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Guide To The Menopause

Our complete guide to the menopause aims to help women of all ages understand this natural part of life.

Mature friends women laughing together

Menopause is a natural part of life and is a gradual biological process that women have been experiencing over many years.  However, in today’s modern world where we have a longer life expectancy, women are spending more of their life in post-menopause.

Therefore, it is important that women are informed about the menopause, the potential long-term health issues caused by changes in hormone levels, and the options available to help manage menopause symptoms and maintain quality of life post-menopause.

That’s why we’ve written this guide, to help women gain a better understanding of the changes taking place in their bodies – from perimenopause to post-menopause.

We are also thrilled to hear that menopause will be added to the school curriculum in England from September 2020. Helping a new generation of women gain a better understanding of their bodies.

Download this guide as a PDF.

What This Guide Contains

The Facts About The Menopause

According to a study by Nuffield Health Group[1] women going through the menopause are not getting the support they need with diagnosis and/or treatment.  This is resulting in 1 in 4 women saying they are struggling to cope with life due to symptoms of the menopause. According to the survey:

  • 45% of women failed to recognise they could be experiencing menopause symptoms
  • 42% thought they were too young to be experiencing menopausal symptoms, putting it down to stress
  • 67% of women felt there was little help and support for those going through the menopause
  • 38% of women went to their GP for help
  • 25% who visited their GP said the possibility of the symptoms being related to the menopause wasn’t mentioned


In our own study into menopause in the workplace, we found:

  • 63% of women said their working life had been negatively affected in some way by their symptoms
  • 29% had significantly lost self-confidence
  • Only 6% of the whole sample group said that they did not experience any menopause symptoms at work

 

Infographic on the problems menopausal women face at work

Women are clearly struggling with the menopause and it’s a topic that is only just being given more attention. 

Every woman is different, and her experience of the menopause will be unique to her, so it’s important to understand the changes that are taking place.

“Treat women as individuals, not statistics”, Vice President Royal College of Obstetrics and Gynaecologists, BMJ Editorial 2019

This guide aims to help women who are - or think they are - experiencing the menopause to make them feel more informed and in control of the changes they are experiencing.

Understanding the Menopause

What is Menopause?

The Menopause is the term used to describe the phase in a woman’s life where the ovaries become unresponsive and oestrogen and progesterone levels decline. Menopause is the point in time when ovulation stops, usually defined when a woman has not had a period for 12 months.

What is Perimenopause?

The perimenopause is the term used to describe the transition phase to menopause.  During the perimenopause the ovaries become less responsive, producing decreasing levels of oestrogen and progesterone and increasing levels of the control hormones FSH and LH - with some fluctuations in levels along the way. It is these fluctuations in hormone levels that cause the symptoms that many women experience, including increasing irregularity of ovulation and periods.

What Is Post-Menopause?

Post-menopause is the term used to describe the time period after the menopause when menstruation has ceased.

How Do Hormone Levels Change During the Menopause?

The chart below shows how a woman’s hormones fluctuate during the menopause.  As a woman transitions through the perimenopause phase to menopause, the ovaries produce less oestrogen and progesterone. The ovaries become less responsive to the control hormones released by the pituitary gland in the brain - Follicle stimulating hormone (FSH) and Luteinising hormone (LH) -  resulting in higher levels of these control hormones.

 

menopause hormone levels chart

 

FSH levels in women rise and fall throughout their menstrual cycle but will start to increase as women transition through the perimenopause phase and to menopause.

LH levels also rise around the time of the menopause, highlighting the reduced function of the ovaries with a reduction in oestrogen and progesterone production.

With so many changes taking place in a woman’s body due to fluctuating hormone levels, there are physical as well as mental symptoms experienced to varying degrees by women during the perimenopause phase.

“From the start of periods up to menopause, the control and response hormones of the menstrual cycle work in finely tuned fluctuations. The perimenopause sees a disconnect between control and response hormones. As hormones have actions throughout the body, this explains why these hormonal changes have physical and mental effects”, Dr Nicky Keay, Forth Chief Medical Officer, BA, MA (Cantab), MB, BChir, MRCP.

