Menopause and Hormone Replacement Therapy (HRT): Symptoms, Causes & Treatment Options

In short: The menopause is the permanent end of periods. Symptoms include hot flushes and sweats, which affect 70–80% of women, disturbed sleep and mood, vaginal dryness, urinary incontinence and bone thinning. Treatment includes hormone replacement, calcium, exercise and some natural alternatives, according to each woman’s situation.

Menopause marks the natural ending of menstrual cycles — the central marker of a woman’s fertility. It is diagnosed after 12 consecutive months without a period (with no other cause) in women aged 45 years or older; in this age group a blood test is usually not needed to confirm it.

It is best understood as a transitional phase, gradually moving the body from a fertile state to a non-fertile one — not a sudden illness, but a natural stage of life.

Menopause happens when the ovaries’ supply of oocytes (eggs) and primordial follicles becomes depleted, leading to a drop in estrogen production.

The way periods stop can vary quite a bit from woman to woman.

Some women notice their cycles stop abruptly, while others go through a stage of more frequent bleeding (polymenorrhea) followed by a stage of infrequent bleeding (oligomenorrhea) before periods stop completely.

Other causes of menopause

1- Surgical menopause:

This occurs after surgical removal of both ovaries for any reason, such as ovarian cancer.

If the uterus is removed but the ovaries are kept, the ovaries continue to work, although studies show that menopause may come on average one to two years earlier than it otherwise would.

2- Premature ovarian failure (POF):

Loss of ovarian function can occur at any age. If it occurs before age 40 it is called premature ovarian insufficiency (POI); if it occurs between 40 and 45 it is called early menopause. These patients typically show low plasma estrogen and increased levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). POI can be associated with other autoimmune conditions (such as thyroid disease), but an autoimmune cause is found in only a minority of women; in most cases no cause is identified, and some cases are genetic.

3- Radiation and chemotherapy:

Treatment for cancer in younger women may bring on menopause in a couple of ways. Radiotherapy to the pelvis (or deliberately to the ovaries, to suppress estrogen in some breast cancers) can stop ovarian function, and chemotherapy for breast cancer or lymphoma can suppress or stop ovarian cyclic activity.

Symptoms of menopause

1- Vasomotor symptoms:

The most noticeable effect of falling estrogen levels is vasomotor symptoms — hot flushes and night sweats. These are very common, affecting at least 70-80% of women.

Their frequency can range from a few to several dozen episodes per day, and they may last anywhere from a few weeks to many years.

2- Insomnia:

Many women experience repeated awakening during the night, which affects both the quantity and quality of sleep.

3- Psychological symptoms, including:

Mood swings, anxiety, difficulty concentrating, low mood, and short-term memory lapses.

4- Vaginal dryness:

Lower estrogen levels can cause thinning of the vaginal tissue, leading to dryness and discomfort during intercourse (dyspareunia).

5- Urinary symptoms:

Estrogen deficiency can also affect the urethra and bladder, making some women more prone to stress incontinence, urgency, and urge incontinence.

6- Osteoporosis:

In the early postmenopausal years, bone density decreases faster than at any other time, as bone breakdown outpaces bone formation.

In many women, this leads to osteopenia, which increases the risk of fractures over time.

About one in two women over 50 will have a fracture related to osteoporosis during her lifetime; the lifetime risk of hip fracture is about one in six, with most hip fractures occurring after age 75.

Risk factors for osteoporosis

1- Family history of osteoporosis

2- Smoking or alcohol use

3- Early menopause

4- History of prolonged immobilization

5- Treatment with corticosteroids or heparin

6- Certain medical conditions such as hyperthyroidism, Cushing’s disease, chronic kidney failure, and liver insufficiency

7- Black women tend to have a lower risk of osteoporosis compared to white or Asian women.

Thinner women tend to be more prone to osteoporosis than women with higher body weight.

Cardiovascular system:

Heart and blood vessel function is affected by the presence or absence of estradiol.

• Heart attacks are much less common in pre-menopausal women than in men of the same age. As estrogen levels decline, changes in lipid profile can promote both atherosclerosis and vasoconstriction, since estrogen has direct protective effects on blood vessel walls.

Dietary changes and menopause

Diet is thought to be one reason for cultural differences in menopausal symptoms around the world.

