Stages
- Perimenopause: the years before menopause, with irregular periods and emerging symptoms; pregnancy is still possible.
- Menopause: 12 months after the last period.
- Postmenopause: the years after menopause.
In women over 45 with typical symptoms, menopause is usually diagnosed from the menstrual pattern and symptoms, and hormone tests are often not needed. Blood tests can help in younger women or when the picture is unclear.
Symptoms
- Hot flushes and night sweats
- Sleep problems and fatigue
- Mood changes and difficulty concentrating
- Vaginal dryness, painful sex, recurrent urinary infections (genitourinary syndrome)
- Urinary incontinence
- Joint pain, skin and hair changes
Hot flushes last several years in most women; the average is around 7 years, and longer in some. The type and severity of symptoms vary widely.
Early menopause and premature ovarian insufficiency
Loss of ovarian function before 40 is called premature ovarian insufficiency. Causes include genetic factors (fragile X premutation, chromosomal differences), autoimmune disease and chemotherapy or radiotherapy; often no cause is found. Hormone therapy is recommended at least until the natural age of menopause to protect bones and heart unless contraindicated. For women wanting pregnancy, options are discussed after assessing ovarian reserve. Young women with a family history of early menopause benefit from reserve monitoring and information on egg freezing.
Healthy ageing after menopause
Menopause is a natural life stage, not a disease, and women now spend around a third of their lives after it. The aim is therefore not only to ease symptoms such as hot flushes but to support an active, independent and healthy life in the years ahead. Falling oestrogen affects bones, heart, metabolism, the pelvic floor, sleep and mental health, and much of this can be positively influenced by lifestyle, regular check-ups and treatment when needed.
Bone health
Bone loss accelerates in the first years after menopause and can lead to osteoporosis and fractures of the hip, spine and wrist. Low body weight, smoking, early menopause, a family history of hip fracture, long-term steroid use and some chronic diseases increase risk. Bone density scanning (DXA) is recommended from 65, or earlier with risk factors. Hormone therapy prevents bone loss and reduces fracture risk, and other bone medicines are also available.
Cardiovascular and metabolic health
After menopause LDL cholesterol tends to rise, fat shifts to the abdomen, and insulin resistance and high blood pressure become more common. Cardiovascular disease is a leading health problem for women after menopause. Pre-eclampsia or gestational diabetes in pregnancy and early menopause are important clues to future risk. Blood pressure, cholesterol, blood sugar and waist circumference should be checked regularly. Hormone therapy is not started solely to prevent heart disease; lifestyle and control of risk factors are the foundation.
Pelvic floor and genitourinary syndrome
Lower oestrogen thins the tissues of the vagina, vulva and urinary tract, causing dryness, burning, painful sex, urinary frequency, leakage and recurrent urinary infections, known as the genitourinary syndrome of menopause. Unlike hot flushes, these symptoms usually do not resolve and often progress. Vaginal moisturisers, lubricants and low-dose vaginal oestrogen are effective, and very little vaginal oestrogen reaches the bloodstream; vaginal oestrogens have no adverse effect on the uterus or breast. Pelvic floor muscle training is the first step for leakage and prolapse symptoms.
Sleep
Night sweats, anxiety and sleep apnoea, which becomes more common with age, can disturb sleep. Regular sleep times, avoiding caffeine and alcohol in the evening, a cool dark bedroom and daytime activity help. Snoring with daytime sleepiness warrants assessment for sleep apnoea. Cognitive behavioural therapy (CBT) is effective for insomnia.
Mood and cognition
Mood swings, anxiety and low mood can be more frequent in perimenopause. Forgetfulness and poor concentration are common and usually temporary. CBT can help with the psychological impact of menopausal symptoms. Persistent low mood, loss of interest or hopelessness should be assessed for depression. Hormone therapy is not recommended to prevent dementia.
