostic.
In women under 45, testing is particularly important to exclude premature ovarian insufficiency (POI). Anti-Müllerian hormone (AMH), oestradiol, and LH are also measured in a full workup. Thyroid function (TSH) should be checked because many menopausal symptoms overlap with hypothyroidism.
Hormone replacement therapy (HRT): what the evidence shows
HRT remains the most effective treatment for menopausal symptoms, and its risk profile has been substantially re-evaluated since the controversial 2002 WHI study — which was later found to have significant design limitations. Modern HRT, particularly transdermal (patch or gel) oestrogen with micronised progesterone, has a different and much more favourable risk profile than the oral conjugated equine oestrogen used in early trials.
Benefits of HRT: significant reduction in hot flushes and night sweats (typically 80–90%), improved sleep, mood, cognitive clarity and genitourinary symptoms. Protective effect on bone density. Evidence of reduced cardiovascular risk when started before 60 or within 10 years of menopause.
Risks: slightly increased risk of breast cancer with combined (oestrogen + progesterone) HRT used for more than 5 years — though the absolute risk is small and comparable to or lower than risks from alcohol, obesity or inactivity. Women with a uterus require progesterone alongside oestrogen to protect the uterine lining.
"For most women under 60 with significant menopausal symptoms, the benefits of HRT clearly outweigh the risks. That equation changed significantly after the 2002 data was properly reanalysed."
Dr. Lina Haddad, CMO, Looms
Non-hormonal options
For women who cannot or prefer not to take HRT, several non-hormonal options have good evidence for vasomotor symptoms: SSRIs/SNRIs (particularly venlafaxine and paroxetine), gabapentin, and the newer neurokinin B receptor antagonist fezolinetant — specifically licensed for hot flushes.
Genitourinary syndrome (vaginal dryness and urinary symptoms) responds well to local vaginal oestrogen — which carries minimal systemic absorption and is appropriate for most women, including those with a history of oestrogen-sensitive breast cancer (pending oncologist advice).
Lifestyle factors that matter
- Alcohol worsens hot flushes and disrupts sleep — reducing intake consistently improves both
- Regular aerobic exercise reduces vasomotor symptom severity and improves mood, bone density and cardiovascular risk
- Maintaining a healthy weight reduces symptom severity — adipose tissue converts androgens to oestrogen but also increases cardiovascular and breast cancer risk
- Pelvic floor exercises (Kegel exercises) reduce urinary urgency and leakage
- Stress management — yoga, mindfulness and CBT have evidence for reducing hot flush frequency and improving sleep
Long-term health after menopause
Oestrogen loss accelerates bone loss — the average woman loses 10% of bone density in the first 5 years after menopause. A DEXA scan to assess bone density is recommended at menopause for women with risk factors. Cardiovascular risk increases after menopause as oestrogen's protective vascular effects are removed. Annual blood pressure checks and lipid panels are a practical minimum.