Menopause is far more than the end of the menstrual cycle. It represents a significant neuroendocrine, metabolic and musculoskeletal transition that can influence sleep, body composition, bone health, cardiovascular risk and overall wellbeing.
In this article, Dr Ati Jhajj and the Veritas medical team explore how our understanding of menopause has evolved, including the lasting impact of the 2002 Women’s Health Initiative study and the subsequent shift in how menopausal hormone therapy has been viewed and prescribed. We examine five key areas where the evidence and clinical thinking have changed, from recognising perimenopause and its fluctuating symptoms, to understanding the role of exercise and nutrition, and taking a more individualised approach to hormone therapy.
Key points:
- Menopause is a whole-body transition, not simply the cessation of menstruation.
- Perimenopause can begin years before menopause and is often overlooked or misdiagnosed.
- Exercise and nutrition are fundamental to long-term health, but are not substitutes for effective treatment of significant menopausal symptoms.
- Current evidence supports a more nuanced understanding of menopausal hormone therapy and its risks and benefits.
- Treatment decisions should consider an individual woman’s symptoms, age, timing of menopause and personal risk profile.
- Proactive management of muscle, bone, metabolic and cardiovascular health is an important part of menopause care.
Menopause is often described as a gradual decline in hormones. In reality it is a major neuroendocrine and metabolic transition; one that roughly half the population will experience, and one that can have important downstream effects on sleep, bone health, body composition, sexual function and cardiovascular risk.
I have been practising medicine for more than 15 years, and I still remember when menopause was barely discussed in the consultation room.
In 2002, the Women’s Health Initiative (WHI) published findings from a large US randomised controlled trial that linked one form of combined hormone therapy with increased risks of breast cancer, blood clots and cardiovascular events (1,7). The headlines landed before the nuance did and rapidly changed the way women’s health was approached around the world. Hormone therapy use fell sharply, nearly halving in the US within a few months of the publication. An entire generation of doctors, including me, trained under the pervasive message that “hormones are dangerous” (7).
What rarely made it into our training was the rest of the story.
The average woman in the combined WHI trial was around 63 years old, more than a decade beyond the average age of menopause. Many were starting hormone therapy decades after their final period, and the study used an oral estrogen-progestin pill that’s largely been replaced by newer formulations (1,7). By then, though, the damage to prescribing culture was done. Menopause became something to get through quietly, not something to actively treat. Patients were often left to manage debilitating and widespread symptoms, such as flushes, insomnia, mood changes, joint pain, with reassurance and little else.
Over the last two to three years, as the evidence has been revisited and menopause care has had something of a public reckoning, I’ve had to unlearn a lot of that early training. Here are the five things that have most changed how I think about menopause.
1. Menopause is a major transition, not just an absence of the menstrual cycle
Menopause itself is defined as 12 months without a period. It’s neither a single, sudden transition nor a smooth, gradual decline in hormone levels (2). Menopause is the endpoint of a gradual and bumpy decline in hormones that ends in a relatively steep final drop in hormones.
The average age of menopause in Australia is 51, with most women going through the transition between 45 and 55 (3). Given that average female life expectancy in Australia is now 85.1 years, most women will live roughly a third of their life in the postmenopausal state (3,6). That’s decades of physiology operating with a fundamentally different hormonal environment. This is why it deserves more than a one-off conversation at the time of the last period.
2. Menopause isn’t just a hormonal problem
Oestrogen receptors are distributed throughout the body, not just in reproductive tissue. Their loss affects the thermoregulatory centre in the hypothalamus (hence hot flushes and night sweats), bone remodelling, lipid metabolism, and body composition (4).
Postmenopausal women tend to see a shift toward central adiposity and reduced lean muscle mass, along with an increase in cardiovascular risk factors that isn’t fully explained by ageing alone (4). It is still important to remember that not every midlife symptom is caused by menopause, and not every biological change is driven by oestrogen alone. Ageing, sleep, physical activity, diet and genetics all matter. However, framing menopause purely as “a hormone problem” undersells how systemic the transition really is; it’s a cardiometabolic and musculoskeletal event as much as a reproductive one.
3. Perimenopause can be even more confusing than menopause itself
Established menopause is in some ways easier to identify and therefore manage. Periods have stopped, and the hormone levels are generally low. Perimenopause is far less orderly and much more confusing.
It’s defined as the phase leading up to the final period and typically starts in a woman’s 40s and lasts anywhere from one to ten years (3). Unlike the relatively stable low-oestrogen state of established menopause, perimenopausal hormones can swing dramatically, sometimes within the same day, which makes single blood tests unreliable for diagnosis. Symptoms can come and go, and cycles may become shorter before becoming irregular. Because the hormones fluctuate so significantly, symptom burden during perimenopause can be equal to or greater than in established menopause (20).
In women over 45 with typical symptoms and menstrual cycle changes, perimenopause is a clinical diagnosis. A normal Follicular stimulating hormone (FSH) and Oestogen level does not rule it out because hormone levels can vary substantially from one day to the next (3). But the diagnosis can be delayed and symptoms are often dismissed, especially in younger women. The symptoms are often misattributed to stress or ageing or investigated for months down other pathways before perimenopause is considered as a diagnosis.
4. Hormones aren’t the only treatment
Lifestyle measures are sometimes offered as though they’re a polite alternative to hormonal treatment: exercise more, cut back the coffee, try to manage stress. That’s not enough for a woman who’s waking up drenched in sweat several times a night.
