Menopause

Menopause is when a person’s ovaries stop producing eggs and therefore, they no longer have periods and cannot fall pregnant naturally. Many people use the term ‘menopause’ to refer to the time when they notice changes in their periods and begin to experience associated symptoms.

In fact, menopause is a single point in time when a person has not had a period for 12 consecutive months (The Menopause Charity, 2022a).

Note: This is the case with naturally occurring menopause, but not with induced menopause. This article focuses on naturally occurring menopause.

The average age of menopause in the UK is 51, but it’s not uncommon for it to happen much younger than that. Early menopause is when a patient reaches menopause before the age of 45. If they are younger than 40, it’s sometimes called premature menopause or premature ovarian insufficiency (The Menopause Charity, 2022a). Around 1 in 100 people

People can experience symptoms for months or several years before their final period. This is known as perimenopause or pre-menopause, and typically, people begin to have some symptoms in their 40s. Everybody is different, so individual symptoms may vary, and a patient’s symptoms may change over time.

Menstrual cycle symptoms

The main symptom is a change to a patient’s periods, which might become heavier or lighter than normal, as well as more or less frequent.

The person could bleed every few weeks or go without a period for months at a time. Many people experience a combination of these changes, before their periods stop altogether.

Other symptoms

Most people – around 8 in 10 – will experience other symptoms alongside menstrual changes and they can have a significant impact on the patient’s quality of life.

The National Institute for Health and Care Excellence (NICE) lists symptoms as vasomotor (relating to

The ovaries are responsible for producing the two main female sex hormones, oestrogen and progesterone, which control menstruation and ovulation. Over time, the supply of eggs diminishes (as they are released each month during a period), and the ovaries gradually stop making the associated hormones (WebMD, 2022)

In people who reach menopause as a natural part of ageing, this doesn’t suddenly happen. Rather, it occurs over a period of several years, and coincides with a patient experiencing symptoms. After 12 months of having no periods, a person has reached menopause.

Surgical menopause happens when a patient has their ovaries removed (oophorectomy), for example during a hysterectomy. Menopause can be medically induced, too, for example by treatments or medication that affect the balance of hormones – like some breast cancer treatments, chemotherapy and radiotherapy (NHS, 2018a)

Menopause can also be caused by an underlying health condition, such as Down’s syndrome or

In otherwise healthy patients aged 45 or older, symptoms alone are normally sufficient to determine whether or not they are menopausal. NICE guidance states that, in these cohorts (NICE, 2015b):

• Perimenopause can be diagnosed based on vasomotor symptoms and irregular periods
• Menopause can be diagnosed where the patient has not had a period for at least 12 months and are not using hormonal contraception
• Menopause can be diagnosed in symptomatic patients without a uterus (e.g., those who have undergone a hysterectomy)

In patients under the age of 45, a blood test might be useful in diagnosing perimenopause. Typically, this will be to check for elevated levels of follicle-stimulating hormone (FSH), where a level of 30 IU/L indicates perimenopause (or premature ovarian insufficiency in patients under 40) (NICE, 2022a; NICE, 2022b).

Hormone tests are not recommended to diagnose patients who are using combined oestrogen and progesterone contraception, or high-dose progestogen. 

Some

Treatment is aimed at easing the symptoms of perimenopause – which can continue long after a patient’s final period – and making the transition more manageable.

Hormone replacement therapy

The main treatment is hormone replacement therapy (HRT), which helps to boost low levels of hormones that are thrown out of balance leading up to and after menopause. HRT is most effective when it’s begun before reaching menopause, or within 10 years (The Menopause Charity, 2022c).

HRT includes the hormones oestrogen, progesterone and sometimes testosterone. Patients could benefit from one, two, or a combination of all three depending on their medical history and symptoms.

There are different ways of taking HRT, the most common being tablets, patches, gels, implants, sprays, and preparations inserted vaginally (NHS, 2018c; The Menopause Charity, 2022d).

Different types and/or combinations of HRT can effectively treat many of the most debilitating symptoms, including vasomotor symptoms (night sweats, hot

References

American Society for Reproductive Medicine (ASRM): Reproductivefacts.org. Age and Fertility. 2022. www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/age-and-fertility/ (accessed 24 January 2022)

British Fertility Society (BFS): A guide to fertility. At what age does fertility begin to decrease? 2022. www.britishfertilitysociety.org.uk/fei/at-what-age-does-fertility-begin-to-decrease/ (accessed 24 January 2022)

National Institute for Health and Care Excellence. Menopause: diagnosis and management – Information and advice. NICE guideline [NG23]. 2015a. www.nice.org.uk/guidance/ng23/chapter/Recommendations#information-and-advice (accessed 24 January 2022)

National Institute for Health and Care Excellence. Menopause: diagnosis and management – Diagnosis of perimenopause and menopause. NICE guideline [NG23]. 2015b. www.nice.org.uk/guidance/ng23/chapter/Recommendations#diagnosis-of-perimenopause-and-menopause (accessed 24 January 2022)

National Institute for Health and Care Excellence. Menopause: diagnosis and management – Managing short-term menopausal symptoms. NICE guideline [NG23]. 2015c. www.nice.org.uk/guidance/ng23/chapter/Recommendations#managing-short-term-menopausal-symptoms (accessed 24 January 2022)

National Institute for Health and Care Excellence. Menopause: How should I diagnose premature ovarian insufficiency? (CKS) 2022a. https://cks.nice.org.uk/topics/menopause/diagnosis/diagnosis-of-premature-ovarian-insufficiency/#:~:text=The%20NICE%20clinical%20guideline%20states,indicates%20a%20diagnosis%20of%20POI (accessed 15 December 2022)

National Institute for Health and Care Excellence. Menopause: When should I suspect a diagnosis of menopause or perimenopause? (CKS) 2022b. https://cks.nice.org.uk/topics/menopause/diagnosis/diagnosis-of-menopause-perimenopause/ (accessed 15 December 2022)