During the “Modern Medicine: Menopause” lecture hosted by the Royal College of Physicians of Edinburgh, Edinburgh, Scotland, general practitioners and menopause specialists Claire Phipps, MBBS, BMS advanced menopause specialist, London Gynaecology Ltd, and Sarah Glynne, MBBS, MRCGP, Claire Mellon & Associates, The Portland Hospital, London, England, discussed evidence-based approaches to diagnosis and hormone therapy. Their message to clinicians was clear: Menopause varies considerably from woman to woman, and hormone replacement therapy (HRT) should neither be recommended routinely nor rejected outright.

At least three quarters of women experience menopausal symptoms, and about one quarter seek medical advice as a result. Despite this, care remains inadequate; some symptoms are downplayed, whereas others are attributed to menopause too quickly.

Perimenopause

Perimenopause is the period leading up to the final menstrual cycle. Menstrual cycles may remain regular even as psychological, cognitive, or physical symptoms begin to appear. Menopause is defined retrospectively as the point at which a woman has not had a menstrual period for 12 consecutive months. Thereafter, the postmenopausal period begins.

Early menopause is defined as menopause occurring before age 45. When ovarian function ends before age 40, the condition is classified as primary ovarian insufficiency. Surgical menopause occurs after removal of the ovaries or as a result of medical treatment and is often accompanied by an abrupt decline in oestrogen levels.

Early symptoms can be easily overlooked. Women may initially experience low mood, anxiety, restlessness, difficulty concentrating, or a feeling that they can no longer manage their daily lives.

Symptoms

In addition to hot flashes and night sweats, common symptoms include sleep problems, muscle and joint pain, headaches, tinnitus, skin changes, and weight gain. Menstrual cycles may also change substantially. Some women experience palpitations, difficulty concentrating, or a noticeable loss of self-confidence.

Genitourinary syndrome of menopause is another commonly overlooked symptom. It may cause vaginal dryness, burning, itching, pain during intercourse, postcoital bleeding, or recurrent urinary tract infections, as well as distressing loss of libido. Many women do not raise these concerns themselves, even though effective treatments are available.

Therefore, during the medical history, physical, psychological, and genitourinary symptoms should be assessed systematically but separately. This approach can help clinicians understand how symptoms change over time and identify less obvious concerns. At the same time, diagnostic caution is important: Fatigue, palpitations, and mood changes can have other causes and should not be attributed to perimenopause too quickly.

Lifestyle First

Treatment does not always require medication. Nutrition, physical activity, sleep, and psychological well-being provide the foundation for care. Regular physical activity is particularly important for maintaining muscle and bone health and can include strength training, Pilates, yoga, or short periods of activity incorporated into daily life.

Alcohol consumption and spicy foods can worsen hot flashes and night sweats. A calcium-rich diet supports bone health. Phipps also highlighted vitamin D but advised caution with many over-the-counter supplements because the evidence is limited. Good sleep hygiene, reduced exposure to screen light in the evening, and allowing time for relaxation may also help alleviate symptoms.

Nonhormonal and HRT

When HRT is inappropriate, individual symptoms can be treated using other approaches. Venlafaxine may help with hot flashes, night sweats, and psychological symptoms, although potential adverse sexual effects make it unsuitable for some women.

Oxybutynin may be used to treat certain bladder symptoms. Menopause-specific cognitive-behavioural therapy is another option. It can help with anxiety, depressive symptoms, sleep problems, and coping with hot flashes and night sweats. It is not intended to replace other treatments but can form part of a broader treatment approach.

The appropriate option depends on the symptoms, comorbidities, risks, and individual preferences. Therefore, blood tests may be useful in certain situations. However, in women of typical menopausal age with characteristic symptoms, perimenopause cannot be confirmed or excluded on the basis of a single hormone measurement.

HRT is approved in the UK for treating vasomotor and genitourinary symptoms in postmenopausal women and for preventing osteoporosis. For other menopausal symptoms or during perimenopause, it is prescribed off-label; however, Glynne said this is supported by menopause guidelines.

Glynne described HRT as the most effective treatment for symptoms related to hormone deficiency when there are no contraindications. Bone health is an important consideration because bone loss accelerates several years before the final menstrual period. According to the data presented, HRT can reduce the risk for osteoporosis by 30%-40%.

The effect depends on the dose and duration of treatment. Low doses of transdermal oestrogen can stabilise bone density, whereas high doses can increase it. However, the protective effect diminishes rapidly after treatment is discontinued. Women receiving HRT primarily for bone protection, therefore, need a different long-term perspective from those receiving treatment for temporary vasomotor symptoms.

Timing and Benefits

Potential cardiovascular effects may also depend on when the treatment begins. Glynne cited data suggesting that starting treatment early, within 10 years of menopause, or before age 60, may be associated with lower cardiovascular risk. However, HRT has not been approved solely for the prevention of cardiovascular disease.

Evidence regarding the risk for dementia remains inconsistent. Early initiation, particularly of oestrogen-only therapy, may be associated with a lower risk, but a definitive preventive effect cannot be established from these data. The presentation also did not suggest that HRT increases the risk for dementia.

In summary, HRT can alleviate symptoms and support bone health. Potential long-term effects can be considered as part of shared decision-making but should not be presented as established benefits.

Risks, Dosage, and Duration

At the start of treatment, women may experience bleeding, breast tenderness, headache, bloating, or mood changes. These symptoms are usually mild and improve over time. The risk for thrombosis depends largely on the route of oestrogen administration; oral oestrogen increases the risk, whereas transdermal oestrogen delivered through patches, gels, or sprays does not.

If the uterus is intact, oestrogen must be combined with progestin to prevent excessive endometrial thickening. The progestin dose should be as appropriate as the oestrogen dose. Some women have difficulty tolerating progestins and may skip doses that can reduce endometrial protection.

When discussing breast cancer risk, Glynne cautioned against a broad generalisation. In the Women’s Health Initiative, combined therapy with conjugated equine oestrogens and medroxyprogesterone acetate was associated with a small absolute increase in risk. In contrast, oestrogen monotherapy after hysterectomy was associated with a lower risk for breast cancer than was the placebo.

Transdermal oestrogen is absorbed to varying degrees. Even with the same dose of gel or patch, serum oestrogen levels can vary substantially. Therefore, dose adjustments are primarily based on clinical response. If symptoms persist, a gradual dose increase or change in the route of administration may be appropriate.

Treatment needs can change as perimenopause progresses. Therefore, a dose that is appropriate at the beginning may become insufficient over time.

The professional associations cited in the presentation do not recommend a rigid time limit for HRT. The treatment goal, individual risks, tolerability, and ongoing benefits should guide decisions about continuing treatment.

This story was translated from Univadis Germany, part of the Medscape Professional Network.