Menopause: what's actually happening and what helps

Menopause is the point at which a woman's menstrual periods stop permanently, marking the end of the reproductive years. It's confirmed after 12 consecutive months without a period, and in most women it arrives somewhere between the ages of 45 and 55. The average age in the UK and US sits around 51. But menopause isn't a single moment. It's a years-long hormonal shift that can start a decade before periods stop, and its effects can run well past them.

What menopause actually does to the body

The core of menopause is a steep drop in oestrogen and progesterone, two hormones produced by the ovaries. As egg reserves fall, the ovaries produce less of both. The brain responds by pumping out more follicle-stimulating hormone (FSH) in an attempt to coax the ovaries into action. That hormonal back-and-forth is what drives most of the symptoms.

Oestrogen doesn't just regulate periods. It plays a role in bone density, cardiovascular function, skin elasticity, brain chemistry, and the health of the urinary tract and vagina. A sustained drop in oestrogen affects all of these systems simultaneously. That's why menopause can feel so wide-ranging, and why it's often misunderstood or underestimated in medical settings.

The three stages: perimenopause, menopause, postmenopause

Perimenopause is the transition phase. It can start in the early 40s (sometimes late 30s) and typically lasts 4 to 8 years. Periods become irregular. Hormone levels swing rather than simply decline. Hot flushes, mood changes, and disrupted sleep often begin here, even while periods are still happening.

Menopause itself is a single point in time: 12 months after the last period. Everything after that is postmenopause. In postmenopause, oestrogen stabilises at a consistently low level. Some symptoms ease; others, particularly vaginal dryness and bone loss, can intensify without treatment.

Common symptoms, and the ones that get ignored

Hot flushes get most of the attention. They affect roughly 75% of women going through menopause and can last anywhere from 2 to 10 years. Night sweats are the nocturnal version: a spike in body temperature that disrupts sleep, often severely.

Less discussed but equally significant symptoms include:

• Genitourinary syndrome of menopause (GSM): vaginal dryness, discomfort during sex, and urinary urgency or recurrent UTIs, affecting up to 60% of postmenopausal women
• Brain fog and difficulty concentrating, which some researchers now link directly to oestrogen's role in brain metabolism
• Joint pain, which rises sharply during perimenopause and often gets attributed to ageing rather than hormonal change
• Mood shifts including low mood, anxiety, and irritability, distinct from but sometimes overlapping with clinical depression
• Changes in skin, hair thickness, and body composition, particularly increased abdominal fat

What the evidence says about treatment

Hormone replacement therapy (HRT), now more commonly called menopausal hormone therapy (MHT), remains the most effective treatment for moderate to severe menopause symptoms. It works by replacing the oestrogen (and, for women with a uterus, progesterone) that the ovaries are no longer producing. Most clinical guidelines from organisations including the Menopause Society now state that for healthy women under 60 who are within 10 years of menopause onset, the benefits of MHT outweigh the risks for the majority of symptom profiles.

The 2002 Women's Health Initiative study generated widespread fear about HRT and breast cancer. Subsequent analysis showed those findings were specific to a particular formulation (oral conjugated equine oestrogen combined with medroxyprogesterone acetate) in an older population. Transdermal oestrogen, which is absorbed through the skin rather than the gut, carries a lower clot risk. Body-identical progesterone (micronised progesterone) shows a more favourable breast tissue profile than synthetic progestins. These distinctions matter, and they're worth discussing with a doctor who is up to date on the evidence.

Non-hormonal options

Not every woman can or wants to use MHT. Certain cancers, blood clot history, and personal preference all factor in. Non-hormonal options with genuine clinical backing include fezolinetant, a neurokinin receptor antagonist approved in 2023 specifically for vasomotor symptoms (hot flushes and night sweats). SSRIs and SNRIs, particularly paroxetine and venlafaxine, reduce hot flush frequency by around 60% in trials, though they carry their own side effect profiles.

For GSM specifically, low-dose vaginal oestrogen is effective, has minimal systemic absorption, and is considered safe even for women who can't use systemic MHT. Non-hormonal vaginal moisturisers and lubricants help with day-to-day comfort but don't reverse the underlying tissue changes the way oestrogen does.

Lifestyle factors carry real weight too. Resistance training protects bone density and muscle mass. Cutting alcohol and smoking reduces hot flush frequency. Cognitive behavioural therapy (CBT) has clinical trial support for improving sleep and managing mood symptoms related to menopause. These aren't substitutes for medical treatment in severe cases, but they're not placebo either.

Bone health and cardiovascular risk

Two longer-term risks deserve attention beyond the acute symptoms. Bone density drops sharply in the first 5 years after menopause, because oestrogen normally slows the rate at which old bone is resorbed. Women lose up to 20% of bone density in this window. A DEXA scan (bone density scan) is worth discussing with a GP, especially for women who experience early menopause (before 45) or premature ovarian insufficiency (before 40).

Cardiovascular disease risk also rises after menopause, partly because oestrogen has a protective effect on blood vessel walls. Women who start MHT before 60 show a lower rate of cardiovascular events in several large observational studies, though this isn't yet established as a primary reason to prescribe it. Monitoring blood pressure, cholesterol, and blood glucose becomes more important from perimenopause onward.

Getting the right support

A significant number of women report that their menopause symptoms were dismissed or misdiagnosed, particularly mood symptoms, which are sometimes treated as depression without the hormonal context being explored. If a consultation doesn't feel thorough, a second opinion from a menopause specialist is a reasonable step. The British Menopause Society maintains a directory of accredited specialists in the UK. In the US, the Menopause Society's clinician finder serves the same purpose.

Menopause is not a condition to be managed in silence or powered through without support. The treatments that exist work. Knowing what's available is the first step to using them.