Frequently Asked Questions
Menopause can present with a wide variety of symptoms, including anxiety, hot flushes, night sweats, vaginal irritation, recurrent UTIs, low mood, irritability and joint pains. Some people have only one or two symptoms, but these can still be debilitating. Symptoms can sometimes start up to 10 years before a woman stops menstruating.
As hormones can fluctuate wildly during perimenopause, blood tests are often not useful and treatment can be started based on symptoms alone. Blood tests may be used to determine if a woman is in early menopause, to confirm menopause if a woman still needs contraception, and to monitor treatment.
To assess your own symptoms, I highly recommend downloading Dr Louise Newson's free balance app
You can log your symptoms and print out a free health report that you can bring in to discuss at your consultation. The app also has a wealth of resources and information.
Or if you would prefer, use this downloadable PDF
The most common symptoms of menopause are:
Brain fog
Anxiety
Low libido
Memory problems
Sleep problems
Fatigue/ low energy
Hot flushes
Weight gain
Headaches
Low motivation
Night sweats
Irritability
Difficulty concentrating
Mood swings
Feeling tense
Lack of interest in things
Increased urinary tract infections
Joint aches and pains
Other symptoms include:
Itchy dry skin
Tinnitus
Dry eyes and mouth
Burning mouth
Gum soreness
Joint swelling
Shortness of breath
Irritable bowel syndrome
Heartburn
Restless legs
Other psychological symptoms that can be experienced include:
Panic attacks
Feeling low
Reduced self esteem/ confidence/ 'imposter syndrome'
Frustration
Tearful
Difficulty coping
Mood swings
Can increase addictive behaviours
Increased ADHD symptoms
Increase in eating disorders
Hormones are chemical messengers, letting the body know what to do and when. They travel throughout your body where they bind to receptors (like a key in a lock) and control a wide range of bodily functions, including growth and development, metabolism, mood, sleep, appetite and reproductive processes. Glands around our bodies produce a variety of hormones, with our ovaries producing most of our oestrogen, progesterone, and testosterone.
Oestrogen:
In girls, oestogen starts being produced in puberty, typically around 8-13 years old. Oestrogen is essential for many different body processes. Menstrual cycle regulation, reproductive health support, the development of secondary sexual characteristics (e.g. breast growth, body fat distribution), bone density, and mood regulation are some of its major roles. Oestrogen also affects the skin and hair in addition to being connected to cardiovascular health.
Crucially, immune cells also carry oestrogen receptors, which help to reduce inflammation in our bodies. With ageing comes more inflammation in the body, driven in part by a lack of oestrogen after menopause, a process known as 'inflammageing'. This can result in a number of long term health risks.
Progesterone:
Progesterone is produced mainly in the second half of the menstrual cycle and helps maintain and control the thickness of the lining of the womb (endometrium), balancing the effect of oestrogen.
Additionally, progesterone helps to boost our mood, is calming, helps reduce anxiety and promotes sleep.
Women who are sensitive to low progesterone in the second half of the cycle may be more prone to PMS and PMDD (premenstrual dysphoric disorder), and may suffer from hormonal migraines before their periods.
Testosterone is important for both men and women.
A little known fact is that before menopause, women have 3 x the amount of biologically active testosterone in their bodies compared to oestrogen!
Testosterone helps with libido, increases bone and muscle strength, reduces brain fog, improves memory and promotes overall vitality and wellbeing.
Low testosterone symptoms include:
Hypoactive sexual desire dysfunction (HSDD)/ loss of sex drive
UTIs and incontinence
Muscle and joint aches
Hot flushes
Muscle loss
Changes in cognition
Memory loss
Insomnia
Bone loss
Physical fatigue
Lack of wellbeing
Low mood
Testosterone can be replaced safely in women with a cream (Androfeme). Blood levels are monitored before and after starting replacement to ensure the correct dosage is given. It may take 3-6 months to notice any improvement when taking testosterone.
Dr Louise Newson Podcast Ep 250: Testosterone: The missing piece of the jigaw?
