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Menopause is the point at which periods stop permanently, confirmed once you have gone twelve months without one. The average age in the UK is 51.
The symptoms, though, begin long before that — often in your mid-forties — and it is that earlier phase, perimenopause, that catches most people out. Because periods are still happening, the connection frequently is not made.
Fewer than half of women experience the classic hot flushes as their main symptom. Mood, sleep and cognitive symptoms are extremely common and are the ones most often attributed to something else.
Menopause happens when the ovaries stop producing oestrogen. It is a normal life stage, not a disease.
It can happen earlier following surgery to remove the ovaries, after chemotherapy or radiotherapy, or spontaneously — premature ovarian insufficiency affects around 1 in 100 women under 40 and needs treating rather than accepting.
If you are over 45 with typical symptoms, no blood test is needed — UK guidance says so explicitly. The history is the diagnosis.
A normal FSH does not rule menopause out, and this specific misunderstanding causes real harm: it is routinely used to refuse treatment to women whose symptoms are unmistakable. Hormones fluctuate so widely through the transition that one sample can read premenopausal in March and postmenopausal in May.
Thyroid function and ferritin. An underactive thyroid and iron deficiency produce almost exactly the same picture — fatigue, low mood, poor concentration, hair thinning, feeling cold — and both are common at this age.
Attributing everything to hormones without checking those two is the commonest error made here.
Salivary hormone testing and "hormone balance" panels have no validated basis. They are used almost entirely to sell compounded bioidentical hormones — unregulated, and specifically advised against by the British Menopause Society.
In women over 45 with typical symptoms, menopause is diagnosed clinically — on your history, not a blood test. Hormone levels fluctuate week to week and can be actively misleading.
Under 45, or with irregular cycles, hormone testing genuinely helps.
Treatment options are discussed in full: HRT in its various forms, non-hormonal alternatives, and what the evidence actually says about risk. A review at three months follows, because the first preparation is frequently not the final one.
Report any bleeding after menopause — that is, any vaginal bleeding twelve months or more after your last period. It is usually benign, but it always needs investigating and should not wait.
Also seek advice promptly for unexpected bleeding on HRT that persists beyond the first few months, or for calf pain, chest pain or sudden breathlessness.
Bone loss accelerates sharply in the years after menopause, and cardiovascular risk rises too. Both are silent, and both are the reason menopause care is about more than symptom control.
Weight-bearing exercise, adequate vitamin D and calcium, and knowing your blood pressure are the practical steps. A free pharmacy blood pressure check is a good place to start.
Vaginal dryness and urinary symptoms do not improve on their own and they do not settle with time — unlike flushes, which usually do.
Vaginal oestrogen is highly effective, is used by almost everyone who needs it without difficulty, and carries a different and much lower risk profile than systemic HRT. It can be used alongside HRT or on its own, including by many women who cannot take systemic treatment.
It is under-prescribed, largely because it is under-asked-about.
The HRT prepayment certificate covers all your HRT prescriptions for a year for one payment. For most women it is a substantial saving, and it is badly under-claimed.
HRT is free on the NHS, and since 2023 England has had an HRT prepayment certificate costing roughly the price of two prescriptions and covering all HRT for a year. NHS prescriptions are free in Wales. Anyone paying per item for HRT in England should check this — it saves a substantial amount and is widely unknown.
Your NHS GP can prescribe HRT, and most menopause care belongs there. There is no blood test needed to diagnose menopause in women over 45 — it is a clinical diagnosis based on symptoms, and FSH testing in that age group is explicitly not recommended, which matters because private clinics sometimes sell it.
Where a private consultation genuinely helps is time. Menopause is not a ten-minute problem: it involves weighing symptoms, risks, preparations, routes and what you actually want from treatment. Twenty minutes allows that conversation properly.
What we will be honest about: compounded “bioidentical” hormones sold by private clinics are not recommended — they are unregulated, unmonitored for purity, and there is no evidence they are safer than regulated body-identical HRT, which is available on the NHS. Salivary hormone testing has no clinical value.
Where private care is worth paying for: a complex history — previous breast cancer, clotting disorders, migraine with aura — where a specialist menopause opinion is genuinely useful, and NHS menopause clinic waits are long.
NICE NG23, Menopause: diagnosis and management, is the governing guideline. It states menopause should be diagnosed clinically without laboratory tests in women over 45 with typical symptoms, and reserves FSH testing for women under 45 or with atypical presentations.
NG23 sets out the benefits and risks of HRT, including that transdermal oestrogen does not carry the increased venous thromboembolism risk associated with oral preparations — relevant to route choice.
NG23 recommends discussing the small increased breast cancer risk with combined HRT in absolute rather than relative terms, and notes that oestrogen-only HRT carries little or no increased risk.
NICE and the British Menopause Society both advise against compounded bioidentical hormones and salivary hormone testing, which is the basis for the position above.
NG23 also covers non-hormonal options and CBT for vasomotor symptoms and low mood.
Over 45 with typical symptoms, no. The diagnosis is clinical and HRT can be started without one.
A normal result should never be used to refuse you treatment.
On average around seven years, and for some women considerably longer. "It will pass" is true eventually and not much comfort in year four.
Vaginal and urinary symptoms are the exception — they persist and worsen without treatment rather than settling.
For most women starting under 60 or within ten years of menopause, the benefits outweigh the risks. That is the current UK position and it is a meaningful shift from what many people absorbed twenty years ago.
Combined HRT carries a small increase in breast cancer risk that falls after stopping; oestrogen-only carries little or none. Against that sit symptom control, bone protection and quality of life.
It is a genuine decision, and being frightened out of treatment by a headline is its own harm.
HRT does not cause weight gain. Weight tends to redistribute around the middle at this stage of life regardless, driven by falling oestrogen and age.
Some women find HRT makes it easier to manage, by improving sleep and energy enough to exercise.
Yes. Treatment can begin during perimenopause — you do not have to wait until periods stop.
You still need contraception until twelve months after your last period, and HRT does not provide it.
The first preparation is frequently not the final one, and switching type, dose or route resolves most problems.
Non-hormonal options exist too — including CBT, which has good evidence for flushes and for sleep, and certain non-hormonal medicines.
Possibly, and it is worth excluding. An underactive thyroid produces near-identical symptoms and is entirely treatable in a different way.
Iron deficiency does the same, and both are common in women of this age.
Get it checked, always. Any bleeding twelve months or more after your last period needs investigating, however light and however brief.
It is usually not cancer — but it is the symptom that finds the cases that matter, and it should never be watched and waited on.
August 23, 2026
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It means the diagnosis can usually be made from your history and photographs, and that treatment can be arranged safely without examining you. Where a condition is not marked treatable online, it is because examination is the diagnosis — listening to a chest, feeling an abdomen, examining an ear or a joint — or because a procedure or device is needed.
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If your problem turns out to be genuinely outside what we can do remotely, the doctor will tell you straight away, point you to the right service, and refund your fee in full. We would rather do that than fill twenty minutes to justify the charge.
Call 999 or go to A&E — do not book an online appointment and do not wait for a reply to an email. For urgent problems that are not emergencies, NHS 111 is available 24 hours a day, online or by phone, and can direct you to the right service.
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