How to Check Your Hormone Levels

Perimenopause

It can be hard to know what is going on in your body during the transition to menopause and the physical and mental symptoms caused by the perimenopause can leave women feeling confused and no longer able to cope with certain, everyday situations. 

Generally, perimenopause is diagnosed based on symptoms and once all other possibilities have been excluded.

Another way to establish whether the symptoms are related to hormone changes is with a blood test to track your changing hormone levels over time. 

During the transition to menopause three key hormones - FSH, LH and oestrogen - will begin to change. FSH and LH will start to rise whilst oestrogen levels will start to fall.

A menopause blood test can be taken at home and measures these three key hormones, as well as other biomarkers key to long term health. Understanding how your hormones levels are changing over time will help confirm whether your symptoms are due to a change in hormones levels.

Once you have had your symptoms diagnosed as perimenopause and understand how your hormone levels are changing over time, you will be able to make any necessary lifestyle changes and decide which treatments are best for you.

“Blood test results, in the clinical context of any symptoms, can be helpful in confirming if these symptoms could be due to menopause and informative in excluding medical conditions that might be the cause.” Dr Nicky Keay, Forth Chief Medical Officer

Menopause

While transitioning to menopause or once a woman is post-menopausal, there are a number of health conditions that women will be more at risk of developing.  These include osteoporosis and cardiovascular disease.

Oestrogen, along with calcium, vitamin D, magnesium and albumin play key roles in bone health, so it’s important to track these as you transition through the menopause.

In addition, the way the body stores and processes fat such as cholesterol and triglycerides changes as you go through the menopause.  There are also changes in the reactivity of arterial blood vessels. These changes put women at an increased risk of developing cardiovascular disease.

It is important that women not only understand the hormone changes taking place but the changes in the levels of key vitamins and fats, such as cholesterol, within their body. 

The menopause blood test also measures key biomarkers such as vitamin D, calcium, albumin, cholesterol, and triglycerides. 

Understanding your normal levels will help you make any necessary lifestyle changes as you go through the menopause.  This will help reduce the risk of developing cardiovascular disease and osteoporosis as you get older.

What Age Do You Go Through the Menopause?

Women’s hormones begin to fluctuate as they reach their 30s and beyond. The average age of a woman to start to experience the symptoms of the perimenopause is between the ages of 40 and 50.

Late 30s

Women’s ovaries make less oestrogen and progesterone which are the hormones associated with ovulation and the menstrual cycle, as a result fertility declines.

40s

Most women begin to experience the perimenopause in their 40s - although it can start in the early 50s. During this time women’s periods may become longer or shorter, heavier, or lighter, and more or less frequent.

The age at which a woman experiences the perimenopause is largely determined by her genes, though some environmental and lifestyle factors can play a part.

50s

Periods will continue to be irregular until a woman reaches her early 50s when the ovaries stop producing eggs and the woman has no more periods – this phase is known as the menopause.

Group of Women Happiness Cheerful

What is Early Menopause?

Women naturally experience reduced fertility from 40 years of age. Early menopause - also known as premature ovarian insufficiency - is when periods stop before the age of 45.  Approximately 5 in 100 women experience menopause before the age of 45.

The symptoms of an early menopause are the same as the menopause.  Women who start the menopause early are at risk of developing diseases such as osteoporosis and heart disease for a longer period of time due to the drop in oestrogen which offers some protection for women from health issues such as heart disease.

How Long Does the Menopause Last?

The transition phase from perimenopause to menopause can last between 8 and 10 years.

Symptoms of the perimenopause can last for four years on average but can be longer.  On average, symptoms last approximately 4 years from your last period but 10% of women may experience symptoms for up to 12 years after menopause.

symptoms experienced through the menopause

What Are the Symptoms of the Menopause?

The menopause brings about a host of physical and psychological symptoms for women. Each woman has her own journey as she transitions through to menopause and the symptoms experienced can differ. Some women may experience severe symptoms, whilst for others, life isn’t disrupted as much.

