The first publications from the WHI trial in 2002 frightened millions of women and doctors, who stopped hormones overnight. Two decades of later analyses have shown that this reading missed a key detail – the age at which therapy began. Hormone replacement therapy is returning to clinics, but in a different form than twenty years ago. Find out what medicine says today about treating menopausal symptoms.
Key facts about hormone therapy in menopause:
- Hormone replacement therapy is the most effective treatment for hot flushes and night sweats
- The therapeutic window covers the first ten years after menopause or up to the age of 60
- Transdermal oestrogen carries a lower risk of thrombosis than older oral tablets
- Natural methods reduce symptom severity in some women but won’t replace treatment for severe symptoms
- The decision to start therapy requires individual risk assessment and regular follow-up
What is menopause?
Menopause is the moment of a woman’s final menstrual period, confirmed only after twelve months without bleeding. The average age of onset in the UK is 51. Before that, the body goes through perimenopause – a phase in which the ovaries gradually reduce their production of oestrogen and progesterone.
When does menopause begin?
Menopause begins between the ages of 45 and 55, although the moment of the final period becomes visible only a year later. The first cycle disturbances and hot flushes can appear as early as the 40s. The last period before the age of 40 is called premature ovarian insufficiency.
How does perimenopause differ from menopause?
Perimenopause is the phase that lasts on average 4 to 8 years before the final period, when hormones swing sharply from month to month. Cycles become irregular, and irritability or sleep problems are often stronger than in menopause itself.
What are the symptoms of menopause?
Menopause symptoms include hot flushes, night sweats, insomnia, vaginal dryness, mood swings and a drop in libido. Around 75 per cent of women experience vasomotor symptoms (hot flushes, night sweats, palpitations), which last on average 7 to 10 years.
The most common groups of menopausal symptoms:
- Vasomotor symptoms – hot flushes, night sweats, palpitations
- Sleep disturbances – difficulty falling asleep, frequent waking
- Psychological changes – irritability, anxiety, low mood
- Urogenital symptoms – vaginal dryness, painful intercourse, urinary urgency
- General symptoms – joint pain, brain fog, drop in energy
What are the first signs of approaching menopause?
The first signs are a shortening of the cycle, missed periods and worsening of premenstrual syndrome. Some women notice hot flushes while their periods are still regular. A cycle diary helps the gynaecologist with the assessment.
What causes early menopause?
Early menopause affects around 5 to 10 per cent of women. The main causes are genetic factors, autoimmune conditions (Hashimoto’s, lupus), cancer treatment and surgical removal of the ovaries.
How is menopause diagnosed?
Diagnosis in women over 45 relies mainly on tracking the cycle and symptoms. When symptoms appear earlier or HRT is being considered, blood tests provide hard data.
Which hormone tests should be done before considering HRT?
The gynaecologist orders a panel that includes FSH, oestradiol, TSH and a lipid profile, plus Full Blood Count, fasting glucose and possibly prolactin. Standard checks also include cervical screening, ultrasound and mammography to rule out contraindications.
What is the FSH test?
FSH is follicle-stimulating hormone from the pituitary gland. Which prompts the ovaries to develop follicles. When the ovaries lose their ability to respond, the pituitary increases FSH production.
What do its levels mean?
In women of reproductive age, FSH levels don’t exceed 10 mIU/ml. Values above 25 to 30 mIU/ml suggest perimenopause. Persistently above 40 indicate menopause.
How are menopausal symptoms treated?
Treatment combines pharmacotherapy with lifestyle changes. The choice depends on symptom severity, age and medical history. Mild symptoms ease with diet changes and exercise; severe symptoms call for a discussion about HRT.
What is hormone replacement therapy (HRT)?
Hormone replacement therapy involves topping up the hormones that the ovaries produce in declining amounts. The aim is to ease symptoms and protect oestrogen-sensitive tissues. Modern HRT uses lower doses than the products of the 1990s.
Which hormones are used in HRT?
Therapy uses oestrogen and a progestogen (a synthetic equivalent of progesterone). Women who’ve had a hysterectomy receive oestrogen alone. The remaining patients receive combined therapy, in which the progestogen protects the endometrium, the lining of the womb.
