Based on the British Menopause Society’s March 2025 summary of the updated NICE menopause guideline.
Menopause is a natural stage of life caused by falling levels of hormones, particularly oestrogen. Although it is often associated with hot flushes and night sweats, menopause can affect many areas of health, including mood, sleep, muscles, joints, sexual wellbeing, the vagina, bladder, bones and cardiovascular health.
Every woman’s experience is different. Some have mild symptoms, while others find that symptoms significantly affect their work, relationships and quality of life. Treatment should therefore be based on the individual’s symptoms, medical history, family history, lifestyle, preferences and concerns.
What is the difference between perimenopause and menopause?
Perimenopause is the period leading up to menopause. During this time, hormone levels fluctuate and periods may become irregular, heavier, lighter, shorter or further apart.
Menopause happens when the ovaries significantly reduce their production of oestrogen and menstrual periods eventually stop.
Menopause usually occurs naturally, but it can also happen earlier because of surgery, certain medical treatments or premature ovarian insufficiency.
Common menopause symptoms
Menopause can cause a wide range of symptoms, including:
- Hot flushes and night sweats
- Difficulty sleeping or waking during the night
- Low mood, anxiety, irritability or mood changes
- Problems with concentration or memory
- Muscle aches and joint pains
- Vaginal dryness, soreness or irritation
- Pain during sex
- Reduced sexual desire
- Needing to pass urine more often
- Recurrent urinary infections
- Changes in menstrual periods during perimenopause
The effects of lower oestrogen levels may continue beyond the menopause transition and can also influence bone and cardiovascular health.
Do you need a blood test to diagnose menopause?
For most women aged 45 or over, blood tests are not normally needed to diagnose perimenopause or menopause. Diagnosis is usually based on age, symptoms and changes in menstrual periods.
A blood test measuring follicle-stimulating hormone, or FSH, is often unhelpful in this age group because hormone levels can change considerably from day to day. The result does not reliably show how severe symptoms are or how long they will last.
An FSH blood test may be considered when:
- A woman is aged 40 to 45, has menopause symptoms and has noticed changes in her periods.
- Menopause is suspected in someone aged under 40.
People from some ethnic minority backgrounds and those with certain lifelong medical conditions may experience menopause at a younger age.
Managing menopause symptoms
Treatment should be personalised. Options may include lifestyle changes, hormone replacement therapy, menopause-specific cognitive behavioural therapy and selected non-hormonal treatments.
Lifestyle and general health
Healthy lifestyle measures can improve overall wellbeing and protect long-term health. These include:
- Stopping smoking
- Maintaining a healthy weight
- Reducing excessive alcohol intake
- Taking regular weight-bearing and muscle-strengthening exercise
- Eating a balanced diet
- Protecting sleep and emotional wellbeing
Lifestyle measures can be helpful, but women with troublesome symptoms should not be expected simply to “put up with them.” Medical treatments should also be discussed.
Hormone replacement therapy
Hormone replacement therapy, commonly called HRT, replaces some of the hormones that decrease during menopause.
HRT is the most effective treatment for hot flushes and night sweats. It may also improve sleep, mood symptoms related to menopause, vaginal symptoms and overall quality of life.
The most suitable HRT depends on several factors, including:
- Whether the woman still has her womb
- Whether she is perimenopausal or postmenopausal
- Her symptoms
- Personal and family medical history
- Other medications
- Her preferences
Women who still have a womb usually need a progestogen alongside oestrogen to protect the womb lining. Women who have had a hysterectomy can often take oestrogen without a progestogen.
Cognitive behavioural therapy
Menopause-specific cognitive behavioural therapy, or CBT, can help some women manage:
- Hot flushes and night sweats
- Sleep disturbance
- Anxiety or low mood linked to menopause
It may be used alongside HRT or as an alternative for women who cannot or do not wish to use HRT.
Antidepressants and clonidine should not routinely be offered solely to treat menopause symptoms. However, women who have clinical depression should receive appropriate assessment and treatment for depression.
Tablets, patches, gels and sprays
HRT can be taken in different ways.
Oral HRT is taken as a tablet.
Transdermal HRT delivers oestrogen through the skin using a patch, gel or spray.
Oral oestrogen is associated with a higher risk of blood clots than oestrogen delivered through the skin. Transdermal HRT is therefore usually preferred for women with a higher risk of blood clots, including those with a body mass index above 30.
The guideline also reports an increased stroke risk with oral HRT but not with transdermal HRT. However, the underlying stroke risk in women under 60 is generally very low.
Vaginal dryness and bladder symptoms
Falling oestrogen levels can cause vaginal, vulval and bladder symptoms. These are common but frequently under-recognised and undertreated.
Symptoms may include:
- Vaginal dryness, burning or soreness
- Pain during sexual activity
- Vulval discomfort or itching
- Urinary urgency or frequency
- Discomfort when passing urine
- Recurrent urinary tract infections
Vaginal oestrogen
Vaginal oestrogen can be offered as a cream, gel, tablet, pessary or ring. It acts mainly in the vagina and surrounding tissues, with very little hormone entering the bloodstream.
It can usually be used safely for the long term and may be required even when a woman is already taking systemic HRT. Vaginal moisturisers and lubricants may be used alongside it.