Dr Louise Newson Podcast Ep 116: Testosterone: The forgotton hormone
Dr Louise Newson: Testosterone booklet
As oestrogen is a natural anti -inflammatory, the lack of this hormone after menopause increases 'inflammaging' in our bodies. As hormone production of oestrogen, progesterone and testosterone decline, women face an increased risk of developing a variety of chronic conditions over time, including:
Cardiovascular disease
Dementia
Osteoporosis
Osteoarthritis
Sacropenia (muscle loss)
Rheumatoid arthritis
Autoimmune disease
Inflammatory bowel disease
Type 2 DM
Obesity
Parkinsons
Depression
Schizophrenia
Cancer
Increased Covid severity
Earlier death
Menopause is best treated holistically as part of a healthy lifestyle.
As part of shared care decision making, women should be given all the available choices and then decide which option is best for them. This could include HRT, alternative therapies or no treatment at all.
The most effective treatment for menopause is hormone replacement therapy (HRT), also known as menopause hormone treatment (MHT). Nothing else works as well to address the underlying cause of hormone deficiency, treat symptoms and maintain our future health.
We now prescribe natural body-identical hormones. 17-betaestradiol is the main type of oestrogen we produce when we are younger. Both oestradiol and micronised-progesterone are plant based and are derived from wild yam plants.
Some women also benefit from the addition of testosterone, especially for symptoms such as low libido, memory issues and brain fog.
Studies have shown that by using body identical estradiol through the skin (transdermal route) via a gel or a patch, it does not pass through the liver and therefore does not increase the risk of blood clots. This makes it is safe to take by women with a history of DVT, blood clots, stroke and migraines.
Micronised- progesterone is usually taken orally, is well absorbed due to its tiny particle size and has not been found to increase our breast cancer risk.
You might still feel that HRT is not for you, and that’s absolutely fine. Remember, it's your choice and any decision you make can be changed in the future.
Although evidence is lacking to support supplements and herbs, some women will still try these to help manage their symptoms. Other alternative treatment options are CBT, acupuncture.
There are also non hormonal medications, such as anti depressants, and the new drug fezolinetant, that are used for symptoms such as hot flushes and night sweats. Unfortunately, many of these medications come with unwelcome side effects and in the case of fezolinetant, do not have enough long term studies to ensure their safety.
In addition to treating menopausal symptoms, HRT also helps to reduce the risk of long term health issues such as osteoporosis, cardiovascular disease, depression, bowel cancer and type 2 diabetes. The small risks of HRT are generally far outweighed by the benefits.
HRT can help manage many symptoms, including:
- Anxiety/ irritability
- Vaginal dryness and bladder irritation
- Joint aches and pains
- Skin and hair texture changes
- Sleep and mood disturbances
- Hot flushes and night sweats
- Low libido
- Brain fog/ memory issues
When starting HRT, it is important to remember that it may take several weeks or months for the positive benefits to be felt. As your body needs time to adjust to any new medication, you may experience some temporary side effects.
Common side effects include:
Bleeding
Breast tenderness
Feeling bloated
Headaches
Low mood
Lower abdomimal/ pelvic discomfort
These symptoms should settle within the first few weeks, but can occasionally last for a few months. If symptoms persist, the dose or type of HRT may need to adjusted. If you have prolonged or heavy bleeding, discuss this with your doctor.
In terms of risks, synthetic oestrogen and progestins can slightly increase the risk of breast cancer and blood clots. As we now prefer newer, body-identical HRT, given through the skin (transdermal route), this risk is reduced further.
If you still have a uterus, there is a risk of endometrial hyperplasia (thickening of the lining of the uterus) if oestrogen is given without a progestin/ progesterone.
Getting the truth around HRT and Breast Cancer with Dr Avrum Bluming
Body-identical HRT is now available: Oestradiol or oestrogen comes as a tablet, gel, patch and cream. Using oestrogen through the skin negates the risk of blood clots as it does not pass through the liver.
Micronised progesterone is body identical progesterone- it's easily absorbed, helps protect the womb and assists with sleep.
Body identical HRT has not been shown to increase the risk of breast cancer or blood clots.
Compounded HRT is not regulated and not recommended as there can be inconsistencies in dosage, purity, and quality control. They are often more expensive than commercially available HRT.
