As part of our Lunch & Learn series of webinars, Henpicked’s Sally Leach was joined by Dr Clare Spencer, registered GP, BMS-accredited menopause specialist and co-founder of My Menopause Centre, to answer your most asked questions on menopause and treatment options. 

Henpicked: when does menopause usually start and how long does it last?

Dr Clare Spencer: Menopause is a transition. We go from fairly regular hormone patterns to more erratic oestrogen fluctuations with an overall drop and then oestrogen stays low in postmenopause.

Perimenopause is the start of the transition when symptoms can begin as hormones fluctuate. Menopause is a point in time where you can look back and say you have not had a period for 12 months. After that you are postmenopausal for the rest of your life.

The average age of menopause in the UK is 51 and the usual range is 45 to 55. Perimenopause often starts around five years before that. A small percentage of women go through menopause under 40, so if symptoms start before 40 it is still worth raising the question.

In terms of how long symptoms last, it is unpredictable. Symptoms can start in perimenopause and carry on into postmenopause for an uncertain length of time while the body and brain adapt to lower oestrogen. You might read averages like eight years but it varies hugely and we cannot reliably predict it.

Henpicked: how can I tell where I am in the menopause transition?

Dr Clare Spencer: If you are not taking hormones and you are having periods then your cycle can be a useful guide. A change in your cycle timing by more than a week can be a sign of perimenopause. Periods stopping for 12 months is the marker for menopause.

It can be much harder if you are using hormonal contraception that affects bleeding or if you start HRT in perimenopause. In those situations you often cannot tell where you are and it does not usually matter. If you really want to know you would need to stop hormones, which most people understandably do not want to do.

Henpicked: if I have a Mirena and no periods how do I know if I am peri or postmenopause?

Dr Clare Spencer: If you are not bleeding because of a Mirena or other progestogen-only contraception then you mainly go by symptoms. Getting familiar with the range of symptoms and keeping a note of changes can help and then it is worth discussing with your GP.

Henpicked: what is HRT and when can someone start it?

Dr Clare Spencer: HRT is primarily for symptom management. If you are experiencing symptoms that are bothering you then it can be a good time to consider HRT.

If you have NOT had a hysterectomy and you still have your womb you usually need two hormones:

• Oestrogen to top up levels and help you feel better
• A progestogen alongside oestrogen to keep the womb lining thin

The Mirena can be used as the progestogen part of HRT.

Oestrogen can be taken as a patch, gel, spray or tablet. Progestogen options include the Mirena, combined patches, micronised progesterone capsules and other tablet options. It can be a bit mix and match to find what suits you.

Henpicked: how long can someone take HRT for and when should they stop?

Dr Clare Spencer: You can take HRT for as long as you want, as long as you understand the balance of benefits and risks for you.

There is a small increased risk of breast cancer that relates to how long you take HRT. There are also benefits such as reduced risk of fractures and osteoporosis, and for many women reduced risk of heart disease.

There is no single right answer. This is why annual reviews matter so you can check the dose still feels right and decide if you want to continue and review any changes in your medical history.

Henpicked: why do some people get told they must stop after five years?

Dr Clare Spencer: Sometimes this comes from older ways of interpreting the data. Risk does not suddenly start at five years. It gradually changes with time and type of HRT.

If you are using transdermal oestrogen (through the skin) and micronised progesterone then for many women the benefits outweigh the risks well into their early 60s. Beyond that there is less data so we have a data gap which is important to be aware of.

If you are told you must stop, ask why and do not be afraid to discuss updated resources with your clinician.

Henpicked: what is the five-year “maximum” rule for sequential HRT?

Dr Clare Spencer: This is about sequential HRT where you take oestrogen every day and progestogen for part of the month and you have a regular withdrawal bleed. When you take oestrogen without progestogen for part of each cycle over too long a period it can thicken the womb lining. Guidance limits sequential regimes to reduce the risk of womb lining problems.

It is different from the question of how long you can take HRT overall.

Henpicked: does HRT increase stroke or clot risk?

Dr Clare Spencer: If you swallow oestrogen there is a small increased risk of clots. If you use oestrogen through the skin (patch, gel or spray) then it does not increase the risk of stroke or blood clots in the same way. Route matters and this is a key point for conversations with your clinician.

Henpicked: can HRT bring back bleeding?

