Menopause
The Change That Changes Everything
Why Is Everyone Talking About Menopause?
Menopause is all over social media these days, yet the basic facts are still hard to find. This page explains the essentials in plain language, so you can feel informed and take care of yourself through this stage of life.
Menopause isn’t new. It’s a natural stage in every woman’s life, and it has been part of human existence since the beginning of time. So, why it matters more now? In medieval times, average life expectancy was only around 26 years, so relatively few women lived long enough to experience it, and it wasn’t recognised as a key stage of life.Why Is Everyone Talking About Menopause?
Today, women live to around 84 on average, which means they may spend up to half their lives after menopause. That is why menopause is finally getting the attention it deserves. Because we are living longer, it now carries greater medical, social and emotional significance
Why Menopause Care Still Falls Through the Cracks
Despite its significant impact on physical, mental and emotional health, menopause remains a taboo subject, often overlooked within families, workplaces and even healthcare settings. Many women are unaware that their symptoms are treatable, while gaps in healthcare training and policy leave countless women without adequate support.
Although many menopausal symptoms and long-term health consequences can be effectively managed, millions of women worldwide still lack access to appropriate care and treatment.
At Vividah, we aim to change this by raising awareness and sharing the essential knowledge every woman should have about menopause — how to manage its symptoms, reduce long-term health risks and, most importantly, enjoy this stage of life rather than simply endure it.
Diagnosing Menopause
Menopause usually occurs between the ages of 45 and 54, with an average age of 51. Menopause between 40 and 45 is considered early, and menopause before 40 is classed as premature.
It is diagnosed retrospectively, after 12 consecutive months without a period in a woman who is not using hormonal contraception or another treatment that alters menstrual bleeding. It cannot usually be confirmed in advance with a blood test.
Menopause is not a sudden event. It is the final stage of a gradual transition called perimenopause.
Diagnosing Perimenopause
Perimenopause is the transition leading up to menopause, when ovarian function becomes increasingly irregular and oestrogen levels fluctuate. It is diagnosed mainly from your symptoms and changes in your periods, rather than a single blood test.
Common features include:
Irregular or changing periods
Hot flushes and night sweats
Sleep disturbances
Mood changes, irritability or anxiety
Poor concentration or “brain fog”
Vaginal dryness and urinary symptoms
Reduced libido
Perimenopause varies considerably in length and often lasts several years before the final period. This transition, together with menopause itself, is known as the climacteric.
What Is Menopause?
Menopause is the permanent end of menstruation and ovulation, caused by the ovaries ceasing to function. It is often called the change that changes everything, because oestrogen supports nearly every system in the body, including the production of collagen, a key structural protein found in most tissues and organs.
Why does it happen?
Women are born with a finite number of ovarian follicles, and this supply declines gradually throughout life. Each menstrual cycle uses up several follicles, but usually only one releases an egg while the rest degenerate. Over time the reserve runs very low.
The role of oestrogen
The developing follicles produce oestrogen, which during our reproductive years:
Regulates the menstrual cycle
Protects bone and heart health
Regulates body temperature
Maintains skin and urogenital health
Supports mood, cognition and sexual wellbeing
When the follicles are almost gone, the ovaries can no longer produce enough oestrogen, and levels fall. This is what leads to menopause.
Natural vs Iatrogenic Menopause
Menopause can happen in two main ways: gradually through natural ageing, or earlier and more abruptly as a result of medical or surgical treatment.
Natural (physiological) menopause develops gradually over several years as the ovaries slow down and oestrogen levels fall, giving the body time to adapt. It is generally the least abrupt form of menopause. Around 15-20% of women have few or no symptoms, while others experience symptoms that vary in type and severity. For many women, symptoms ease within a few years, although some last considerably longer.
Iatrogenic menopause (menopause caused by medical treatment) brings an earlier and sometimes sudden drop in ovarian hormones. It may follow:
Surgery: Removal of both ovaries (bilateral oophorectomy) causes an abrupt fall in oestrogen, often producing sudden and intense symptoms. It is the most immediate hormonal change and can be particularly hard for younger women.
Chemotherapy: This can damage the ovaries, leading to temporary or permanent menopause.
Radiotherapy: Radiation to the pelvis can damage the ovaries and cause premature menopause.