Synthetic (man-made) oestrogen and progestogins can slightly increase the risk of blood clots and breast cancer, especially when taken orally.
HRT should ideally be started as close to menopause as possible to maximise the benefits, but there is no age limit to starting HRT.
There are no absolute contraindication to HRT. Even if a woman has had breast cancer, if she decides the benefits greater than the risks for her, she should not be denied HRT.
Topical vaginal oestrogen (pessary or cream) helps with vaginal dryness, thinning, UTIs, discomfort and irritation. It acts locally with no systemic effects. It may take up to 6 weeks to feel the effects.
HRT is not a contraceptive. If a woman is still having periods, she will need additional contraception. The Mirena IUD is particularly useful around menopause.
HRT is safe to use life long.
For the majority of women, the benefits of HRT far outweigh the risks.
(Thanks to Dr Ceri Cashell for this summary )
In most cases, it is menopause itself that causes weight gain. Transdermal oestrogen and micronised progesterone do not appear to increase weight, and in fact, many women find it easier to lose weight on HRT.
In comparison to women in their teens and 20s, we need 200 calories less per day as we head into menopause, so it is easy to ingest more calories than we need.
Article: Help- I'm heading for menopause and can't control my weight! - Dr Sally Norton
Body identical hormones are highly regulated by the TGA and thoroughly tested. They are derived from the yam plant and have the same molecular structure as the hormones naturally produced by our bodies. They are the only type of HRT recommended by the Australian Menopause Society guidelines.
Compounded 'bioidentical' hormones are custom made by compounding pharmacies and do not follow the same stringent regulations, are not subject to any quality controls, are more expensive and can be unpredictable in their effects. Topical progesterone has been found to be poorly absorbed and is not recommended.
HRT is the most effective treatment for symptoms resulting from menopausal hormonal changes.
However, if you cannot take HRT or would prefer not to, there are alternatives that can be tried.
1. Lifestyle Changes
Diet and Nutrition:
Phytoestrogens: Consuming foods high in phytoestrogens, like soy, flaxseed, dried fruit and berries may help some women.
Balanced Diet: A diet rich in fruits, vegetables, lean proteins, and whole grains can support overall health and potentially ease symptoms.
Hydration: Drinking plenty of water can help reduce headaches, decrease dryness and improve cognition.
Reducing caffeine and alcohol may also help sleep and help reduce hot flushes and night sweats.
Exercise:
Regular physical activity, including aerobic exercise and strength training, can help reduce symptoms like hot flushes and improve mood, sleep, and overall well-being.
Stress Management:
Techniques like mindfulness, yoga, and meditation can help manage stress, which may exacerbate menopausal symptoms. Meditation apps like Headspace and Calm may be useful.
Sleep Hygiene:
Improving sleep hygiene can help manage insomnia and night sweats. This includes keeping a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulants especially before bedtime.
2. Non-Hormonal Medications
Antidepressants:
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been found to help reduce hot flashes and improve mood.
Gabapentin:
An anticonvulsant that can also reduce hot flashes, especially if they occur at night.
Clonidine:
A medication used to treat high blood pressure that can also reduce the frequency and severity of hot flashes.
Fexolinitant:
A medication that reduced hot flushes and night sweats by affecting the receptors that control body temperature.
3. Topical Treatments
Vaginal Moisturisers and Lubricants: These can help relieve vaginal dryness and discomfort. Try to use natural/ organic products if possible to help reduce disruption of the vaginal microbiome.
Recommended brands of moisturisers include: Yes VM, Olive and Bee intimate cream
Recommended lubricants include: Yes, Sutil, Uberlube, The Department of Bed Intentions
Vaginal Oestrogen: Although it’s a hormone, vaginal oestrogen such as Ovestin or Vagifem only acts locally and can help to improve vaginal dryness, discomfort, pain during sex and reduce UTIs. It is used nightly for 2 weeks, then 2-3 times a week ongoing.
Vaginal DHEA (Intrarosa):
This pessary is used nightly and converts locally to oestrogen and testosterone. This can help with symptoms of vaginal dryness, bladder symptoms, painful sex and UTIs.
4. Complementary Therapies
Herbal Supplements: Black cohosh, red clover, and evening primrose oil are popular, though their effectiveness varies and more research is needed.