Hormone replacement therapy – who should consider it and up to what age?
HRT is recommended for women with troublesome symptoms who begin therapy in the first decade after the final period or before the age of 60 – within the therapeutic window. Contraindications: active breast cancer, unexplained vaginal bleeding, severe liver disease, a history of venous thrombosis.
What are the benefits and risks of HRT?
The benefits include relief of hot flushes, improved sleep, reduced vaginal dryness and protection of bone density. A re-analysis of the WHI trial, published in JAMA in 2017, showed that starting HRT before the age of 60 doesn’t increase mortality. Every decision should also take into account the individual impact of chronic stress, which worsens vasomotor symptoms.
How does HRT affect the thyroid and metabolism?
Oral oestrogen increases the liver’s production of thyroid-binding protein, so women with hypothyroidism often need a dose adjustment of their thyroid medication. The transdermal form has a smaller effect on the thyroid. A practical tip: have your TSH checked 6 to 8 weeks after starting HRT.
How can troublesome menopausal symptoms be prevented? Natural methods of symptom relief
Natural methods mean a change of diet, movement and work on sleep. Studies published in Menopause in 2020 show that women who follow a Mediterranean diet and exercise regularly report 20 to 30 per cent fewer hot flushes.
Practical methods of easing symptoms:
- Regular physical activity – 150 minutes of moderate exercise a week plus two strength sessions
- Sleep hygiene – a cool bedroom, a fixed bedtime, less alcohol in the evening
- Diet adjustments – more vegetables, fish and whole grains, less sugar and alcohol
- Stress reduction techniques – cognitive-behavioural therapy, meditation, breathing exercises
- Avoiding triggers – spicy foods, coffee, hot drinks before bed
What kind of diet supports women in menopause?
A diet that supports women in menopause is built on the Mediterranean pattern, with emphasis on protein, calcium and vitamin D. Protein (1.0 to 1.2 grams per kilogram of body weight) protects muscle, calcium (1000 to 1200 mg a day) and vitamin D support bone density. Phytoestrogens (plant compounds with a structure similar to oestrogen) from soy and flax can reduce hot flushes – the effect is moderate.
Which forms of exercise help in menopause?
The best results come from combining strength training, aerobic activity and balance work. Strength training after 40 twice a week slows the loss of muscle and bone.
Postmenopausal women lose 1 to 2 per cent of muscle mass a year without resistance training – a phenomenon known as sarcopenia, the age-related loss of muscle. Three 30-minute strength sessions a week halt this process and help improve sleep.
Menopause – an informed decision about therapy and lifestyle
An informed decision begins with recognising your own symptoms and their impact on daily life. For one woman natural methods may be enough; for another with severe insomnia HRT is the fastest route to better quality of life.
This text is for educational purposes only and doesn’t replace medical consultation. The decision to start HRT requires individual risk assessment and the supervision of a gynaecologist or endocrinologist.
FAQ: Frequently asked questions about hormone replacement therapy
Which tests should be done before HRT?
The standard panel includes FSH, oestradiol, TSH, a lipid profile, Full Blood Count, glucose, cervical screening, pelvic ultrasound and mammography.
Does HRT increase the risk of breast cancer?
Combined therapy slightly increases the risk of breast cancer after five years, while oestrogen alone after a hysterectomy shows no such effect in WHI data.
Can HRT be taken without a prescription?
Hormone replacement therapy requires a prescription and the supervision of a gynaecologist or endocrinologist – over-the-counter products don’t contain hormones and have a weaker effect.
How long should hormone replacement therapy be used?
The duration is set individually – most guidelines refer to 5 to 10 years with regular follow-up, although some women with severe symptoms stay on low doses.
References:
- Manson, J. E., et al. (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: The Women’s Health Initiative randomized trials. JAMA. https://doi.org/10.1001/jama.2017.11217
- Hodis, H. N., et al. (2016). Vascular effects of early versus late postmenopausal treatment with estradiol (ELITE trial). New England Journal of Medicine. https://doi.org/10.1056/NEJMoa1505241
- Miller, V. M., et al. (2019). The Kronos Early Estrogen Prevention Study (KEEPS): What have we learned? Menopause. https://doi.org/10.1097/GME.0000000000001326
