Menopause and perimenopause

What is menopause / perimenopause ?

Menopause is a natural life stage that occurs when your ovaries stop releasing eggs and reduce hormone production like estrogen and progesterone. It is diagnosed after you have gone 12 consecutive months without a menstrual period. Most women experience menopause between the ages of 45 and 55 years, with the average age being around 51 years.

Perimenopause, also called the menopausal transition, is the phase leading up to menopause. This transitional period can last several years. The starting point of perimenopause is sometimes hazy and is characterized by declining estrogen levels (with symptoms such as hot flushes, dryness of vagina / skin, sleep disturbances, mood changes and reduced libido) and irregular menstrual cycles. During perimenopause, your periods may become unpredictable — either closer together or further apart — and the flow may vary. If there are erratic bleeding during this period, a gynaecological assessment is necessary to rule out structural abnormalities in the inner lining of the uterus (womb).

Common Symptoms

The symptoms of perimenopause and menopause vary greatly between individuals. Some women experience minimal discomfort, while others find symptoms significantly impact their quality of life.

The most common symptoms include:

·         Hot flushes and night sweats – sudden intense feelings of warmth or heat, often

accompanied by sweating and flushing of the skin, usually starting from the chest, and then going towards the head and neck; may last from 30 seconds to 5 minutes per episode

·         Irregular periods – changes in cycle length, flow, or frequency

·         Sleep disturbances – difficulty falling asleep or staying asleep

·         Mood changes – including anxiety, irritability, or low mood

·         Vaginal dryness – which may cause discomfort during intercourse

·         Reduced libido – decreased interest in sexual activity

·         Cognitive changes – including difficulty concentrating or memory concerns

·         Urinary symptoms – including urgency, frequency, or recurrent infections

·         Joint and muscle aches

·         Fatigue and headaches

You can score your symptom on the chart attached below, and serially monitor the seriousness of the symptoms to see how they progress.

How is Menopause Diagnosed?

The diagnosis of perimenopause and menopause is typically made clinically based on a combination of your age, menstrual pattern changes, and symptoms. Blood tests to measure hormone levels are generally not necessary or recommended for diagnosis, as hormone levels fluctuate significantly during the transition period, and may even be abnormal in different parts of the menstrual cycle in a non-menopausal woman.

When to Seek Help

If you are experiencing symptoms that affect your daily life, work, relationships or wellbeing, you may want to seek treatment. There are many effective treatment options available, including hormone therapy and non-hormonal approaches, tailored to your individual needs and health profile.

Hormone Replacement Therapy (HRT) or Menopausal Hormone Therapy (MHT) for Perimenopause and Menopause

HRT or MHT is the most effective treatment for managing bothersome menopausal symptoms, particularly hot flushes, night sweats, and genitourinary symptoms.

Advantages of Hormone Replacement Therapy

When started in women under 60 years of age or within 10 years of menopause, hormone therapy offers several benefits:

• Symptom relief: Most effective treatment for hot flushes, night sweats, and genitourinary symptoms

• Bone protection: Reduces risk of hip and spinal fractures by 30-50% from the baseline when HRT is given to postmenopausal women 50-69 years old for an average of 4.3 years (see https://pubmed.ncbi.nlm.nih.gov/35833956/).

• Quality of life: Improves sleep, mood, and overall wellbeing

• Metabolic benefits: Appears to reduce risk of new onset type 2 diabetes during the period of treatment.

• Cardiovascular considerations: Starting HRT before age 60 and within 10 years from menopause onset does not appear to increase heart attacks. Maintaining HRT after 60 years old when already initiated before age 60 and within 10 years from menopause onset also does not appear to increase risk of heart attacks. Conversely, starting HRT after age 60 years old or after 10 years of menopause onset may increase heart attacks, and should be avoided.

• All-cause mortality: Considering all causes of death, hormone replacement therapy (HRT) tends to reduce the rates of dying prematurely in women aged < 60. These were based on 2 studies (https://pubmed.ncbi.nlm.nih.gov/28898378/ and https://pubmed.ncbi.nlm.nih.gov/15209595/) given HRT for 5-7 years, and followed up for up to 18 years. The all-cause mortality benefit disappears from aged 60 onwards.

Risks of Hormone Replacement Therapy

It is important to understand the potential risks, which are generally small for healthy women starting treatment in their 50s:

1)      Breast cancer: With combined estrogen-progestogen therapy used short term (<5 years), any increase in breast cancer risk is small.

Newer progesterone preparations now available in newer HRT preparations appear to be safer than older synthetic progesterone like medroxyprogesterone acetate. In observational study (the French E3N) cohort, micronized progesterone and dydrogesterone appear not to increase the risk of breast cancer when these were used < 5 years.