Menopause Symptoms

Although it’s common to refer to menopause symptoms, it’s actually the transition phase called the perimenopause that causes the majority of symptoms women experience.

In our study into menopause in the workplace, we found that:

  • 73% of women reported having hot flushes
  • 63% said they regularly felt tired or drowsy
  • 48% suffered from low mood
  • 47% struggled to concentrate
  • 43% had trouble with their memory
  • 34% of women said that they had developed depression and anxiety

 

Menopause symptoms at work


The most common menopause symptoms (or more accurately perimenopause symptoms) are:

  • Irregular periods
  • Hot flushes & night sweats
  • Trouble sleeping
  • Vaginal dryness
  • Reduced sex drive (low libido)
  • Mood swings


But there are also other symptoms that many women may not realise are associated with the menopause, these include:

  • Memory lapses, trouble concentrating and ‘brain fog’
  • Anxiety and depression
  • Fatigue and tiredness
  • Headaches, vertigo and dizzy spells
  • Breast soreness
  • Burning mouth and gum problems
  • Joint pain and muscle tension
  • Digestive issues and bloating
  • Hair loss, dry, itchy skin and brittle nails
  • Weight gain


Read more on symptoms and causes

Impact on Long-Term Health

As well as the drop in oestrogen levels, the menopause causes changes to the metabolism and cardiovascular system.  This increases the risk of women developing:

  • Cardiovascular disease
  • Cancer
  • Metabolic diseases
  • Osteoporosis


However, understanding these risks early on, mean women can make lifestyle changes to help improve their health in later life.  Even if you are post-menopausal, there are changes you can make to your diet and lifestyle to ensure you stay fit and healthy.

“With increasing life expectancy, women are spending more time of their life in the menopausal state. So, looking for strategies to enjoy this part of your life is time well spent.”, Dr Nicky Keay, Forth Chief Medical Officer

It is also a good idea to start to research and inform yourself about HRT (hormone replacement therapy). 

How to Cope with Symptoms & Improve Long-Term Health

The best place to start when looking to address perimenopause symptoms is with lifestyle changes related to exercise and diet. 

Making changes to your diet, controlling your weight, and taking more regular exercise can help you stay fit, healthy, and happy during the menopause.

Healthy Fats

One way to do this is by ensuring you have enough healthy fats in your diet, such as Omega 3 found in oily fish, nuts, and avocados.  Healthy fats play an important role in the production of hormones as hormones are produced from fat and cholesterol.  Fats also help your body absorb vitamins such as vitamin D.  You can read more on fats and hormones in this article.

bowl of prawn feta salad

Sugars

Another part of your diet to keep an eye on is the amount of sugar you are eating.  This is because changing oestrogen and progesterone affect insulin levels causing blood sugar level fluctuations.

This not only includes cutting back on cakes, biscuits, chocolates, alcohol, and fizzy drinks, but sugar you add to your diet such as in your tea, coffee, or on your morning cereals.   You also need to watch out for hidden sugars in things such as bread and cereals. 

You don’t have to cut all sugars out of your diet, just ensure you are not eating too much sugar and balance it out with healthy alternatives.  The menopause is bad enough without giving up wine and chocolate!

As well as having a diet that is low in unhealthy fats, sugar and salt, it’s important to eat a balanced diet rich in fruit, vegetables, fibre, whole grains and starchy carbohydrates.  But it’s particularly important during and after the menopause to reduce the risk of developing diseases such as osteoporosis or heart disease in later life.

The vitamins and minerals that are key for menopausal women are listed below:

Vitamin/Mineral Health Benefit Foods Supplement Required?
Vitamin D

Helps maintain strong bones, teeth, and immunity.

Protects again osteoporosis.

Oily fish, red meat, eggs, fortified foods like bread, breakfast cereals and dairy products.

Yes, particularly during the winter months.

The NHS recommends 10 micrograms a day in winter.

Calcium

Helps maintain strong bones and teeth.

Protects against osteoporosis.

Milk, cheese, yoghurt, green leafy vegetables, fish, sesame seeds, fortified foods such as bread and breakfast cereal.