Exercise and resistance training
Regular activity benefits bones, muscles, heart, weight, sleep and mood. The general recommendation is at least 150 minutes of moderate aerobic activity a week (brisk walking, swimming, cycling) plus muscle-strengthening (resistance) exercise for the major muscle groups on at least 2 days a week. Because muscle mass and strength decline with age, strength training with weights, bands or body weight is especially important around menopause. Weight-bearing exercise supports bone density and balance training helps prevent falls. Build up gradually according to your health.
Nutrition, calcium and vitamin D
A Mediterranean-style diet rich in vegetables, fruit, whole grains, legumes, olive oil and fish supports heart and metabolic health. Adequate protein helps preserve muscle, while salt, sugar and processed foods should be limited. Calcium needs after menopause are about 1000-1200 mg a day, ideally from dairy, green leafy vegetables and nuts; supplements can be considered if intake is insufficient. Vitamin D deficiency is common in Türkiye; levels can be checked when needed and deficiency treated with appropriate doses, avoiding unnecessarily high doses.
Smoking and alcohol
Smoking can bring menopause forward, worsen hot flushes and increases the risk of bone loss, cardiovascular disease and many cancers; stopping helps at any age. Alcohol increases breast cancer risk, disturbs sleep, can trigger hot flushes and harms bone health, so intake should be kept as low as possible.
Screening and regular check-ups
- Breast screening: the national programme offers mammography every two years between 40 and 69; this may change with personal or family risk.
- Cervical screening: HPV testing and smear every five years between 30 and 65 in the national programme.
- Bone density: for all women from 65, earlier with risk factors such as early menopause, low body weight or steroid use.
- Cardiovascular and metabolic checks: blood pressure, lipid profile, fasting glucose or HbA1c and waist circumference at regular intervals.
- Bowel screening: faecal occult blood testing and colonoscopy between 50 and 70 in the national programme.
How often these are needed depends on individual risk. Any vaginal bleeding after menopause, however light, should be assessed.
Treatment options
Not every woman with menopausal symptoms needs treatment. Decisions consider how much symptoms affect daily life, age, time since menopause, personal and family history and personal preference.
Lifestyle
Regular exercise, a healthy weight, stopping smoking, enough calcium and vitamin D, and avoiding triggers such as hot drinks, alcohol, spicy food and hot environments ease symptoms for many women.
Menopausal hormone therapy
Hormone therapy is a first-line treatment with strong evidence for hot flushes and night sweats. It also treats genitourinary symptoms and prevents bone loss. Women with a uterus need progestogen with oestrogen to protect the lining; women without a uterus can use oestrogen alone. Oestrogen can be taken as tablets or applied to the skin as gel or patches (transdermal).
Why timing matters
According to current guidelines, for most women with bothersome symptoms who start individualised therapy before 60 or within 10 years of menopause, benefits outweigh risks. When therapy is started for the first time after 60 or more than 10 years after menopause, absolute risks of heart disease, stroke, blood clots and dementia are higher, so the balance is less favourable and the decision is made more cautiously.
When hormone therapy is not suitable
- Current or past breast cancer, or suspected breast cancer
- Oestrogen-sensitive cancers such as endometrial cancer
- Unexplained vaginal bleeding
- Previous deep vein thrombosis or pulmonary embolism, or known high clotting tendency (transdermal therapy may be considered in some cases after specialist assessment)
- Previous heart attack or stroke
- Active liver disease
- Pregnancy
Non-hormonal treatments
For women who cannot or do not wish to use hormones, some antidepressants, gabapentin and newer medicines targeting the brain's temperature-control centre (neurokinin-3 receptor antagonists) can reduce hot flushes. CBT can also ease the distress of hot flushes, sleep and mood symptoms.
Vaginal treatments
Moisturisers, lubricants and low-dose vaginal oestrogen help dryness and painful sex. Vaginal oestrogen may also be suitable for many women who cannot use systemic hormone therapy; this is assessed individually.
What is body-identical (bioidentical) hormone therapy?
Bioidentical or body-identical hormones have exactly the same chemical structure as hormones made by the body. In menopause care these are mainly 17-beta estradiol and micronised progesterone. They are usually made in the laboratory from plant-derived substances; the word "natural" refers to this origin, but the product itself is manufactured. It is important to distinguish two different groups.