A British Menopause Society summary makes the distinction clearly, for estrogen with micronized progesterone or dydrogesterone:

• Up to five years: not associated with a statistically significant increase; HR 1.11, 95% CI 0.89–1.38.

• More than five years: a small but statistically significant increase; HR 1.31, 95% CI 1.15–1.48.

• After discontinuation: the association was no longer statistically significant; HR 1.15, 95% CI 0.93–1.42.

The older preparations of HRT uses medroxyprogesterone acetate, a type of synthetic progesterone . When these older preparations were used long-term (more than 5 years), there is an increased risk: out of 100 women aged 50, about 6.3 would develop breast cancer without HRT over the next 20 years compared to about 8.3 with HRT used for 5 years. Estrogen-only therapy (for women without a uterus) does not appear to increase breast cancer risk. See https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)31709-X.pdf

2)      Blood clots in deep veins (venous thromboembolism): There is a small increased risk with oral estrogen. The risks appear to be concentrated in the first 1 year after oral HRT, and probably unmasks a small group of patients who are genetically or otherwise prone to getting venous thromboembolism anyway. Transdermal estrogen does not increase the risk of venous thromboembolism (https://pubmed.ncbi.nlm.nih.gov/42778212/).

3)      Stroke: Small increased risk with oral oestrogen, dose-dependent, and not seen with transdermal oestrogen. Like VTE, stroke risk with HRT is tied to oral dosing rather than accumulating with duration of use — high-dose oral oestradiol (>1 mg daily) carries a clearly elevated risk, while low-dose oral oestradiol does not appear to raise risk at all. This makes stroke risk more a question of route and dose than of how long therapy continues.

In real numbers, oral HRT overall raises ischaemic stroke risk by about 30% compared with not using it, but this is a small absolute increase — roughly 1 extra stroke per 1,600 women per year of use. This risk holds whether starting therapy in the early 50s or later 60s. When broken down by dose, only high-dose oral oestradiol (>1 mg daily) shows a clear increase (about 50% higher), while low-dose oral oestradiol shows no significant increase at all. Transdermal oestrogen, at any dose and with any progestogen, has not been shown to raise stroke risk above that of never-users — reinforcing transdermal low-dose regimens as the safer choice for stroke and clot risk alike.

Treatment Options

1. Transdermal Estrogen + Micronized Progesterone (Bioidentical Hormones)

This combination is one of the most popular combination that uses hormones that are chemically identical (bioidentical) to those your body naturally produces. Transdermal estrogen is applied to the skin (arms or thighs) once daily, where it gets absorbs directly into the bloodstream. This form of estrogen (compared to the oral forms) is more likely to have sustained levels of the hormone in the body and less likely to have complications such as venous thromboembolism (or clots in the leg veins or pelvic veins). Micronized progesterone is taken as an oral capsule, usually at bedtime. This is particularly useful for patients with sleep disorders as the oral micronized progesterone causes sleepiness, and may have a more favourable safety profile for breast health than other oral synthetic progestins.

2. Transdermal Estrogen + Mirena (Levonorgestrel IUD)

This option combines a transdermal estrogen gel with the Mirena intrauterine device, which releases a small amount of levonorgestrel (a progestogen) directly into the uterus.

3. Femoston (Combined Estradiol and Progestogen Tablets)

Femoston is an oral combined hormone therapy available in different doses to match your symptom severity and individual needs. It contains estradiol (bioidentical estrogen) combined with dydrogesterone (a synthetic progestogen).

Available doses:

·         Lower dose options for milder symptoms or as maintenance therapy

·         Standard dose for moderate to severe symptoms

·         Higher dose for more severe symptoms

4. Tibolone (Synthetic Steroid with Estrogenic, Progestogenic, and Androgenic Activity)

Tibolone is a synthetic hormone taken as a once-daily oral tablet. It is metabolized into compounds that exert estrogenic, progestogenic, and mild androgenic effects, providing a combined approach to menopausal symptom relief without the need for separate estrogen and progesterone.

5. Transdermal estradiol only

This is appropriate if your uterus has already been removed. Then there is no need for concomitant progesterone treatment to reduce the risk of endometrial (inner lining of the womb) cancer.

Who Should Not Use Hormone Therapy

Hormone therapy is not suitable for everyone. You should not use HRT if you have:

·         Unexplained vaginal bleeding

·         History of breast cancer or other estrogen-sensitive cancers

·         History of blood clots, stroke, or heart attack

·         Active liver disease

·         History of venous thromboembolism or pulmonary embolism

·         Personalized Treatment Approach

Duration of Treatment

There is no arbitrary time limit for hormone therapy. Typically, hormone replacement therapy is started before the age of 60 or within the first 10 years after menopause. Treatment should continue if the benefits outweigh the risks for you individually. We recommend regular reviews (typically annually) to reassess your symptoms, health status and treatment goals.