No, you should get enough through your diet.

Avoid eating too much cheese as this is very acidic and can encourage calcium loss from the bones.

Magnesium Magnesium plays a key role in the maintenance of strong bones, blood pressure regulation, muscle contraction and energy production. Whole grains, dark, green leafy vegetables, low-fat milk and yoghurt, breakfast cereals fortified with magnesium, dried beans and legumes, baked beans, soybeans, peanuts almonds and cashews. No, you should get enough through your diet.
Iron

Iron helps produce healthy, functioning red blood cells.

Many menopausal women are low in iron, potentially causing iron deficiency anaemia.

Lean red meat, eggs, leafy greens, nuts, and certain fortified foods.

No, you should get enough through your diet.

Omega 3

Help to maintain a healthy heart and flexible joints.

Oily fish such as mackerel, salmon and herring. Flaxseeds.

No, you should get enough through your diet.

The menopause health blood test measures your levels of vitamin D, calcium, magnesium and iron (ferritin) to help establish if you are deficient in any of these key vitamins and minerals.

Read more about diets tips for menopausal women.

Weight Loss

Weight gain, in particular change in body composition, is an issue for some women during the menopause. Being overweight also increases the risk of developing diabetes and heart disease.  So how can you maintain a healthy weight during the menopause? As we’ve mentioned above, it’s all about maintaining a healthy diet:

  1. Keep blood sugar levels balanced so as not to exacerbate hormone fluctuations
  2. Eat a balanced diet rich in fresh fruit, vegetables
  3. Introduce soya, lentils, chickpeas, flaxseeds, oats, and wholegrain rice into your diet
  4. Eat protein at every meal, such as chicken, turkey, eggs, soya beans, lentils, tofu and oily fish. Not only will it make you feel full for longer, it helps balance out blood sugar levels


You can find out more in our article on Managing and Losing Weight During the Menopause.

Exercise

The types of exercises that are good during the menopause are those that focus on bone and muscle strength, flexibility, and cardio.  Resistance exercise is important to maintain body composition, muscle strength and bone health. Exercise also increases the level of endorphins, helping to reduce stress and make you feel happier.

Older woman lifting hand weights

If you regularly exercise already, it’s important to keep it up as you get older, and tailor your exercise routine to suit your needs.

As osteoporosis is a risk for post-menopausal women, The National Osteoporosis Society offers three tips to keeping our bones healthy and strong:

  1. Strong - Promote bone and muscle strength
  2. Straight - Care for your back by improving back muscle strength
  3. Steady - Keep you steady and improve balance to prevent the risk of falls

You can get more advice from their website.

Yoga

Yoga is great for all ages, but particularly during the menopause. Not only is it a weight-bearing exercise so good for your bones, but it helps keep your muscles strong and flexible. It is also good for your mind, helping to reduce tension and stress.  It works well alongside meditation.

Older woman doing yoga

Swimming

Swimming is a great all-round exercise that works all the major muscles groups in the body.  It’s also a great cardiovascular workout.  It’s low impact, so if you are suffering from sore or achy joints, this is a much gentler way to exercise.

Coldwater swimming can potentially help with symptoms of the menopause.  The BBC reported a little while ago a story about a group of women who found relief from their menopause symptoms by cold water swimming.  It is not known how the cold water helps, but the women found it relieved some of their symptoms.  If you are feeling adventurous and this is something you’d like to try, why not research wild swimming in your local area.  But don’t be tempted to go and dive into the nearest lake or river on your own, cold water can cause the body to go into shock, so always go with someone who is experienced.

Walking

Walking is a great way to get fit without having the same level of impact as running.  It is still weight-bearing, and a brisk walk is good for getting your heart and lungs working.  In addition, walking in nature has the added benefit of improving your mental wellbeing.

Other good ways to exercise include dancing, Zumba, aerobics, cycling and strength training.

Menohealth offer classes specifically for women going through the menopause.