What they have in common: Menopause is more than the end of periods. Falling oestrogen affects many parts of the body, so it is a whole-body transition rather than just a reproductive event. Whether natural or iatrogenic, menopause can cause short-term symptoms and long-term health effects, and these vary considerably from woman to woman.
Menopause Changes
Now and Later
Menopause has been called “the change that changes everything”, and with good reason. Oestrogen helps the body make and maintain collagen, the protein that keeps skin, bones, joints, blood vessels and the tissues of the vagina and bladder strong and flexible. When oestrogen falls, collagen production drops too, which is why menopause affects so many parts of the body, not just periods.
The good news is that symptoms can be treated and long-term risks reduced. Knowing what to expect is the first step.
Short-Term Symptoms
Short-term symptoms are the ones you notice first, often starting in perimenopause. They include hot flushes, night sweats, poor sleep, mood changes and vaginal or urinary symptoms. They affect up to 80% of women, and while they are usually temporary, they can have a big effect on daily life.
Long-Term Consequences
Long-term changes develop quietly over the years and often give no early warning. Lower oestrogen can affect bone strength, heart health, the brain, skin and weight, so it is important to understand these changes and act on them early.
Unlike short-term symptoms, which are disruptive but temporary, long-term consequences are silent. They develop gradually, give no obvious early warning, and carry significant morbidity and mortality if left untreated.
They are driven mainly by prolonged oestrogen deficiency, which affects far more than the reproductive system.
Key effects include osteoporosis, increased cardiovascular risk, urogenital and sexual changes, metabolic syndrome, cognitive effects, and changes to skin and connective tissue.
Early recognition, sensible lifestyle measures and appropriate medical intervention, including HRT where suitable, can significantly reduce these risks.
Bone health and osteoporosis
Peak bone mass is reached around the fourth decade. After menopause, bone loss accelerates sharply as oestrogen falls: women may lose up to 50% of their bone mass by age 70, compared with roughly 25% in men by age 90.
This raises the risk of osteoporosis (weak, porous, brittle bones) and fragility fractures, mainly of the hip, spine and wrist.
Hip fracture is the most serious complication. Between 20% and 30% of women die within a year, and up to half of survivors lose the ability to walk independently.
Deaths from osteoporotic hip fracture exceed those from breast and endometrial cancer combined, so bone health needs attention before a fracture occurs.
Skin and connective tissue
Menopause accelerates skin ageing: collagen loss rises to about 2.1% a year, leaving skin thinner, drier, less elastic and more prone to wrinkles.
Treatment can improve skin thickness, collagen and elasticity. One trial found an 11.5% increase in skin thickness after 12 months.
Nearly half of postmenopausal women say no one told them menopause would affect their skin, and many link these changes to their self-esteem.
Hot flushes and night sweats (vasomotor symptoms)
Affect around 70% of women during perimenopause and after menopause, and are the most recognisable feature of menopause.
Caused by the brain’s temperature-control centre becoming more sensitive to hormone changes as oestrogen falls.
Often peak in the first year after menopause, then ease, though some women have them for over a decade.
One in three women has moderate or severe symptoms, and this is often what prompts women to seek medical advice.
Severity varies with factors such as ethnicity and BMI. Some Asian women report bone and joint pain instead of flushing.
Body weight and hot flushes
Fat tissue converts other hormones into oestrogen, so you might expect a higher BMI to mean fewer flushes.
Several large studies find the opposite: a higher BMI is linked to more flushes, probably because body fat traps heat. The oestrogen made by fat is also weaker than the oestrogen made before menopause.
Not all studies agree, and some point to other factors such as smoking, so the overall effect is still unclear.
Sleep and mood
Sleep problems (such as insomnia and sleep apnoea) affect over 40% of women. Hormone changes alone can disrupt sleep, even without night sweats.
Low mood, anxiety and mood swings affect roughly one in three women, and are sometimes mistaken for ordinary life stress.
Sleep and mood affect each other: poor sleep worsens mood, and low mood makes restful sleep harder.
Vaginal, urinary and sexual symptoms
These tend to develop later, as long-term low oestrogen thins the tissues of the vagina, vulva and urinary tract.
They include vaginal dryness and thinning (atrophy) and urinary incontinence, often with reduced sex drive and discomfort during sex.
Unlike hot flushes, they often continue or worsen without treatment, because the tissue changes don’t reverse on their own.
