Menopause symptoms and hormone therapy: benefits and risks

Menopause is a natural stage of life, not a disease. But for many women in India the symptoms are real, disruptive and quietly endured, often without anyone explaining the options. Hormone therapy has also had a confusing history, with fears from studies in the early 2000s that later analyses have put in clearer context.

What is menopause, and when does it happen?

Menopause is the last menstrual period. It is confirmed once you have gone 12 months without a period, without another cause. Worldwide the average age is around 51, and some Indian studies suggest it often comes a few years earlier in Indian women. The years leading up to it, when periods become irregular and symptoms start, are called perimenopause.

Menopause before 40 is called premature ovarian insufficiency, and between 40 and 45 is called early menopause. Both need medical review, because the lack of oestrogen at a young age affects bones and the heart. Read irregular periods: which hormone tests are needed.

What symptoms are common?

• hot flushes and night sweats (vasomotor symptoms)
• poor sleep and tiredness
• mood swings, irritability, anxiety or low mood, and poor concentration
• vaginal dryness, discomfort during sex, and urinary urgency or repeated infections
• joint aches
• lower interest in sex
• weight gain around the waist

Some symptoms overlap with thyroid problems, anaemia or depression, so your doctor may check these too. Read why thyroid tests can be normal with symptoms.

Longer term, falling oestrogen speeds up bone loss, raising the risk of osteoporosis and fractures, and the risk of heart disease rises after menopause. Read how cholesterol leads to a heart attack.

What is hormone therapy?

Menopausal hormone therapy (MHT), often called HRT, replaces some of the oestrogen the ovaries no longer make.

• Women who still have a womb (uterus) need oestrogen plus a progestogen, which protects the womb lining from thickening and cancer.
• Women who have had a hysterectomy can usually take oestrogen alone.
• Oestrogen can be given as tablets, or through the skin as gels or patches. Through-the-skin forms appear to carry a lower risk of blood clots.
• Vaginal oestrogen creams or tablets treat dryness and urinary symptoms with very little absorption into the body.

Your doctor will choose the type, form and duration that suits you. This page does not cover specific regimens.

What are the benefits?

• Hormone therapy is the most effective treatment for hot flushes and night sweats, and often improves sleep and mood linked to them.
• It treats vaginal dryness and related urinary symptoms.
• It prevents bone loss and lowers fracture risk while it is taken.
• For women with premature ovarian insufficiency or early menopause, guidelines advise hormone therapy at least until the usual age of menopause, unless there is a reason not to, to protect bones and the heart.

What are the risks?

The size of the risk depends on your age, how long since menopause, your health, and the type of hormone.

• Blood clots (venous thromboembolism) and stroke: a small increase with oral oestrogen, which is lower with skin forms.
• Breast cancer: combined oestrogen-progestogen therapy is linked to a small increase in risk, which rises with longer use. Oestrogen alone, in women without a womb, carries little or no increase in breast cancer risk in major studies.
• Heart disease: starting hormone therapy many years after menopause, especially after 60, may increase heart risk. Starting it closer to menopause does not appear to have this effect in most healthy women.
• Gallbladder disease is somewhat more common.

The North American Menopause Society’s 2022 statement concludes that for healthy women under 60, or within 10 years of menopause, with bothersome symptoms and no reasons to avoid it, the benefits of hormone therapy generally outweigh the risks. For women starting later, the balance is less favourable.

Who should not use hormone therapy?

Hormone therapy is usually avoided, or needs specialist advice, if you have:

• had breast cancer or endometrial cancer
• had a blood clot, stroke or heart attack
• active liver disease
• unexplained vaginal bleeding
• a high risk of these conditions

What are the non-hormonal options?

• lifestyle measures: layered cotton clothing, a cool bedroom, regular exercise, limiting alcohol, caffeine and spicy food if they trigger flushes, and stopping smoking
• cognitive behavioural therapy, which has evidence for hot flushes and sleep
• some non-hormonal prescription medicines, including certain antidepressants and other drugs, which your doctor may discuss. Newer medicines approved in other countries may not yet be available in India.
• vaginal moisturisers and lubricants for dryness

Be cautious with “natural” or herbal menopause products. Their benefits are often unproven, and some contain plant oestrogens or interact with other medicines.

How long can hormone therapy be continued?

There is no fixed cut-off. Many women use it for a few years, while others continue longer when benefits still outweigh risks. Your doctor will review the decision with you at least once a year.

What should I ask my doctor?

• Are my symptoms due to menopause, or could something else be contributing?
• Am I a suitable candidate for hormone therapy, and which form is safest for me?
• How should my bones and heart health be checked?
• What non-hormonal options suit me?

To discuss your symptoms, book a consultation.