Other treatments, such as vaginal prasterone or oral ospemifene, may be considered when vaginal oestrogen or non-hormonal products are ineffective, not tolerated or impractical.
Vaginal laser treatment should not currently be offered outside a properly controlled clinical trial.
Low sexual desire
Menopause can affect sexual desire for several reasons, including vaginal discomfort, poor sleep, low mood, relationship difficulties and hormonal changes.
Testosterone treatment may be considered for persistently low sexual desire when HRT alone has not been effective. This should be discussed and monitored by an appropriately trained healthcare professional.
HRT and breast cancer risk
The relationship between HRT and breast cancer depends partly on the type of HRT and how long it is used.
- Oestrogen-only HRT is associated with little or no increase in breast cancer risk.
- Combined oestrogen and progestogen HRT may be associated with an increased risk that rises with longer use.
- The additional risk gradually reduces after HRT is stopped.
Individual risk also depends on factors such as age, weight, alcohol intake, family history and previous breast disease. Women should discuss their personal benefits and risks rather than relying on generalised headlines about HRT.
Menopause symptoms after breast cancer
Women who have had breast cancer should still be offered help with menopause symptoms. Treatment should ideally involve a clinician with expertise in both menopause care and breast cancer.
For vaginal and bladder symptoms, non-hormonal moisturisers and lubricants are usually tried first. Low-dose vaginal oestrogen may be considered when symptoms continue despite non-hormonal treatment. Women taking an aromatase inhibitor should discuss this with their breast cancer specialist.
Fluoxetine and paroxetine should generally be avoided in women taking tamoxifen because they may reduce its effectiveness. Herbal treatments such as St John’s wort may also interact with prescribed medicines.
Other health effects of HRT
Bones
HRT reduces the risk of fractures caused by osteoporosis while it is being taken. This can be particularly important for women who experience menopause at a young age.
Heart and circulation
For many healthy women who start HRT before age 60 or within approximately 10 years of menopause, the overall balance of benefits and risks is favourable.
However, HRT should not be prescribed solely to prevent cardiovascular disease. Women who have previously had a heart attack, coronary heart disease or stroke should have an individual assessment with a clinician experienced in menopause care.
Diabetes
HRT is unlikely to increase the risk of developing type 2 diabetes or significantly worsen blood glucose control. Women with diabetes may still be offered HRT after their overall health and other medical conditions have been considered.
Dementia
It remains uncertain whether HRT reduces or increases dementia risk. HRT should not be started solely to prevent dementia. Starting combined HRT for the first time at age 65 or over may increase dementia risk.
Starting, reviewing and stopping HRT
HRT should be prescribed at the lowest dose that effectively controls symptoms.
A review should normally take place around three months after starting treatment. Once treatment is settled, it should usually be reviewed once a year. The review should consider:
- Whether symptoms have improved
- Side effects
- Bleeding patterns
- Blood pressure and general health
- Whether the dose or type of HRT needs changing
There is no fixed maximum length of time for taking HRT. Some women need it for a relatively short period, while others benefit from longer treatment. Continued use should be reviewed individually.
When stopping HRT, it can be reduced gradually or stopped suddenly. Neither method appears to change the long-term likelihood of symptoms returning.
Bleeding while taking HRT
Some vaginal bleeding can occur during the first three months after starting or changing systemic HRT.
Seek medical advice promptly when:
- Bleeding begins more than three months after starting HRT.
- Bleeding continues beyond the expected settling period.
- Bleeding is heavy or persistent.
- Bleeding occurs after a period of having no bleeding.
- There is bleeding after sex.
Unexpected bleeding does not necessarily mean that something serious is wrong, but it should be properly assessed.
Premature ovarian insufficiency
Premature ovarian insufficiency, or POI, occurs when the ovaries stop working normally before the age of 40.
Women under 40 who have menopause symptoms and absent or infrequent periods should usually have two FSH blood tests taken four to six weeks apart to help confirm the diagnosis.
Unless there is a medical reason not to use hormones, HRT or the combined contraceptive pill is normally recommended until at least the average natural menopause age of approximately 51. Hormone treatment helps control symptoms and supports bone and cardiovascular health.
HRT does not provide contraception. Pregnancy may occasionally still occur in women with POI, so contraception should be discussed when required.
When should you ask for specialist help?
Referral to a healthcare professional with menopause expertise may be helpful when:
- Symptoms remain troublesome despite treatment.
- Treatment causes persistent side effects.
- There are medical reasons that may make HRT unsuitable.
- There is uncertainty about the safest treatment.
- Menopause occurs unusually early.
- There is a history of breast cancer, heart disease, stroke or blood clots.
- Vaginal bleeding requires further assessment.
Women experiencing early menopause between ages 40 and 44 may also benefit from psychological support, particularly when the diagnosis or its possible effect on fertility is distressing.
The main message
Menopause is not experienced in the same way by everyone, and there is no single treatment that is right for all women.
Women should receive accurate information about their symptoms, the available treatments and the possible benefits and risks. For many women, appropriately prescribed HRT provides more benefits than risks. CBT, vaginal treatments, lifestyle support and other therapies may also play an important role.
Treatment decisions should be made jointly by the woman and her healthcare professional and reviewed as symptoms, health and personal preferences change.
This article provides general information and does not replace individual medical advice. Speak to your GP, menopause specialist or another qualified healthcare professional before starting, stopping or changing treatment.