They are talked about far less than hot flushes but can be just as disruptive, so it is worth raising them with your doctor, even if it feels embarrassing.
How long do they last?
Duration and severity vary enormously. For many women, symptoms settle within about two years, but moderate to severe hot flushes and night sweats can last over a decade.
BMI, lifestyle and your own hormone patterns all play a part, so there is no single “typical” menopause.
Short-term symptoms are what usually bring women to the clinic, but they are only the visible surface. Menopause also brings quieter, longer-term changes that develop gradually and matter far more for long-term health.
Genitourinary syndrome of menopause (GSM)
Without oestrogen, vaginal and urinary tract tissues become dry, thin and less flexible.
This can cause painful sex, urinary urgency and frequency, recurrent UTIs, a weakened pelvic floor, pelvic organ prolapse, incontinence, and reduced desire or satisfaction.
Unlike many menopausal symptoms, GSM does not resolve on its own and tends to worsen without treatment.
Effective, gentle treatments exist, but they only help if women raise the problem with their doctor.
Cardiovascular health
Falling oestrogen raises LDL (“bad”) cholesterol, lowers HDL (“good”) cholesterol and stiffens blood vessels. This increases the risk of hypertension, heart disease, heart attack and stroke.
Before menopause, oestrogen is protective: heart disease is about three times more common in men than in premenopausal women of the same age.
After menopause this protection fades, and by around age 70 women’s risk is roughly equal to men’s.
Cognitive and neurological health
Many women experience “brain fog”: poor concentration, difficulty finding words and forgetfulness. For most, this is temporary.
Prolonged oestrogen deficiency is linked to a higher long-term risk of cognitive decline and dementia, though this is not inevitable. Cardiovascular health, genetics, lifestyle and ageing also play a part.
Changes in memory or concentration should not be dismissed as “just getting older” and are worth discussing with a doctor.
Menopause and Weight Gain
At least half of women gain weight around menopause, and about 1 in 5 gain more than 10 lbs. Even when the scale barely moves, body composition shifts towards more fat and less muscle.
Fat storage moves from the hips and thighs to deep abdominal (visceral) fat, which is metabolically active and raises the risk of cardiovascular disease, metabolic disease and dementia.
This is not simply a matter of eating too much or exercising too little. Several overlapping factors contribute.
Lifestyle factors
Tiredness, joint pain or low motivation can reduce activity and calories burned.
Hormonal shifts and stress can increase cravings and comfort eating.
Poor sleep raises hunger, especially for carbohydrates, and disrupts the appetite hormones ghrelin and leptin.
Life changes (retirement, children leaving home, caregiving) can disrupt routines, and alcohol adds calories and worsens sleep.
Unlike hormonal changes, lifestyle factors can be acted on.
Metabolic slowdown
Muscle loss (sarcopenia) lowers resting calorie burn, since muscle burns more calories than fat.
The body may need fewer calories than before just to maintain the same weight.
Hormonal changes
Falling oestrogen shifts fat storage to the belly, increases insulin resistance (raising type 2 diabetes risk), raises cortisol and may reduce everyday movement such as fidgeting.
Oestrogen loss also breaks down more muscle and bone, increasing protein needs. If the diet falls short, overall intake may rise to compensate.
Rising FSH may independently affect fat storage and energy use.
Hypothyroidism, which some women develop, further reduces calories burned.
Psychological and emotional factors
Low mood, anxiety and stress can drive emotional eating. Body image changes can create a cycle in which low mood drives eating, and weight change then affects mood further.
Persistent low mood, loss of interest or sadness lasting several weeks is worth discussing with a doctor.
Menopausal weight gain is not a matter of willpower or personal failing. It reflects several overlapping changes.
HRT
Hormone Replacement Therapy
‘The Dilemma’
The Journey
From puberty till menopause, ovaries secret three main hormones e.g., Oestrogen, Progesterone and Androgen. It is the oestrogen deficiency that is responsible for most of the menopause symptoms.
What is HRT?
HRT stands for Hormone Replacement Therapy. It refers to the process of replenishing the diminishing ovarian hormones at or around the commencement of menopause. Women sometimes require the use of HRT earlier in life in cases where early or surgical menopause occurs. Early menopause is the cessation of periods (ovarian function) before the age of 40. Surgical menopause occurs when both ovaries are removed before the usual age of the menopause.
