Menopause and Hormone Therapy: Symptoms, Diagnosis and Treatment Options

The menopause is the permanent cessation of menstruation that follows the natural decline of ovarian hormone production. The medical definition is retrospective: 12 consecutive months without a period, in the absence of another cause. The average age is 48–51 years. It is a physiological transition rather than a disease — but its symptoms and long-term health consequences are, in most women, entirely treatable.

The perimenopause

The 4–8 year transition preceding the menopause is called the perimenopause. As ovarian reserve declines, oestrogen levels fluctuate unpredictably. Periods first become closer together, then more widely spaced, and bleeding becomes variable in volume. Hot flushes, disturbed sleep and mood changes usually begin during this phase. An important point: conception remains possible in the perimenopause, so contraception should be continued for 12 months after the final period.

Symptoms of the menopause

• Vasomotor symptoms: hot flushes and night sweats, affecting around 75% of women and lasting an average of seven years.
• Sleep disturbance and fatigue: sleep fragmented by night sweats leads to daytime difficulty with concentration.
• Genitourinary syndrome of the menopause: vaginal dryness, pain during intercourse, urinary frequency and recurrent urinary tract infections. Unlike other symptoms, this progresses over time if untreated.
• Mood symptoms: mood swings, irritability, anxiety and depressive symptoms.
• Bone loss: falling oestrogen accelerates bone resorption; 10–20% of bone density may be lost in the first 5–7 years. It is silent until a fracture occurs.
• Metabolic change: central weight gain, an adverse lipid profile and rising cardiovascular risk.

How is it diagnosed?

In a woman over 45 with typical symptoms and absent periods, the diagnosis is clinical and no routine hormone testing is required. FSH and oestradiol measurement is helpful where periods stop between 40 and 45, where they stop before 40 (suspected premature ovarian insufficiency), after hysterectomy, and in users of hormonal contraception. Thyroid function tests are frequently added, since thyroid disease can produce very similar symptoms.

Important: any vaginal bleeding after the menopause is abnormal and must be assessed. Endometrial thickness should be measured by ultrasound, with endometrial biopsy or hysteroscopy where indicated.

What is hormone replacement therapy (HRT)?

HRT replaces the oestrogen the ovaries no longer produce. Women with a uterus must also receive a progestogen to protect the endometrium; oestrogen alone is sufficient after hysterectomy. The main routes are:

• Transdermal (patch or gel): avoids first-pass hepatic metabolism, so the thrombotic risk is lower than with oral therapy. Preferred in migraine, hypertension and raised triglycerides.
• Oral tablets: convenient and highly effective.
• Local vaginal oestrogen: used where vaginal and urinary symptoms are the only complaint. Systemic absorption is negligible, so it carries no systemic risk and requires no added progestogen.

Who is suitable for HRT?

Current guidelines share the "window of opportunity" concept: in healthy women who begin treatment under the age of 60 and within 10 years of the menopause, the benefit-to-risk balance is favourable. In this group HRT reduces hot flushes by up to 75%, improves sleep and quality of life, halts bone loss and lowers fracture risk. For women who reach the menopause before the age of 40, HRT is not a preference but a requirement, and should normally be continued at least until the average age of natural menopause.

Risks and contraindications

The risks of HRT depend closely on the age at initiation and on the regimen used. Combined oestrogen–progestogen therapy used beyond five years is associated with a small but real increase in breast cancer risk; oestrogen-only therapy is not. Oral oestrogen increases venous thromboembolic risk, whereas transdermal preparations do not appreciably do so. Contraindications include:

• Active or previous breast cancer and other oestrogen-sensitive cancers.
• Unexplained vaginal bleeding.
• Previous deep vein thrombosis or pulmonary embolism.
• Previous stroke or myocardial infarction; uncontrolled hypertension.
• Active liver disease.

Treatment is reviewed at three months and annually thereafter, and breast examination and mammographic screening should be maintained.

Non-hormonal options

• For hot flushes: low-dose SSRIs/SNRIs, gabapentin, clonidine and the newer non-hormonal NK3 receptor antagonists.
• For vaginal dryness: water-based lubricants, long-acting vaginal moisturisers and very low-dose local oestrogen.
• For bone health: 1000–1200 mg calcium daily, vitamin D supplementation, walking and resistance exercise; bisphosphonates where indicated.
• Lifestyle: stopping smoking, weight management, reducing alcohol and caffeine, layered clothing and consistent sleep hygiene.

Routine checks after the menopause

The menopause is the point at which annual health screening becomes particularly valuable: breast examination and mammography, cervical screening (cytology/HPV), blood pressure and glucose measurement, lipid profile, thyroid function and, at the appropriate age, DEXA bone density scanning.

When to see a specialist

• Any bleeding or spotting after the menopause.
• Periods stopping before the age of 40.
• Hot flushes, insomnia or mood changes that disrupt daily life.
• Pain during intercourse, vaginal dryness or recurrent urinary tract infections.
• Loss of height, back pain or a fracture after minor trauma.

Menopause care in Adana

Good menopause management is not a single prescription applied to everyone, but an individual plan built from age, time since the menopause, symptom severity and personal and family risk factors. Op. Dr. Sadık Kükrer, MD offers comprehensive assessment of the menopausal transition, suitability review for hormone replacement therapy, non-hormonal alternatives and long-term bone health monitoring in Adana, Türkiye.