Menopause: What Changes and What Helps

Most women come to the OPD in their mid-forties not asking about menopause but about something else — periods that have turned unpredictable, knees and shoulders that ache in the morning, sleep that breaks at three o’clock. Menopause itself is one point in time. The years on either side of it are what women live through, and most of what troubles them in those years can be treated.

What the words actually mean

Menopause is a diagnosis made looking backwards. The World Health Organization describes natural menopause as confirmed after 12 consecutive months without a period, with no other obvious cause, and places it generally between 45 and 55 years of age.

In India it arrives earlier. A 2024 analysis of the National Family Health Survey and the Longitudinal Ageing Study in India put the average menopausal age at about 46 years, from roughly 44 in Bihar to 47.6 in Kerala. A woman of 44 whose periods have stopped is not unusual here, and not “too young” to be believed.

What changes, and for how long

Hot flushes and night sweats occur in up to 80% of women, and last longer than most people expect: the Menopause Society’s 2023 review puts their mean duration at seven to nine years, and in about a third of women more than ten. “Wait it out” is not a plan for someone whose sleep breaks every night.

But the hot-flush stereotype describes Indian clinics poorly. In a community study of 401 women aged 40 to 50 in urban Mumbai, muscle and joint pains were the commonest complaint at 65%, while hot flushes and sweating were reported by only 12.5%. That is one city, not a national figure — but it matches what comes through the door, and it is why aching joints in a woman of 46 deserve to be taken seriously rather than treated as unrelated.

Does it need a blood test?

Usually not. Over 45 it is a clinical diagnosis, made from the pattern of periods and symptoms. A single FSH or oestradiol level in the perimenopause can mislead, because the hormones swing from week to week; the UK Faculty of Sexual and Reproductive Healthcare advises going by symptoms rather than FSH unless premature menopause is a concern. A hormone test earns its place when periods stop before 40, when the picture is unclear in the early forties, or when a hormonal contraceptive masks the pattern. Worth checking instead: haemoglobin, thyroid function, blood sugar and lipids — anaemia and thyroid disease imitate menopause closely and both are common here.

What helps hot flushes and night sweats

This is where the most money is wasted. The Menopause Society reviewed the non-hormonal options in 2023 and separated them clearly.

That last line needs care. Exercise and yoga were not found to reduce hot flushes — a narrow verdict on one symptom. They remain among the most useful things a woman in her forties can do for her bones, blood pressure, blood sugar, sleep and mood, and nothing here argues against them. What the review does argue against is paying for supplements marketed for menopause.

Hormone therapy: who it suits, and who it does not

Hormone therapy remains the most effective treatment for hot flushes and night sweats. The Menopause Society’s position is that for most healthy women with symptoms who are under 60 and within ten years of their menopause, the benefits outweigh the risks; the British Menopause Society adds that it is first-line for preventing osteoporosis in symptomatic women under 60. The decision is individual, and the conversation covers three things.

• Route and type matter. Transdermal oestradiol — a patch or gel — is unlikely to raise the risk of clot or stroke the way oral oestrogen can, and micronised progesterone appears kinder than older progestogens. A woman who still has her uterus needs a progestogen alongside oestrogen; a 52 mg hormonal IUCD can do that and handle heavy perimenopausal bleeding at the same time.
• Breast cancer is the question everyone asks. Oestrogen alone shows little or no change in risk. Combined therapy carries a small risk that depends on duration and on the progestogen used — low in context, the British Menopause Society says, smaller than the effect of obesity or regular alcohol. A past breast cancer is a contraindication to systemic therapy, and that discussion belongs with the treating oncologist.
• There is no fixed stopping date. Arbitrary limits on duration are not supported, and treatment need not stop at 60 or 65 for the birthday alone. It is reviewed at least once a year.

Two points that get missed: hormone therapy is not contraception — pregnancy in the perimenopause is uncommon but real, and contraception can be stopped at 55 — and compounded “bioidentical” hormones made up by a pharmacy are not better than licensed ones, only untested.

Vaginal dryness and urinary symptoms are a separate problem

Dryness, soreness, pain with intercourse and recurrent urinary symptoms form a different group — the genitourinary syndrome of menopause — and behave differently. Flushes fade with time; these do not, and without treatment they are generally progressive. They affect a large share of postmenopausal women, and most never mention them, because nobody asks.

Treatment is usually local and straightforward. Lubricants for intercourse and a regular vaginal moisturiser come first. Where that is not enough, low-dose vaginal oestrogen is effective, is only minimally absorbed into the bloodstream, does not need a progestogen alongside it and is not associated with an increased risk of breast cancer. It usually has to be continued, because symptoms return when it stops. Laser and other energy-based devices sold for this have not been shown to work in properly controlled trials.

Bones, heart and the checks that matter after 45

Bone loss speeds up around the menopause, and Indian women start from a lower base. In a community study of 150 postmenopausal women aged 50 and over in semi-urban Tamil Nadu, osteoporosis was present at some site in about half, and half had vitamin D insufficiency or deficiency. Those are research figures from one region, not a measure of any clinic’s own patients, but the direction is consistent across Indian studies: calcium, vitamin D, weight-bearing activity and, where indicated, a bone density scan and treatment all earn their place.

The cardiovascular advantage women hold over men also narrows after menopause as oestrogen falls, which makes the mid-forties the point to start checking blood pressure, blood sugar and lipids at intervals rather than only when something hurts — alongside breast awareness and cervical screening.

Bleeding after menopause always needs a look

One rule matters more than anything else here: any bleeding after a full year without periods needs to be assessed — not watched, and not treated over the phone. So does bleeding between periods, bleeding after intercourse, or a sudden change to much heavier bleeding in the perimenopause. Most have a benign explanation — a polyp, a fibroid, a thin fragile lining, a hormonal cause. The rule exists for the minority that do not, and because assessment is quick: an examination, a pelvic ultrasound, and a hysteroscopy with a biopsy where the scan or the history calls for it. Our article on heavy periods and what actually treats them covers that work-up, and fibroid treatment the commonest structural cause.

If it happens before 40

Periods stopping before 40 is premature ovarian insufficiency — a different situation, needing investigation rather than reassurance. The British Menopause Society position is that women with premature or early menopause should use hormone therapy at least until the average age of natural menopause, because those extra years without oestrogen affect bone and cardiovascular health as well as symptoms. Fertility questions there are best raised early.