Approved (regulated) body-identical hormones
These are licensed products with standardised dose and purity and with efficacy and safety data: estradiol gel or patches, estradiol tablets, micronised progesterone capsules and vaginal estradiol. They can form part of individualised menopausal hormone therapy.
- Transdermal estradiol: because it avoids first-pass metabolism in the liver, observational studies show that, unlike oral oestrogen, it does not increase the risk of venous thrombosis. It may therefore be preferred in women with a BMI over 30 or other clotting risk factors.
- Micronised progesterone: used in adequate dose and duration to protect the lining of the uterus in women with a uterus. Studies show a more favourable breast and clotting profile than some synthetic progestogens, which is why it is a commonly preferred part of hormone therapy in women with a uterus.
Custom-compounded "bioidentical" preparations
Creams, gels, lozenges or capsules said to be tailored to saliva or blood hormone levels are marketed in some places as "bioidentical hormones". These preparations do not go through drug approval, are not standardised for dose, purity or absorption, and lack adequate evidence of efficacy and safety. It is not known whether they adequately protect the lining of the uterus, which may add risk in women with a uterus, and they do not carry the risk warnings of approved products.
The Menopause Society (formerly NAMS), ACOG, the Endocrine Society, the British Menopause Society and the International Menopause Society do not recommend routine use of such preparations when approved products are available.
Salivary hormone testing is also unreliable. Hormone levels vary during the day and from day to day, so saliva tests are not recommended to guide treatment. Except in specific situations, the dose of hormone therapy is adjusted according to symptom control and side effects rather than blood levels.
The right product, for the right person, at the right time
No single product or dose suits every woman. The decision takes into account age and time since menopause, the type and severity of symptoms, whether the uterus is present, personal and family history of breast cancer, blood clots, cardiovascular disease, migraine and liver disease, and personal preference. The hormone, route (tablet, gel, patch or vaginal) and dose are chosen accordingly.
Benefits and side effects are reviewed about 3 months after starting and at least once a year thereafter. Unexpected bleeding after the first months of treatment must be assessed. Hormone therapy does not stop or reverse ageing; its purpose is to relieve menopausal symptoms, support quality of life and protect bone health in suitable women.
Prof. Dr. İkbal Kaygusuz is a co-author of studies on the effects of menopausal hormone therapy and plant-derived treatments such as genistein on vascular health, platelets and kidney function.
When should you see a doctor?
- Hot flushes, sleep or mood symptoms affect your daily life
- Your periods became irregular or stopped before 40
- You have vaginal dryness, painful sex or recurrent urinary infections
- You have any vaginal bleeding after menopause
- You are considering starting hormone therapy or reviewing your current treatment
Frequently Asked Questions
Is bioidentical hormone therapy safer because it is natural?
How long can hormone therapy be used?
Does hormone therapy cause cancer?
Do I need a hormone test to diagnose menopause?
Can I get pregnant around menopause?
Sources
- The 2022 Hormone Therapy Position Statement of The North American Menopause Society (The Menopause Society). Menopause, 2022.
- National Institute for Health and Care Excellence. Menopause: identification and management (NG23), 2015, updated 2024.
- International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause. Climacteric, 2025.
- British Menopause Society. Consensus statement: Bioidentical HRT (reviewed 2026).
- American College of Obstetricians and Gynecologists. Compounded Bioidentical Menopausal Hormone Therapy. Clinical Consensus No. 6, 2023.
- Santoro N, et al. Compounded Bioidentical Hormones in Endocrinology Practice: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab, 2016.
- Effects of oral hormone replacement therapy on mean platelet volume in postmenopausal women. Turkish Journal of Medical Sciences, 2014.
- Does hormone replacement therapy have beneficial effects on renal functions in menopausal women? Archives of Gynecology and Obstetrics, 2012.
- Effect of genistein therapy on plasma levels of asymmetric dimethylarginine in healthy postmenopausal women: a randomized, placebo-controlled study. Fertility and Sterility, 2010.
The information on this website is for general information only and does not replace a medical consultation.