“Exercise is helpful at all stages in life for physical, mental and social aspects of health, including the menopause. The type of exercise is important during menopause and including some resistance exercise helps with body composition and bone health”, Dr Nicky Keay, Forth’s Chief Medical Officer

Rest and Relaxation

It’s equally important to ensure you are getting enough rest and relaxation. This is especially important for your mental health, particularly if you are experiencing anxiety or depression.  Hormone changes and mental health issues such as anxiety can increase levels of the stress hormone cortisol, so it’s important that you give your mind and body sufficient time to rest.

  • Sleep

A good night’s sleep of around 7-8 hours helps our mind and body repair, but we know sleep can be a challenge during the menopause due to the symptoms such as night sweats.  It’s important to seek help if you have persistent insomnia, especially if it is caused by anxiety - whether anxiety is stopping you from sleeping or not sleeping is causing anxiety.  

You may find self-help books such as ‘The Sleep Book’ a good way to overcome your insomnia.  Apps such as Headspace and Calm have sleep stories designed to relax your body and mind so you can drift off to sleep.

Read more on menopause and insomnia.

  • Meditation

A good way to switch off from the day and calm your mind down is to learn meditation.  This takes time but there are now many online resources and apps you can download to help you learn through guided meditations.  It will also ensure you put some time aside each week for yourself, and your own self-care.  Headspace and Calm also have guided meditations.

  • Mindfulness

The changes women go through during the menopause can make them feel overwhelmed and stressed.  Mindfulness helps by making you focus on the present by focusing on your breathing and sensations in your body.  It’s based on accepting rather than trying to control or dismiss how you are feeling.

What Is Hormone Replacement Therapy (HRT)?

HRT stands for Hormone Replacement Therapy and replaces the key hormones you lose during the menopause. It helps stabilise your hormone levels, thereby relieving the symptoms experienced during perimenopause.

What Are the Benefits of HRT?

HRT improves the quality of life by relieving the symptoms of the menopause. It can also help prevent cardiovascular disease and osteoporosis in later life. In addition, HRT helps combat change in body composition and health of tissues, in conjunction with appropriate exercise and diet.

As outlined in BMJ Editorial from Royal College of Obstetrics and Gynaecology 2019, HRT decreases all-cause mortality after the menopause.

What Are the Risks of HRT?

There are some women for whom HRT is not advised due to a personal or family history of breast cancer. 

There has been some misleading press coverage on the risks of taking HRT, in particular the increased risk of developing breast cancer. However, there is a far higher risk of breast cancer if you have a less healthy lifestyle, such as being overweight, smoking and drinking alcohol.

“Whether to take HRT is every women’s personal choice.  Before arriving at a decision, informing yourself beforehand and looking at respected websites such as Royal College of Obstetrics and Gynaecologists and British Menopause Society will enable you to make informed decisions”, Dr Nicky Keay, Forth Chief Medical Officer

According to NICE, the risks associated with HRT are:

  • Blood clots – HRT tablets as opposed to the patches and gels are linked to an increase risk of blood clots.
  • Heart Disease & Strokes – HRT does not increase your risk of dying from heart disease if you start it before the age of 60. However, HRT tablets slightly raise the risk of stroke, but the risk of having a stroke if you are under the age of 60 is very low.
  • Breast Cancer – HRT that includes oestrogen and progesterone may increase the risk of breast cancer. HRT that only contains oestrogen poses little or no risk in developing breast cancer, however, this is contraindicated i.e. not recommended from a medical point of view, in women who have a uterus i.e. have not had a hysterectomy.

Type 2 Diabetes and HRT

According to NICE, HRT does not increase your risk of developing type 2 diabetes or have a negative impact on your blood sugar levels if you have type 2 diabetes.

Doesn’t HRT Just Delay Menopause?

No, HRT does not delay the menopause because the physiological cause of menopause is lack of responsiveness of the ovaries.  Women who come off HRT experience no or less severe symptoms than before they started the treatment.

Some women may find that the amount of HRT they require also changes over time as hormone levels decline. This can lead to women thinking that it’s stopped working for them, when in fact they just need to review their dose.

“HRT replaces oestradiol and progesterone to pre-menopause physiological levels. HRT does not influence the ovarian loss of responsiveness responsible for the menopause.”, Nicky Keay, Forth Chief Medical Officer

What Supplements Help with The Menopause?