Asian women tend to report fewer menopausal symptoms and lower rates of hip fractures compared to Western women. This may be related to diets richer in phytoestrogens (naturally occurring plant estrogens) — typically around 25–50 mg of isoflavones daily, compared with only a few milligrams in typical Western diets.

Phytoestrogens are structurally similar to estradiol but much weaker than the body’s natural estrogen, and may have a cumulative effect when consumed regularly over time.

Soybeans are one of the richest sources of these compounds. Some studies in the USA have found that foods containing soy protein may help lower cholesterol, support healthy artery function, and reduce atherosclerosis — potentially supporting heart health.

Phytoestrogen supplements may slightly reduce hot flushes in some women, but products vary in content and quality, their long-term safety is not established, and they can interact with other medicines; women with a history of breast cancer should avoid them, and all women should discuss them with their doctor.

Some studies suggest that multivitamins and mineral supplements may help reduce hot flushes, though the effect may depend partly on the overall quality of a woman’s diet.

Vitamin E has been tried for hot flushes, but studies show little or no benefit, and high doses (above 400 IU daily) may carry risks, so it is not recommended for this purpose.

Women after menopause are generally advised to get about 1000–1200 mg of calcium daily in total, preferably from food (such as dairy products), using supplements only to make up any shortfall.

Vitamin D, about 800–1000 IU daily, is usually recommended alongside calcium, especially for women with little sun exposure or those at higher risk of fracture.

Exercise during menopause

Regular exercise helps slow long-term, age-related bone loss and supports heart health by helping manage weight, blood pressure, and cholesterol levels.

Women who exercise regularly tend to experience less severe hot flushes, lower rates of depression, better sleep, and an overall greater sense of well-being.

Walking is one of the safest and most accessible forms of exercise to recommend.

Women who walk briskly for about three hours or more per week have been found to have roughly a 30–40% lower risk of coronary heart disease; the general recommendation is at least 150 minutes of moderate activity a week plus muscle-strengthening exercise twice a week.

Hormone replacement therapy (HRT)

Hormone replacement therapy has been in use for decades, and our understanding of its benefits and risks has improved greatly in recent years.

HRT can effectively ease many of the effects of menopause, but it should always be prescribed and monitored under medical supervision.

For most healthy women under 60, or within 10 years of their last period, the benefits of HRT outweigh the risks. Combined HRT (estrogen plus progestogen) is associated with a small increase in breast cancer risk that grows with longer use, and tablet forms of estrogen slightly increase the risk of blood clots and stroke, whereas estrogen through the skin (patch or gel) at standard doses does not appear to increase clot risk. Women who still have a uterus need a progestogen together with estrogen to protect the lining of the womb. The type, dose and duration should be reviewed with your doctor at least once a year.

• Continuous estrogen-progestogen preparations:

This type of therapy is taken daily without interruption and protects the endometrium (uterine lining). It is suitable for women whose last period was at least a year ago; because it does not cause monthly bleeding, many postmenopausal women prefer this approach, although some irregular spotting is common in the first 3–6 months.

• Cyclic estrogen-progestogen preparations:

With this approach, estrogen is taken every day and a progestogen is added for 12–14 days of each 28-day cycle, which produces a regular monthly withdrawal bleed; it is usually used by women who are still having periods or whose periods stopped less than a year ago.

This type effectively relieves symptoms while also regulating the cycle.

• Tibolone (Livial):

This is a synthetic steroid with estrogenic, progestogenic, and androgenic activity, given at 2.5 mg daily to women at least one year past menopause. It helps relieve symptoms and supports bone protection, but it slightly increases the risk of stroke in women over 60 and is not suitable for women who have had breast cancer.

This preparation is generally well tolerated, and the amenorrhea seen in about 80% of patients by six months of use is usually a welcome side effect.

• Subcutaneous hormonal implants:

This treatment option is generally reserved for patients who have had a hysterectomy, with or without removal of the ovaries.

The procedure involves inserting a small estradiol pellet under the skin, usually in the lower abdomen, under sterile conditions with local anesthetic.

The implant is typically reviewed every six months.

This method is generally well tolerated and can effectively relieve menopausal symptoms while helping protect against bone loss.

