The first thing I want to say about menopause is that it is not a disease. It is a natural biological transition - the permanent end of menstruation, occurring on average at 51 in the UK - that every woman with a uterus will experience if she lives long enough.
The second thing I want to say is that for many women, the transition is genuinely difficult. Not because they are weak, but because the hormonal changes involved - particularly the decline in oestrogen - can produce symptoms that are severe, prolonged, and significantly impact quality of life.
The third thing I want to say is that effective treatment exists, is safe for most women, and dramatically improves quality of life during this transition. The fear of hormone replacement therapy (HRT) that developed after a large study in 2002 has been substantially revised by more careful analysis of the evidence. Yet many women - particularly Black and African women, who have more severe symptoms and longer symptom duration on average - are still not being offered or are declining treatment that could significantly help them.
How menopause differs in Black and African women
Research, including the large SWAN (Study of Women's Health Across the Nation) study conducted across multiple US ethnic groups, consistently shows important differences in the menopausal experience of Black women.
Black women experience natural menopause approximately 2 years earlier than white women on average. Vasomotor symptoms - hot flushes and night sweats - are more frequent and more severe in Black women. The duration of vasomotor symptoms is significantly longer - approximately 10 years in Black women compared to 6.5 years in white women in SWAN data. Black women are significantly less likely to be prescribed HRT, despite having more severe symptoms. And Black women are less likely to be asked about menopausal symptoms by their healthcare providers.
The reasons for this undertreatment are multiple: less awareness in African communities that menopause warrants medical attention; cultural narratives that frame suffering through menopausal symptoms as something to be endured rather than treated; healthcare providers who may not discuss HRT proactively with Black patients; and the residual effect of the 2002 WHI study fear that affected all women.
The WHI study - what actually happened and what we now know
In 2002, the Women's Health Initiative published interim results suggesting that combined HRT (conjugated equine oestrogen plus medroxyprogesterone acetate) increased the risk of breast cancer, cardiovascular events, stroke, and blood clots. HRT prescriptions fell by 50-60% almost overnight, worldwide.
Subsequent re-analysis has substantially revised this picture:
The WHI used older, oral, synthetic formulations. The average age of women in the trial was 63 - more than 10 years past the average age of menopause. Many had pre-existing cardiovascular risk. Starting HRT this long after menopause behaves differently from starting it at menopause.
What the evidence now shows: Transdermal oestrogen (patch, gel, spray - absorbed through the skin, bypassing the liver) does not carry the blood clot risk associated with oral oestrogen. This is a fundamental pharmacological difference, not a minor one.
Micronised progesterone (Utrogestan - body-identical progesterone) has significantly lower breast cancer association than the synthetic progestogen (medroxyprogesterone acetate) used in the WHI.
For women who start HRT within 10 years of menopause onset, are under 60, and use transdermal oestrogen with micronised progesterone: the benefit-risk profile is generally favourable for most women without specific contraindications.
The current position of NICE (2023) and the British Menopause Society: for most women under 60 without specific contraindications, the benefits of HRT outweigh the risks. Women should be offered HRT and given full information to make an informed choice.
Symptoms - the full picture
Menopause causes far more than hot flushes. Many women do not connect their symptoms to menopause, particularly psychological symptoms.
Vasomotor: Hot flushes (sudden intense heat spreading from chest to face), night sweats (soaking nightwear and bedding), palpitations.
Psychological: Anxiety (often new-onset or significantly worsened), low mood, irritability, reduced resilience to stress, poor concentration, difficulty finding words, memory difficulties. These symptoms are common, often debilitating, and frequently misattributed to depression or stress rather than recognised as menopausal.
Sleep: Insomnia - often secondary to night sweats but also independent of them. Chronic sleep deprivation compounds every other symptom.
Genitourinary Syndrome of Menopause (GSM): Vaginal dryness, vaginal atrophy, pain during sex, urinary urgency and frequency, recurrent urinary tract infections. Affects approximately 50% of postmenopausal women. Unlike hot flushes, GSM does not resolve with time - it worsens without treatment. Dramatically underreported (many women consider it an embarrassing and inevitable aspect of ageing) and dramatically undertreated. Highly effective treatment exists.
Musculoskeletal: Joint aching, reduced muscle mass, weight redistribution toward the abdomen. Risk of osteoporosis accelerates after menopause as oestrogen's bone-protective effects are lost.
Case study: Veronica's dismissal at 47
Veronica, 47, came to see me after her previous GP had told her she was probably too young for menopause and suggested her symptoms were stress-related. She had been experiencing irregular periods for 18 months, hot flushes up to 12 times per day (including at night, severely disrupting sleep), significant brain fog, and new-onset anxiety. Her mood was the lowest it had been in her life.
She had been prescribed an antidepressant. She did not feel depressed. She felt hormonal - and she knew the difference.
I checked her FSH (follicle-stimulating hormone) and oestradiol - both consistent with perimenopause. We had a full discussion of HRT options.
She started transdermal oestrogen gel (Oestrogel) plus micronised progesterone (Utrogestan) 200mg for 12 days each month.
At her 8-week review: hot flushes reduced from 12 to 1-2 per day. Sleep significantly improved. Brain fog largely resolved. Anxiety almost gone.
"I feel like myself again for the first time in 18 months," she said. "I just needed someone to take me seriously."
Her symptoms had been present for 18 months before she received appropriate assessment and treatment.
Sources: Avis NE et al, JAMA Internal Medicine 2015 (SWAN study - ethnic differences in menopause); NICE Clinical Guideline NG23 - Menopause: Diagnosis and Management (2015, updated 2023); Rossouw JE et al, JAMA 2002 (WHI study); Manson JE et al, NEJM 2013 (WHI reanalysis by age at initiation); British Menopause Society - HRT and Breast Cancer Risk 2022; Baber RJ et al, Climacteric 2016 (IMS menopause recommendations).
