Women's Health Treatments from UK-Registered Doctors

Menopause is defined as 12 consecutive months without menstruation, reflecting permanent cessation of ovarian oestradiol production.

The average UK age at menopause is 51, but the perimenopause — characterised by fluctuating hormones, irregular cycles, and emerging symptoms — typically begins 4-8 years earlier, around age 45-47.

Premature ovarian insufficiency (POI), defined as menopause before age 40, affects 1% of women and carries particular consequences for bone, cardiovascular, and cognitive health.

These women require HRT at least until the average age of natural menopause.

Symptom burden is substantial. The 2022 Newson Health menopause survey of over 5,000 UK women reported:

• Hot flushes and night sweats: 79% (vasomotor symptoms)
• Sleep disturbance: 84%
• Low mood and anxiety: 77%
• Brain fog and poor concentration: 73%
• Joint and muscle pain: 70%
• Reduced libido: 62%
• Vaginal dryness and dyspareunia: 56%
• Urinary frequency and recurrent UTIs: 45%

Pathophysiology centres on declining oestradiol, which acts on receptors throughout the body — brain, cardiovascular system, bone, urogenital tract, skin, and musculoskeletal system.

Falling oestrogen destabilises thermoregulatory centres in the hypothalamus (causing vasomotor symptoms), reduces serotonin and noradrenaline transmission (affecting mood), and accelerates bone resorption (increasing fracture risk).

Diagnosis in women over 45 is clinical — based on symptoms and menstrual pattern changes. NICE NG23 explicitly states that FSH testing is not required in this age group.

FSH testing is helpful only in women aged 40-45 with suspected early menopause or those under 40 with suspected POI (two elevated FSH levels 4-6 weeks apart).

The impact on quality of life is profound.

A 2023 Fawcett Society report found that 1 in 10 UK women left employment due to menopause symptoms, and 44% reported that symptoms affected their ability to work.

Hormone replacement therapy replaces the oestradiol that the ovaries no longer produce, directly addressing the hormonal cause of menopausal symptoms.

NICE NG23 confirms that HRT is the most effective treatment for vasomotor symptoms and should be offered to all symptomatic women after a discussion of benefits and risks.

Oestrogen component — transdermal is preferred:

• Oestradiol patches (Evorel, Estradot): deliver 25-100 mcg/day, changed once or twice weekly. Transdermal delivery avoids first-pass hepatic metabolism, eliminating the VTE and stroke risk associated with oral oestrogen.
• Oestradiol gel (Oestrogel): 1-2 pumps daily applied to the skin. Provides flexible dosing and consistent absorption.
• Oral oestradiol (Elleste Solo, Zumenon): 1-2 mg daily. Effective but carries a small increased VTE risk (approximately 1 additional case per 1,000 women per year).

Progestogen component — required in women with a uterus to prevent endometrial hyperplasia:

• Micronised progesterone (Utrogestan) 100 mg cyclically (12-14 days per month) or 100 mg continuously is the preferred body-identical option. It carries a lower breast cancer risk than synthetic progestogens per the NICE NG23 evidence review.
• The Mirena IUS (levonorgestrel 52 mg) provides endometrial protection and contraception simultaneously, lasting 5 years for HRT use.

Regimen selection:

• Perimenopausal women or within 12 months of last period: sequential (cyclical) HRT — continuous oestrogen plus progestogen for 12-14 days per cycle, producing a withdrawal bleed
• Postmenopausal women (12+ months amenorrhoea): continuous combined HRT — both hormones daily, aiming for bleed-free

Testosterone supplementation may be added for persistent low libido unresponsive to optimised HRT. NICE NG23 supports its use despite the absence of a UK-licensed female product.

Androfeme 1% cream or Testogel at female doses (one-tenth of male dose) are prescribed off-label.

Vaginal oestrogen (Vagifem pessaries, Ovestin cream) is effective for urogenital atrophy — vaginal dryness, dyspareunia, recurrent UTIs — and can be used indefinitely.

Systemic absorption is negligible, so it does not require progestogen cover and is safe even for breast cancer survivors in most cases.

The risk-benefit profile of HRT has been extensively re-evaluated since the 2002 WHI study, which initially caused a dramatic decline in HRT prescribing based on findings that have since been reinterpreted.

The WHI reanalysis (published 2013-2017) stratified results by age at initiation and found fundamentally different outcomes:

• Women starting HRT within 10 years of menopause (the "timing hypothesis"): reduced coronary heart disease (HR 0.68), reduced all-cause mortality (HR 0.70), no significant increase in breast cancer with oestrogen-only HRT over 18 years of follow-up
• Women starting HRT 20+ years after menopause: no cardiovascular benefit and modest breast cancer increase

Breast cancer risk with combined HRT is modest and duration-dependent:

• Oestrogen-only HRT: no significant increase over 20 years (WHI follow-up)
• Combined HRT with micronised progesterone: relative risk 1.0 (no increase) per French E3N cohort over 8 years
• Combined HRT with synthetic progestogen (MPA, norethisterone): relative risk 1.26 after 5+ years, equating to approximately 4 additional cases per 1,000 women over 7.5 years

Bone protection: HRT reduces hip fracture risk by 33% and vertebral fracture by 35-40% during use. It is the most physiological approach to osteoporosis prevention in early postmenopausal women.

Cardiovascular benefits when started early include reduced coronary calcification, improved lipid profiles, and enhanced endothelial function.

The timing matters — oestrogen is protective on healthy endothelium but may destabilise established atherosclerotic plaques.

Key risk considerations:

• VTE: oral oestrogen increases risk 2-fold; transdermal oestrogen does NOT increase risk (supported by multiple observational studies and the ESTHER case-control study)
• Stroke: small absolute risk increase with oral oestrogen (1 additional case per 1,000 women per year); transdermal route appears neutral
• Ovarian cancer: small increase (approximately 1 additional case per 1,000 women over 5 years of use)
• Gallbladder disease: increased with oral (not transdermal) oestrogen

Not all women can or wish to use HRT. NICE NG23 acknowledges the role of non-hormonal pharmacotherapy and lifestyle modifications in menopause management.

Non-hormonal medications for vasomotor symptoms:

• SSRIs/SNRIs: fluoxetine, citalopram, and venlafaxine reduce hot flush frequency by 50-60%. Venlafaxine 75 mg daily has the strongest evidence base. These are particularly useful for women with contraindications to HRT (oestrogen-receptor positive breast cancer, active VTE).
• Gabapentin 300-900 mg daily: reduces hot flushes by 45-55% and also improves sleep. Dose-related drowsiness limits titration in some patients.
• Clonidine 50-75 mcg twice daily: modest efficacy (30-40% reduction in flushes), used less frequently due to side effects (dry mouth, drowsiness, rebound hypertension on withdrawal).
• Fezolinetant 45 mg daily (NK3 receptor antagonist): a new drug class specifically targeting the hypothalamic neurokinin B pathway. Reduces moderate-severe vasomotor symptoms by 60% in phase 3 trials.

Cognitive behavioural therapy (CBT) is NICE-recommended for menopausal mood symptoms and has been shown to reduce the impact of hot flushes by 50-70%, even when frequency does not change.

Group-based or self-directed CBT programmes are available through NHS IAPT services.

Exercise during menopause provides multiple benefits:

• Resistance training 2-3 times weekly preserves bone mineral density and lean muscle mass
• Aerobic exercise (150 minutes/week) reduces vasomotor symptom severity by 20-30%
• Yoga and Pilates improve flexibility, balance, and stress resilience
• Weight-bearing exercise is particularly important for osteoporosis prevention

Additional lifestyle measures:

• Maintain a healthy body weight (adipose tissue aromatises androgens to oestrogens, but excess weight worsens vasomotor symptoms)
• Limit alcohol: reduces sleep quality and triggers flushes
• Layer clothing and use handheld fans for practical hot flush management
• Vaginal moisturisers (Sylk, YES) provide non-hormonal relief for vaginal dryness between oestrogen applications

Herbal supplements (black cohosh, red clover, evening primrose oil) lack consistent evidence of efficacy in systematic reviews.

The MHRA has issued safety warnings about black cohosh and rare hepatotoxicity.

Menopause management is usually straightforward, but certain scenarios warrant face-to-face medical assessment or specialist referral.

Contraindications to HRT require specialist menopause clinic input:

• Personal history of oestrogen-receptor positive breast cancer (consider non-hormonal alternatives; vaginal oestrogen may be permissible under oncologist guidance)
• Active or recent venous thromboembolism (transdermal oestrogen may be considered with haematology input)
• Undiagnosed vaginal bleeding (investigate before starting HRT)
• Active liver disease with deranged liver function tests
• Known thrombophilia (Factor V Leiden, prothrombin mutation) — transdermal route preferred if HRT used

Post-menopausal bleeding — any vaginal bleeding occurring 12+ months after the last period — is a red flag requiring urgent investigation to exclude endometrial pathology.

Referral via the 2-week cancer pathway is indicated.

Premature ovarian insufficiency (POI) diagnosed before age 40 warrants specialist review. These women need HRT at minimum replacement doses until age 51 to protect bone and cardiovascular health.

Fertility counselling should be offered, as spontaneous conception remains possible in 5-10% of cases.

Other scenarios requiring further assessment:

• Symptoms not responding to optimised HRT after 3 months (consider dose adjustment, route change, or alternative diagnosis)
• Significant mood disturbance, suicidal ideation, or severe anxiety (may need combined approach with SSRI/SNRI and psychological therapy)
• Recurrent urinary tract infections despite vaginal oestrogen (investigate underlying causes including urodynamics)
• Family history of breast cancer (individual risk assessment using validated tools; HRT is not absolutely contraindicated)
• Bone density concerns (DEXA scan indicated for women with POI, low BMI, glucocorticoid use, or fragility fracture history)

NICE recommends annual HRT reviews to reassess symptom control, side effects, and ongoing appropriateness.

There is no arbitrary duration limit on HRT — treatment can continue as long as the benefits outweigh the risks for the individual woman.