• Transdermal estrogen (patches):

Estrogen through the skin (patch or gel) is preferred for women with a higher risk of blood clots, those who are overweight, women with migraine, and older women, because it does not appear to increase clot risk. Patches are available in various strengths — 25, 37.5, 50, 75, or 100 mcg of estradiol per day.

Seven-day patches are also available.

Skin reactions are usually minimal, and this treatment is generally well tolerated.

• Local estrogen:

This form is applied as a cream, pessary, or vaginal ovule.

It is particularly suitable for women with localized symptoms, or for those for whom systemic estrogen would not be advisable.

Women on HRT should have regular blood pressure checks and take part in breast screening (mammography) as recommended for their age; a bone density scan is arranged when there are risk factors for osteoporosis, and any unexpected bleeding should be reported.

Follow-up is typically recommended about three months after starting or changing treatment, and then once a year.

Contraindications to hormone replacement therapy (HRT) use:

Absolute contraindications to HRT

1- Breast cancer

2- Pregnancy

3- Endometrial cancer

4- Acute active liver disease

5- Uncontrolled hypertension

6- Confirmed venous thromboembolism 7- Undiagnosed vaginal bleeding (must be investigated first) 8- Recent heart attack, angina or stroke

Relative contraindications to HRT

1- Presence of uterine fibroids

2- Past history of benign breast disease

3- Unconfirmed venous thromboembolism

4- Chronic stable liver disease

5- Migraine (not a reason to avoid HRT; estrogen through the skin is preferred)

• Frequently asked questions:

Does a woman lose her libido after the age of 40?

Research suggests women are more likely to notice a decrease in sexual drive and desire as they age. However, not every woman experiences a decline in libido after 40 — it varies quite a bit from person to person.

Some women continue to experience a strong sex drive well into their fifties. A decrease in libido can be linked to the natural decline in hormone production and the end of menstruation, which may affect arousal.

Is it possible to get pregnant after menopause at age 50?

Once menopause occurs, a woman no longer ovulates and cannot conceive naturally. However, if the uterus is healthy and able to carry a pregnancy, it may still be possible to become pregnant using previously frozen eggs, with medical assistance.

What are the symptoms of menopause at age 40?

Some women notice no clear symptoms at all, though they may have difficulty conceiving. Others experience symptoms similar to natural menopause, such as hot flashes, night sweats, or mood swings, with periods becoming lighter, irregular, or stopping altogether.

Is bloating a symptom of menopause?

Hormonal changes before menopause can lead to fluid retention and bloating that may continue into menopause itself. Dietary changes, appetite shifts, slower digestion, and stress related to menopause — along with smoking and reduced physical activity — can all contribute to weight changes during this time.

When does a woman’s fertility end?

Fertility naturally begins to decline after age 35, and by 40 it is roughly half of what it was before 30. This reflects the gradual, natural decline in ovarian reserve that occurs from birth through to menopause.

Is it possible to get pregnant at age 47?

Chances of pregnancy depend on each woman’s individual ovarian reserve, but generally decrease significantly after age 40, as egg quality also declines with age.

Does menstruation return after a year of absence?

If periods have been absent for a full year, menopause has likely occurred. If bleeding returns after that point, it’s important to consult a doctor to check the cause.

What are hot flashes in women?

Hot flashes are a sudden feeling of warmth, often most intense in the face and neck, and may be accompanied by skin redness.

Can early menopause be cured?

Early menopause cannot be reversed, but hormone replacement therapy relieves the symptoms and, when menopause occurs before 45, is usually recommended at least until the average age of natural menopause (around 51) to protect the bones and heart.

What vitamins should be taken during menopause?

Many products combine natural herbal ingredients, vitamins, and antioxidants aimed at easing menopausal symptoms — it’s best to discuss options with your doctor.

What are the benefits of hormone replacement therapy?

• Helps relieve hot flashes and mood swings.
• Eases vaginal dryness and may improve libido.
• May help reduce the risk of osteoporosis.

Can hormone therapy be taken if one has diabetes or high blood pressure?

In most cases it does not significantly affect these conditions, but it should always be discussed with your doctor first.

If you’re navigating menopause symptoms or considering your HRT options, Dr. Najeeb Layyous and his team are here to guide you through a personalized discussion of what may work best for you.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist