The menopause can creep up on women without obvious warning. Symptoms can include low mood or anxiety, discomfort with intercourse, tearfulness, irritability, flushes, night sweats, loss of libido, insomnia or muscle pains. 

It can occur before the age of 40 when it is called Premature Ovarian Insufficiency or after this, the average age of menopause is typically about 52 but the period before periods stop all together can be complicated by any or all of the above symptoms.

Diagnosis & Treatment

Diagnosis in the expected age group is merely made on the presence of symptoms. FSH blood tests are limited to those younger than 45 or when the diagnosis is in doubt.

Treatment is with oestrogen, usually in topical form as gel, patch or spray. In women with a uterus, a Mirena coil or oral progesterone is required as unopposed oestrogen can lead to uterine cancer.

Younger women often need higher doses of oestrogen to control symptoms. It is important that symptoms are controlled in order to improve quality of life but also to provide the longer term benefits associated with oestrogen, such as reducing osteoporosis and heart disease risk.

People differ in their ability to absorb oestrogen, so doses higher than those normally recommended may be required to achieve symptom relief.

The full impact of oestrogen can take three months to occur and if testosterone is added, this might take as long as 6 months. 

Serum oestradiol blood testing is often unreliable in women taking oestrogen as hormone levels vary considerably in perimenopausal women.

Symptom control is the best guide as blood tests are often unreliable. Micronised or bioidentical progesterone has fewer side effects. Vaginal progesterone may be offered where side effects such as low mood, bloating and nausea are present. 

For those unable to tolerate oral or vaginal Utrogestan, the Mirena coil would be a good alternative.

HRT is not contraceptive and so contraception should be discussed unless the woman has had 2 years amenorrhoea or if over the age of fifty, one year. Contraception is not required over the age of 55 even if menstruation has continued.

The addition of testosterone may be helpful. Symptoms of testosterone deficiency might include lack of libido and fatigue whereas vasomotor symptoms such as flushing would suggest oestrogen deficiency.

NICE recommend FSH and oestradiol testing when investigating women aged 40-45 and in those under 40 but normal results do not rule out menopause. Oestradiol monitoring can be helpful in older women to assess absorption of gels and patches. Oestradiol levels of at least 250pmol/l are usually required for symptom relief. Once relief has been achieved those on higher doses should be monitored 3-6 months after a dose increase and then annually.

If you think you might have symptoms of menopause, or early menopause, book an appointment with our Women’s Health Private GP Dr Seema Chakravarti.

You can use the Green Climacteric scale to give a picture of the type of symptoms you might have that could relate to POI to prepare for your appointment.

Dr Allan Fox, Private GP near Canterbury.