15/10/2025
Menopause is a broad term that includes perimenopause when ovarian function waxes and wanes.
Osteoporosis is usually addressed in the context of the menopause due the drop in ostrogen levels causeing accelerated loss of bone mass (10% the first 5 years after menopause). Loss of bone density can be largely prevented by correcting ostrogen deficiency.
In the early menopausal transition, the cycle length may vary by 7 days (e.g. a 28-day cycle becomes 21).
The late menopausal transition is characterised by two or more skipped menstrual cycles. Variability of the heaviness of periods is common and the pattern can be erratic, with longer bleeding episodes or scanty me**es,
Around 20% will have no symptoms at all, while another 20% will be severely affected, with symptoms continuing into their 60s or later
Benefits and risks of HRT
It is the most effective method for relieving distressing symptoms such as hot flushes, urogenital symptoms, sleeplessness and joint symptoms.
(NICE) guideline on menopause management concluded the following:
MHT was the most appropriate treatment for menopausal symptoms.
🦴improved bone density and reduced fracture.❤️ CVD risk was not increased among women using HRT and may be reduced (in normal target population).
🩵Venous thromboembolism (VTE) risk was increased among women using oral HRT but not among women using non-oral therapy.
🌸Breast cancer risk was not increased for women taking ostrogen but was increased with long-duration use in women taking combined ostrogen and progestin therapy. The effect reduced after ceasing therapy.
The International Menopause Society advises that HRT carries few risks when prescribed for symptomatic women without contraindications if initiated in women aged under 60 years or within 10 years of menopause.
Contraindications to HRT:
History of ostrogen-dependent tumour:
• endometrial cancer
• breast cancer.
•Recurrent thromboembolism
•active SLE
•Acute ischaemic heart disease (absolute)
•History of coronary artery disease (relative)
•Cerebrovascular disease
•Uncontrolled hypertension
•Undiagnosed vaginal bleeding
•Active liver disease
Previous hysterectomy
Women do not need a progestogen and should be prescribed continuous ostrogen in either a transdermal or oral preparation. Transdermal delivery of ostrogen has a lower VTE risk.
Side effects of therapy
In the first 2-3 months, the woman may experience ostrogenic side effects, but these usually resolve or stabilise. Starting with a lower dose may minimise these side effects.
*Nausea and breast symptoms
*bleeding symptms
*vaginal dryness
Non-hormonal therapy regimens
1. Lifestyle changes
Discuss triggers for hot flushes that might be avoidable, including spicy food, 🍺 , coffee ☕️ and emotional stressors. It is advisable to wear loose-fitting clothes and dress in layers.
2. Non-hormonal, medical options for hot flushes include gabapentin, clonidine and antidepressants.
Complementary therapy
Options include black cohosh, red clover, soy products and other phytoestrogens (plants containing oestrogen-like compounds). Black cohosh has been linked to rare cases of abnormal liver function, hepatitis and liver failure.
Each individual case and treatment needs to be discussed with your family doctor and the information provided is not for diagnosis but for education.
