Much more than a matter of “hot flashes,” menopause is still too often trivialized. In clinical practice, complaints are broader and, above all, more concrete. At a conference organized by the Association des médecins diplômés de l’Université de Liège, Anne Firquet , a gynecologist and obstetrician, head of clinic in the Department of Gynecology and Obstetrics of the Citadelle Regional Hospital Center, Liège, Belgium, outlined the stages women pass through during menopause.

Firquet does not stop at a theoretical definition of menopause. She emphasizes what clinicians regularly encounter: irregular menstrual cycles, exhausted and anxious women, painful sex, sleep difficulties, and weight gain. “80% of women at some point have complaints related to menopause,” she said, making it a frontline issue far more common than often assumed.

The Stages

Her first practical message: Menopause does not occur suddenly. It is preceded by a sometimes-lengthy transition, marked by irregular cycles and periods that grow farther apart, and then stop. Long called “premenopause,” the phase is now more commonly referred to as the menopausal transition. Once the transition has passed, the clinical landmark for declaring a woman menopausal remains simple: “When a woman has gone a year without a period, she is menopausal,” with an average age of around 51 in Belgium, Firquet said.

Firquet warns against a common mistake: trying to confirm menopause too quickly with a blood test. Hormone levels fluctuate widely during this period and can give false reassurance or lead to poor decisions. She cited a case of a 42-year-old patient, declared menopausal and started on hormonal therapy who later turned out to be pregnant. The practical message is clear: Before age 50 — and especially at the start of the transition — clinicians should be cautious. If menopause is not clearly established, ovulation can still occur and birth control should not be stopped prematurely. In other words, for a woman aged 45-50 years who has “menopausal symptoms,” the appropriate response is not necessarily immediate medicalization but rather a careful review of cycle timing, symptoms, and context, keeping in mind that the transition does not exclude residual fertility.

Beyond Hot Flashes

The second practical lesson: Broaden the questionnaire in the clinic. Menopause is not limited to hot flashes. Firquet said this period can be accompanied by sleep disturbances, mood swings, anxiety, cognitive difficulties, incontinence, weight gain, increased fat mass, decreased muscle mass, and sexual problems.

One point stands out: The genitourinary syndrome of menopause — vaginal dryness, pain during intercourse, burning, urinary discomfort, or recurrent cystitis — can be related to menopause yet not spontaneously reported by patients. The clinician, therefore, should ask the questions directly but simply: Is there vaginal dryness? Pain during intercourse? Urinary discomfort? Recurrent infections? This approach avoids diagnostic uncertainty and repeated treatments without a clear underlying cause.

Another very practical point: Do not trivialize early menopause, before age 45. In that case, earlier loss of estrogen has potentially greater consequences for bone health and cardiovascular risk. Again, Firquet urged distinguishing patient profiles rather than applying a one-size-fits-all view. Menopause at 52 and earlier ovarian insufficiency are not managed in the same way.

Treatments

Firquet advises against overcomplicating menopausal hormone therapy. She noted that transdermal formulations (gels, patches, and sprays) avoid first-pass hepatic metabolism and therefore offer more favorable bioavailability. For oral therapy, she recommends a pragmatic approach: Prescribe an estrogen and a progestin that are as close to physiologic and natural as reasonably possible. She believes there’s no need to make menopause treatment more complicated than that.

She also noted evolving practice patterns. Hormone therapy remains underused — “only 23% of symptomatic patients use it,” she said — largely because of two major fears: breast cancer risk and cardiovascular risk. The treatment decision therefore depends on a risk-benefit balance. The clinician pointed out that lifestyle and quality-of-life factors (lack of exercise, overweight, and alcohol) have a larger influence on breast cancer risk.

Firquet emphasized two concrete criteria for breast cancer risk. First: “Breasts should not be overly dense.” In patients with low breast density, “we feel comfortable with hormone therapy.” By contrast, when breast density is high, “we must be cautious” because treatment may increase density and justify closer mammographic surveillance. On the vascular side: “Arteries should be healthy.” Firquet explained that initiating therapy too late, after plaques are already present, could destabilize them. She also reminded clinicians that estrogens carry a somewhat higher thrombotic risk, which requires attention to a history of phlebitis or pulmonary embolism. In short, her message is neither to trivialize nor demonize hormone therapy but to reserve it for the right patients, at the right time, with appropriate precautions.

Firquet reminded us that menopause is less an “event” than a transitional period that needs to be supported. For primary care, the most useful actions are not to seek a miracle marker but to recognize symptoms, take a detailed history, avoid stopping contraception too soon, screen for genitourinary complaints, and choose treatment at the appropriate time. A simple but valuable approach to a topic that remains too often trivialized.

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