About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Menopause = 12 months of amenorrhoea. Average age in UK: 51. Perimenopause begins ~4 years before (irregular periods + symptoms)
- Diagnosis is CLINICAL in women ≥45 with typical symptoms. FSH testing NOT needed for women ≥45 (NICE NG23)
- Vasomotor symptoms: hot flushes, night sweats — most common reason for seeking HRT
- HRT: oestrogen for symptom relief + progestogen for endometrial protection (if uterus present)
- With uterus: combined HRT (continuous or sequential). Without uterus: oestrogen-only HRT
- Premature ovarian insufficiency (POI): menopause <40 years — needs HRT at least until average age of menopause (51) for bone and cardiovascular protection
Overview
Menopause is defined as permanent cessation of menstruation resulting from loss of ovarian follicular function. It is a retrospective diagnosis, confirmed after 12 consecutive months of amenorrhoea in women ≥45 years. The perimenopause is the transitional phase characterised by irregular menstruation and onset of menopausal symptoms, lasting approximately 4 years on average. Declining oestrogen levels cause vasomotor symptoms (hot flushes, night sweats), urogenital atrophy, mood changes, and increased risks of osteoporosis and cardiovascular disease. HRT is the most effective treatment for menopausal symptoms.
Epidemiology
The average age of natural menopause in the UK is 51 years. Premature ovarian insufficiency (POI) occurs before age 40, affecting approximately 1% of women under 40 and 0.1% under 30. POI may be idiopathic, autoimmune, genetic (Turner syndrome, FMR1 premutations), iatrogenic (surgery, chemotherapy, radiotherapy), or infectious. Approximately 80% of women experience menopausal symptoms, and ~25% describe them as severe. Symptoms last an average of 4–8 years but may persist longer.
Clinical Features
Symptoms
Vasomotor symptoms: hot flushes and night sweats — the hallmark of menopause
Irregular periods (perimenopause), then amenorrhoea
Sleep disturbance (often secondary to night sweats)
Mood changes: low mood, anxiety, irritability, reduced concentration
Vaginal dryness, itching, and dyspareunia (urogenital atrophy)
Recurrent UTIs (urogenital atrophy)
Reduced libido
Joint aches and pains
Postmenopausal bleeding (if already confirmed menopausal)
Signs
Vaginal atrophy: pale, thin, dry vaginal mucosa on speculum examination
No specific signs of menopause on general examination
Investigations
First-line
Clinical diagnosisIn women ≥45 with typical symptoms, NO investigations are needed (NICE NG23). Diagnosis is clinical
FSHOnly needed if: age <45 with suspected menopause/POI, or diagnostic uncertainty. FSH >30 IU/L on two samples 4–6 weeks apart suggests menopause/POI
Second-line
TFTsExclude hypothyroidism (overlapping symptoms: fatigue, weight gain, mood changes)
FBCExclude anaemia (fatigue)
HbA1cScreen for diabetes if relevant risk factors (perimenopausal women often have metabolic risk factors)
Specialist
POI investigationsIf <40: karyotype (Turner syndrome), FMR1 premutation screen, adrenal antibodies (autoimmune), anti-ovarian antibodies, DEXA scan for bone density
1
Lifestyle and general advice
- Regular weight-bearing exercise (bone protection and mood)
- Healthy diet, maintain BMI, reduce alcohol and caffeine
- CBT has evidence for vasomotor symptoms and low mood
- Advise that contraception is still needed until 2 years after last period if <50, or 1 year if ≥50
2
HRT — systemic
- Most effective treatment for vasomotor symptoms and should be offered to all symptomatic women after informed discussion
- With uterus: combined HRT (oestrogen + progestogen for endometrial protection). Sequential (monthly bleed) in perimenopause, continuous combined (no bleed) in postmenopause
- Without uterus: oestrogen-only HRT
- Oestrogen: transdermal patch or gel preferred (no increased VTE risk vs oral). Oral oestradiol is alternative
- Progestogen: micronised progesterone (Utrogestan — preferred, lower risk profile) or synthetic progestogens. LNG-IUS provides endometrial protection and contraception
- Start with standard dose and adjust. Review at 3 months
3
HRT — local (vaginal)
- Vaginal oestrogen (cream, pessary, or ring) for urogenital atrophy symptoms — effective and safe
- Can be used long-term without progestogen cover and without significant systemic absorption
- Can be used alongside systemic HRT if needed
4
Non-hormonal options (if HRT contraindicated/declined)
- SSRIs/SNRIs: fluoxetine, citalopram, venlafaxine — evidence for vasomotor symptom relief
- Gabapentin: effective for hot flushes (off-label)
- Clonidine: limited efficacy, consider only if other options unsuitable
- CBT: evidence for vasomotor symptoms and mood
5
Premature ovarian insufficiency (POI)
- HRT (or COCP if contraception also needed) at least until average age of menopause (51)
- Essential for bone protection, cardiovascular protection, and symptom relief
- DEXA scan at baseline and monitoring
- Refer to specialist menopause/endocrine clinic
Complications
- Osteoporosis: Oestrogen deficiency accelerates bone loss — increased fracture risk. HRT is protective
- Cardiovascular disease: Oestrogen is cardioprotective — risk increases after menopause. HRT started <60 or within 10 years of menopause is not associated with increased CV risk
- VTE risk: Oral HRT increases VTE risk. Transdermal route has NO increased VTE risk — preferred in women with VTE risk factors
- Breast cancer: Combined HRT slightly increases breast cancer risk (approximately 5 extra cases per 1,000 women over 5 years). Oestrogen-only HRT carries minimal or no increased risk. Risk returns to baseline within 5 years of stopping
- Urogenital atrophy: Progressive without treatment — recurrent UTIs, dyspareunia, vaginal dryness
UKMLA Exam Tips
- 1Do NOT measure FSH in women ≥45 with typical symptoms — diagnosis is clinical (NICE NG23)
- 2FSH only needed if <45 with suspected menopause or POI
- 3Transdermal oestrogen (patches/gel) = no increased VTE risk. Oral oestrogen = increased VTE risk
- 4With uterus → MUST add progestogen (endometrial protection). Without uterus → oestrogen only
- 5Micronised progesterone (Utrogestan) preferred over synthetic progestogens — lower risk profile
- 6POI (<40): HRT is ESSENTIAL (not optional) until at least age 51 — bone and CV protection
- 7HRT does NOT increase CV risk if started <60 or within 10 years of menopause ("window of opportunity")
- 8PMB on HRT: investigate as for any PMB — exclude endometrial cancer
practicetest your knowledge on menopause and hrtApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
open q-bank