If you are not keen on taking HRT and want to try supplements, there are a few on the market that may help alleviate the symptoms of the perimenopause.

  • Black Cohosh – helps relieve hot flushes/night sweats and improve mood.
  • St John’s Wort – to help with low mood and mild anxiety (do not take if you are already taking an SSRI or other drug to help with anxiety or depression, check with your GP first).
  • Isoflavone – this supplement helps with the side effects of dropping oestrogen levels and has the potential to act like HRT.
  • Rhodiola – this herbal medicine has been used for relief from symptoms such as fatigue, exhaustion, and mild anxiety.


Before you start to take any natural remedies to help with the symptoms experienced during the perimenopause, ensure that they are good quality and from a reputable brand.  Ensure that THR and a 9-figure number is shown on the outside of the packet.

You can read more about natural remedies to the menopause in our article ‘Alternative Therapies To HRT For Treating The Menopause’.

“Supplements can help with menopause, especially for those in whom HRT is contraindicated”, Dr Nicky Keay, Forth Chief Medical Officer

Learn more about HRT from the British Menopause Society.

Impact on Fertility

As a woman transitions through to the menopause her periods will begin to become more irregular and ovulation less certain.  This can make it more difficult to become pregnant.

Associated with anovulatory cycles, declining progesterone levels – a key hormone in fertility – will also make it more difficult to conceive and maintain a pregnancy.

However, it is still possible to become pregnant during the perimenopause.  So, if you are not planning on having children you should continue to use a contraceptive until you reach menopause.

“With reduced ovarian responsiveness comes sporadic ovulation and hence reduced fertility”, Dr Nicky Keay, Forth Chief Medical Officer

Can I still take HRT and a contraceptive pill?

You should take the combined oral contraceptive pill before menopause and HRT after menopause. Not concurrently. It is possible to continue with Mirena coil (progesterone realising) moving into menopause and add in oestradiol to complete HRT.

Summary

The transition through to menopause can be an incredibly challenging time for women due to fluctuating hormone levels that result in physical and psychological symptoms.

It’s important for women to be as informed as possible about the changes that happen in their bodies as they transition towards the menopause. Having a good understanding of these changes can help women feel more in control and less overwhelmed by the symptoms they are experiencing.

The menopause is something that’s going to happen, so the key is to be prepared and learn as much as you can in advance. Get informed, especially around treatments such as HRT and decide which treatment is best for you. 

“Menopause is a normal physiological process in a woman’s life. Understanding and being prepared for this phase in your life will mean you are in a good position to meet the challenges of this life stage and to maintain your quality of life”, Dr Nicky Keay

If you don’t already, begin to track your periods – especially before your 40s - so you know what is normal for you.  That way, you will know if your periods are becoming irregular.

Finally, begin to put in place lifestyle changes now that will help your long-term health such as a diet to support heart and bone health and building in resistance training into your exercise routine.

Understanding whether you are perimenopausal or menopausal is the first step to helping you on the road to a better life, which is where simple blood tests can help you identify the cause of changes that are taking place in your body. The tests will also help exclude any other medical issues that might be causing similar symptoms and need addressing.

If you are finding it difficult to get support, then there are menopause clinics where you can receive further help and advice.  We’ve also included a list of resources below which you may find helpful.

Resources

Menopause Health

Our menopause blood test is a health check for women who are at various stages of the menopause which can have a detrimental impact on health and wellbeing.
Menopause Health
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A health check for woman during and post menopause.
Medically Reviewed
Dr Nicky Keay
Chief Medical Officer, BA, MA (Cantab), MB, BChir, MRCP.​
This article has been medically reviewed by Forth's Chief Medical Officer, Dr Nicky Keay.
Nicky has extensive clinical and research experience in the fields of endocrinology and sport and exercise medicine. Nicky is a member of the Royal College of Physicians, Honorary Fellow in the Department of Sport and Exercise Sciences at Durham University and former Research Fellow at St. Thomas’ Hospital.

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