The evidence backs this up. Two of the largest randomised controlled trials on exercise and vasomotor symptoms (the NIH-funded MsFLASH trial and a UK primary-care trial of 261 symptomatic women) both found that structured exercise programs did not significantly reduce the frequency or severity of hot flushes and night sweats compared with usual care (11,12). Therefore, exercise and nutrition do not reliably eliminate moderate-to-severe vasomotor symptoms, and they shouldn’t be used to delay effective hormonal or non-hormonal treatment when symptoms are significantly affecting a woman’s quality of life.
But that doesn’t make lifestyle measures unimportant; exercise and nutrition just play a different role in menopause and perimenopause. As the transition to menopause occurs, metabolic changes occur, including higher levels of central adiposity and reduction in muscle mass, leading to increased risk of metabolic disease such as diabetes and insulin resistance. Progressive resistance training helps preserve muscle mass, strength, and bone density. Weight-bearing and impact exercise supports skeletal health where appropriate. Aerobic exercise improves cardiovascular fitness, blood pressure, insulin sensitivity, and mental health, and there’s reasonable evidence it improves sleep and mood through the transition even where it doesn’t touch hot flushes directly (4,5,8). This matters because muscle and bone loss accelerate around the menopause transition; around 23% of Australian women over 50 are estimated to have osteoporosis, including both diagnosed and previously unrecognised disease (16).
Nutrition remains a backbone of treatment too; not because there’s a special “menopause diet,” but because adequate protein, calcium, fibre, and overall diet quality become increasingly important as cardiometabolic and skeletal risk shifts through this life stage.
Lifestyle care isn’t a consolation prize. It’s core preventive treatment. However, in women with severe symptoms, it shouldn’t be presented as the only option, or as a reason to withhold/delay treatment.
5. Hormones are generally safe for most women – when individualised
For most women within ten years of menopause, or under 60, current international and Australasian guidance is that the benefits of menopausal hormone therapy (MHT) are likely to outweigh the risks, with evidence supporting its role in symptom relief, osteoporosis prevention, and reduced fracture risk (1,9,10,13). That does not mean hormone therapy is risk-free. It means the risks are more nuanced than we were once taught.
If you’re over 60 and more than 10 years post menopause, the benefits may still outweigh the risks for you and this requires an individualised conversation of your symptoms and treatment options (13).
A few points I now discuss with patients:
- Progesterone is essential for women with a uterus. Systemic oestrogen stimulates the endometrium. A progestogen must therefore be used to reduce the risk of endometrial hyperplasia and cancer (9,13)
- Route matters. Transdermal oestrogen, delivered through a patch or gel, bypasses first-pass liver metabolism and is associated with a lower risk of venous thromboembolism than oral oestrogen. It is often preferred in women with cardiometabolic risk factors, migraine or an increased risk of thrombosis (9,10).
- Breast cancer risk is not one uniform number. Risk differs between combined therapy and oestrogen-only therapy and appears to vary according to duration of use and the type of progestogen used (14,19).
- Absolute risk matters in the consultation room. What matters in the consultation room is the change in absolute risk for the individual woman. Relative-risk figures can make a treatment sound alarming without showing how often the outcome occurs, particularly when the baseline risk is low.
- The 2022 North American Menopause Society position statement describes the additional absolute risks associated with menopausal hormone therapy as rare. There are generally fewer than 10 additional events per 10,000 women per year for each of the relevant adverse outcomes. The precise risk depends on the type of therapy, route, age at initiation and the woman’s underlying risk profile (13)
- Of 1,000 women who never use MHT, about 63 will be diagnosed with breast cancer between ages 50 – 69. Using HRT from menopause for 5 years adds roughly 5 extra cases with oestrogen-only, 14 with cyclical combined, and 20 with continuous combined therapy. This number roughly doubles at 10 years (14,15). Giving a woman that denominator and timeframe, against her own baseline risk and symptom burden, is usually more useful than “increases breast cancer risk” on its own.
- Testosterone has a role, but it is not a general anti-ageing treatment. Its clearest evidence-based indication is hypoactive sexual desire disorder in appropriately assessed postmenopausal women when other contributing factors have been addressed (17). It can have additional benefits such as assisting in maintaining muscle mass but is not used for this indication alone.
- Local vaginal oestrogen is different from systemic therapy. Low-dose vaginal oestrogen is used to treat vaginal dryness, irritation, painful sex, urinary symptoms and recurrent urinary tract infections. Systemic absorption is minimal, and it can often be used even when systemic MHT is not appropriate, although women with hormone-sensitive breast cancer need an individualised discussion (9,13,18). Local oestrogen therapy is extremely beneficial for women with genitourinary symptoms, and an astounding 50-70% of menopausal women will experience these symptoms (18).
- MHT should not be prescribed solely to prevent cardiovascular disease or dementia. Starting treatment closer to menopause appears to have a more favourable cardiovascular profile than starting it many years later, but its main role remains symptom treatment, with bone protection an important additional benefit (9,10,13).
It’s worth acknowledging this isn’t a settled debate: some clinicians still argue the original WHI-era caution was a reasonable response to genuine trial findings, and that the current swing back toward MHT carries its own risk of overcorrection if individual risk assessment gets skipped in the enthusiasm to right past wrongs. The answer is not to move from “hormones are dangerous” to “everyone should be taking hormones.” It is to stop treating either position as universally true and to have the conversation with each individual women about her symptoms and well-being.