HRT Benefits
HRT is more crucial than ever as we see women's life expectancy increasing year after year with research showing that women are commencing the use of HRT within 10 years of menopause. HRT is considered by many experts as the most effective way of managing the symptoms of menopause. Many women experience long-term health benefits which includes a reduction in the risk of osteoporosis, fractures, and heart disease.
Which Hormones do women need?
Oestrogen given alone, can restore the premenopausal balance and reduces your menopause symptoms. However oestrogen alone will increase the risk of uterine cancer. Unless the woman has had her uterus removed (by hysterectomy), progesterone needs to be given with oestrogen to reduce the risk of uterine cancer. Progesterone can be given in the form of oral tablets, patches or in the form of intrauterine device e.g., Mirena coil.
Androgen (Testosterone) can be added if there is a loss of libido.
HRT For Women with a womb
This group of women can be given HRT in two ways:
1. Combined HRT (oestrogen and progesterone). This can be given in two ways:
a. Sequential HRT. A usual 28 tablets packet contains 14 tablets of Oestrogen followed by 14 tablets of Oestrogen & Progesterone. HRT taken ithis way results in a monthly bleed. This kind of HRT is more appealing for women who still have their periods but suffer from menopause symptoms.
b. Continuous. A usual packet contains 28 tablets of both Oestrogen & Progesterone , taken daily without a break. Both hormones can be taken also as skin patches. This approach results in no bleeding. Continuous combined HRT is usually more suitable for women who are postmenopausal and have had no period for a year or more.
2. Oestrogen-only HRT. This HRT contains oestrogen alone. This is more suitable for women who had hysterectomy or have a Mirena coil inserted.
HRT For Women after hysterectomy
These women can be divided into two groups:
Women who had Total hysterectomy (Uterus and cervix removed):
This group can safely take Oestrogen-only HRT, as there is no risk of developing uterine cancer.
Women who have had a subtotal hysterectomy (the cervix was not removed):
This procedure might not remove all the endometrium (Cells lining the womb). These cells can develop uterine cancer if stimulated by oestrogen only HRT. This group of women should ideally be treated as they are still having their womb and use continuous combined HRT as explained above.
Testosterone
The male hormone testosterone plays an important physiological role in female reproductive tissues, mood, cognition, breasts, bones, muscles, vasculature, and some other systems in women. Currently, the only evidenced-based indication for testosterone therapy in women is for treating low sex drive in women.
If needed, transdermal preparations (Cream, gel or Patches) are preferred. Continuation of treatment should be based on clinical response rather than blood tests, as hormone levels do not usually correlate with symptoms.
Post-menopausal bleeding (PMB)
Post-menopausal bleeding (PMB)
Post-menopausal bleeding (PMB) is defined as unscheduled vaginal bleeding that occurs a year after the last natural menstrual period or any breakthrough bleeding on cyclical HRT or breakthrough bleeding after 6 months on continuous combined therapy when there has been established amenorrhoea. Women using sequential/cyclical HRT are expected to have regular bleed.
Bleeding with HRT
Abnormal bleeding while on HRT is a relatively common problem. Literature reveals that 38% of women using sequential HRT and 41% of women on continuous combined HRT (CCT) report abnormal bleeding. The risk of cancer is usually less when using the continuous combined therapy HRT than when using sequential therapy or not using HRT.
What should I do if I have PMB
PMB is most frequently caused by benign gynaecological conditions, such as vaginal or endometrial atrophy secondary to oestrogen deficiency, endometrial or cervical polyps, uterine prolapse, use of vaginal rings and endometritis. Risk of endometrial cancer increases with diabetes, obesity, oestrogen only HRT, tamoxifen use for breast cancer treatment, nulliparity and some familial cancers. The possibility of a woman with PMB to have cancer is only 9%.
Women with PMB needs an urgent assessment. Other gynaecological cancers should be considered in the differential diagnosis such as vulval, vaginal and cervical cancers. Other non-gynaecological diseases such as urinary or gastrointestinal can also give rise similar bleeding that might be interpreted as vaginal.
Assessment for PMB starts with a detailed history and physical general and pelvic examination. Timely evaluation of the lower genital tract and endometrium, with ultrasound, endometrial sampling and possibly hysteroscopy are all needed to establish a diagnoses and start treatment.