Acupuncture:
Some women find relief from hot flashes and other symptoms with acupuncture.
Cognitive Behavioral Therapy (CBT): CBT can help manage mood swings, anxiety, and depression associated with menopause. CBT-I is specific for insomnia and This Way Up is a free online program: https://thiswayup.org.au/programs/insomnia-program/
Vitamin and Mineral Supplements: Calcium and Vitamin D supplements are important for bone health.
Vitamin C is a powerful antioxidant and may help with brain function and reduce hot flushes.
Normal levels of iron and Vitamin B12 are needed to prevent anaemia and help energy levels and brain health.
Magnesium can help with sleep and prevent muscle cramps.
Omega-3 fatty acids are anti-inflammatory and help support cardiac health and brain function.
If you have been on HRT for a few years and are wondering if you should stop taking it as you get older, the good news is that you can take HRT for as long as you like. As long as the benefits outweigh the risks (which is the case in the majority of women), HRT is safe to be taken for the rest of your life. To maximise the benefits of HRT in terms of reducing long term health risks, HRT should ideally be started within the first 10 years of menopause.
Some women may want to start/ restart HRT later in life. Research is limited in older women starting HRT, but there does appear to still be some cardiovascular benefit even if HRT is started 10 years or more after menopause. If a woman is otherwise healthy, women can decide to start (or restart) HRT at any time. This may because of ongoing menopausal symptoms, or to reduce risks of chronic conditions associated with low hormone levels after menopause.
Dr Louise Newson Podcast Ep 032: Taking HRT forever
The video below is a great starting point. Premature menopause has it's own set of challenges and it is important to get a diagnosis early in order to prevent long term health risks, treat symptoms and discuss options regarding fertility/ contraception.
Dr Louise Newson - What you need to know about POI
The Resources section of this website has a number of books, podcasts and websites which have comprehensive information about menopause.
Dr Louise Newson
Dr Kelly Casperson
Dr Mary Claire Haver
Dr Vonda Wright
Stacy Simms
Talk to your GP or find a health professional with a special interest in menopause.
Batur P, Blixen CE, Moore HCF, Thacker HL, Xu M. (2006). Menopausal hormone therapy (HT) in patients with breast cancer. Maturitas 53 (2006) 123–132. (Full text).
Bluming A. (2022). Hormone replacement therapy after breast cancer: It is time. Cancer J 28(3):p 183-190. (Full text).
Cold S, Cold F, Jensen M-B, et al. (2022). Systemic or vaginal hormone therapy after early breast cancer: A Danish observational cohort study. J Natl Cancer Inst 114(10):1347-1354. (Full text).
Davis SR, Pinkerton J, Santoro N, et al. (2023). Menopause—Biology, consequences, supportive care, and therapeutic options. Cell Sept. 5. (Full text).
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Hodis HN, Mack WJ. (2022). Menopausal hormone replacement therapy and reduction of all-cause mortality and cardiovascular disease: It is about time and timing. Cancer J 28(3):208-223. (Full text).
Glaser R, Dimitrakakis C. (2013). Testosterone therapy in women: Myths and misconceptions. Maturitas 74(3):230-234. (Full text).
Laing AJ, Newson L, Simon JA. (2022) Individual benefits and risks of intravaginal estrogen and systemic testosterone in the management of women in the menopause, with a discussion of any associated risks for cancer development. Cancer J 28(3):p 196-203. (Abstract)
North American Menopause Society (2022). The 2022 hormone therapy position statement of The North American Menopause Society. (Free text).
Panay N, Fenton A. (2009) The role of testosterone in women. Climacteric 12:3,185 — 187. (Editorial)
Stuursma A, Lanjouw L, Idema DM et al. (2022). Surgical menopause and bilateral oophorectomy: Effect of estrogen-progesterone and testosterone replacement therapy on psychological well-being and sexual functioning; A systematic literature review. J Sexual Med 19(12) 1778-1789. (Free text).
Vinogradova Y, Coupland C, Hippisley-Cox J. (2019). Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 364: k4810. (Full text).
Menopause and MHT in 2024: addressing the key controversies – an International Menopause Society White Paper (Full text)
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