Dr Clare Spencer: Yes depending on the type of HRT and where you are in the transition.

If it is less than a year since your last period when you start HRT you are often started on a sequential approach that creates a monthly withdrawal bleed. If it is close to 12 months since your last period you may be started on a no-bleed continuous approach.

If you have a Mirena, many women do not bleed and it can be used alongside oestrogen at any stage and it also provides contraception.

Henpicked: what should I do if HRT feels like it is making symptoms worse?

Dr Clare Spencer: Some people do get side effects to hormones. Sometimes the oestrogen dose can be too high particularly in perimenopause. It is important to go back to your GP or specialist and review dose and type rather than just pushing through.

It is also worth stepping back and checking whether symptoms are definitely menopause-related because stress and life factors can overlap with menopause symptoms and amplify them.

Henpicked: how do I recognise progesterone intolerance?

Dr Clare Spencer: Progesterone intolerance can feel like a sudden low mood or a heavy dark cloud especially during the progestogen part of the month. If this happens go back to your clinician because there are different progestogen options and changing type or regimen can help. Do not stop progestogen without medical advice if you still have a womb.

Henpicked: what can I do if I cannot or do not want to take HRT?

Dr Clare Spencer: There are lots of options and lifestyle changes can reduce symptom impact whether or not you take HRT.

Helpful areas to consider include:

• Reducing alcohol especially for sleep anxiety, low mood, hot flushes and night sweats
• A steady balanced diet that avoids big blood sugar swings and a Mediterranean-style pattern has the best evidence
• Stopping smoking as it can worsen flushes and poor sleep
• Regular movement plus strength and resistance exercise
• Relaxation and CBT which can help break vicious cycles around mood, sleep and motivation
• Complementary therapies like hypnosis or acupuncture can help some people, though cost is a factor
• Herbal remedies but these can interact with medicines and plant oestrogens are still oestrogens, so check safety first
• Vitamin D is important
• Non-hormonal prescription options can help for some symptoms including certain SSRIs and other medications

Henpicked: what vitamin D dose is recommended?

Dr Clare Spencer: Many people are advised to take 400 IU daily in winter months. Some people may need more depending on diet and individual factors but you can take too much so if you are unsure speak with a clinician. If you feel very tired it is also worth checking other causes like anaemia, iron, B12, thyroid and more rather than assuming it is vitamin D alone.

Henpicked: what bleeding changes should be checked by a GP?

Dr Clare Spencer: In perimenopause bleeding can change but you should get checked if you have:

• Very heavy or prolonged bleeding
• Spotting or bleeding between periods
• Any bleeding after sex
• Bleeding after you have gone 12 months without a period when not on hormones

Henpicked: is it unusual to still have periods at 57?

Dr Clare Spencer: Most women have stopped by 55 but a small percentage continue into 56 or 57. If bleeding has been regular and ongoing that can be normal for a small group. If you stopped bleeding and then it restarted then that must be checked. If there is any worry about bleeding after the age of 55, please speak to a GP to get the bleeding checked.

Henpicked: does HRT affect fibroids?

Dr Clare Spencer: Fibroids are benign growths of the womb that are stimulated by oestrogen. They often shrink after menopause as oestrogen drops. HRT does not cause fibroids but adding oestrogen can slow shrinking and occasionally fibroids can increase in size. This is something to discuss if you have symptoms.

Henpicked: I had a hysterectomy and oophorectomy for endometriosis. Do I still need progesterone?

Dr Clare Spencer: If you have had surgery for endometriosis there can be situations where progesterone is used alongside oestrogen for a period of time because oestrogen alone may stimulate any residual endometriosis. This is a good discussion for your gynaecologist and your GP may need specialist input.

Henpicked: can blood tests confirm perimenopause or menopause?

Dr Clare Spencer: The common test is FSH which fluctuates and is not predictive. You can have significant symptoms with a normal FSH and you can have a raised result that later returns to a lower level. This is why we often do not rely on blood tests to prove or exclude perimenopause or menopause. Symptoms and history are usually more helpful.

Henpicked: any final message for anyone feeling unsure?

Dr Clare Spencer: You are not alone and there are options. Keep track of symptoms and ask for support. Push for a conversation if you feel you are not being heard and consider reputable resources to help you advocate for the care you want.