The menopause is the stage in a biological woman’s life when her ovaries stop releasing eggs and she has no more periods. Technically, the reproductive life cycle of a woman (when she can get pregnant) begins with puberty and the start of periods, continues through her adult years, until the ovaries start to fail to produce eggs (ovulate) regularly, and finishes 12 months after her final period.

This article was included in issue 103 (Winter 2024-25) of The Menopause Exchange newsletter. 

Hormone fluctuations
Most women will notice some hormonal fluctuations in their early 40s. These can mimic the start of the menopause, but with regular periods and normal hormone levels when checked with a blood test. Symptoms then usually settle down until the late 40s when the hormone that stimulates the ovaries to produce an egg (FSH) begins to fluctuate. Initially, periods may become a little irregular, but then gaps of at least 60 days can occur between bleeds, and the FSH level can range from low/normal to high/abnormal. There is little correlation between the number of symptoms and the FSH level at this stage, which is why routine blood tests aren’t recommended. Symptoms are felt to be a more accurate way of diagnosing what we call the ‘perimenopause’, or the time leading up to the menopause.

Perimenopause
The perimenopause can be a variable time, with hot flushes, night sweats, mood swings, fatigue and brain fog being just a few of the most common symptoms, as well as increasingly heavy periods for some women. It’s important to remember that even if the ovaries are failing, it’s still possible for women to get pregnant at this time so contraception must be used if pregnancy is possible. HRT isn’t a contraceptive, unless a hormonal coil such as Mirena is being used as the progesterone part of the HRT. Women who have had a hysterectomy or sterilisation procedure that left the ovaries intact will still have perimenopausal symptoms, commonly at the time of their expected natural menopause.

The length of the perimenopause can vary, but the average age for symptoms to start is currently around 47. The early perimenopause, with relatively normal periods, can last for a number of years, but the late perimenopause, with longer and longer gaps between periods usually lasts for one to three years. However, these are only rough guidelines, as every woman is different and factors such as an early puberty (when periods first start), history of breastfeeding, having had children, being a small baby oneself or family history of early menopause (between the age of 40 to 45) can affect the duration of symptoms before the menopause.

Menopause
After a woman has had no periods for a year, following typical symptoms of the perimenopause, she is said to have gone through the ‘menopause’. This essentially means that her ovaries have run out of eggs and she can no longer get pregnant. However, it’s advised that women use contraception for a further two years if their menopause is before the age of 50 or a further one year if it’s after the age of 50. This is because there is an outside chance that they could spontaneously ovulate, resulting in a pregnancy, although this is extremely rare in practice. The Faculty of Sexual and Reproductive Health advise that all hormonal contraception can be discontinued by the age of 55 (UK guidelines), whether a natural menopause has been reached or not.

Hot flushes and night sweats are usually at their worst in the first year of the menopause, but are said to settle after one to three years. However, they can persist for an average of seven years, with some women experiencing symptoms well into their 60s.

There are a number of ways of dealing with the mental and physical symptoms of the menopause, including HRT, exercise, maintaining a normal BMI, not smoking, and cognitive behavioural therapy. GP surgeries and specialist NHS clinics can give advice and support at what can be a challenging time in a woman’s life. Often, reassurance about what is normal (or not normal) is all that’s needed. If more help is necessary, there are many GPs and nurses with specialist knowledge of the menopause, with access to consultant-run hospital clinics for advice/referral.

Postmenopause
The ’postmenopause’ would be considered to be any time after the first 12 months from the last period. This can be a positive time for women, who no longer have to worry about an unplanned pregnancy or anaemia due to heavy periods. For others, it’s a time of loss if they haven’t been able to have the family that they wanted.

Just as every woman experiences periods in a different way due to different personal hormone levels, each woman will also have a different approach to the end of their reproductive life stage. Some women experience a drop in libido (sex drive). There’s currently no good evidence to show why this is, as testosterone levels often stay the same throughout a woman’s life. It was originally thought that low testosterone levels were a cause. This now doesn’t appear to be the case, and fresh research is being carried out to see if testosterone replacement (as a gel on the skin) for women is or isn’t effective/safe. Oestrogen cream used vaginally, or vaginal pessaries, can replace natural oestrogen lost after the menopause and prevent vaginal dryness. This, in turn, can help with a more satisfying sex life and prevent urine infections, which are more common after the menopause due to loss of the natural anti-bacterial action of normal vaginal discharge.

The menopause is a definite time of change in a woman’s life, but help and guidance is available much more now than in the past. There IS life after the menopause, and a good one!

About the author
Dr Jeni Worden is a GP in Christchurch, Dorset, with a special interest in women’s health, especially issues relating to the menopause and contraception.

Created Winter 2024-25
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