Sometimes I meet patients who are utterly exhausted by their monthly cycles — the heavy bleeding, the pain, the unpredictability — and they tell me they “can’t wait for menopause.” It’s an understandable sentiment. But menopause brings its own challenges, and over time I’ve come to think of it as a kind of second puberty: a hormonal transition that reshapes physiology, mood, sleep, and emotional equilibrium.

Before exploring that idea, it’s important to get the terminology right.

What is Menopause?

Menopause literally means “the end of monthly cycles”, derived from the Greek mēn (month) and pausis (pause). Clinically, menopause is diagnosed retrospectively because menstrual cycles often become infrequent and irregular around the menopausal transition. A woman is considered to have reached menopause 12 months after her last menstrual period, and from that point she is postmenopausal.

Why does menopause happen?

Menopause occurs because of the natural decline in ovarian function. Throughout reproductive life, the ovaries contain a finite number of follicles. Over time, this pool diminishes, and eventually the ovaries stop producing new follicles or eggs. As this happens, cyclical production of oestrogen and progesterone gradually decreases.

This process is not abrupt. Instead, it unfolds over several years, which is why the transition feels so changeable and unpredictable for many women.

Understanding the transition

Menopausal symptoms often begin before periods stop. This phase is known as  the ‘perimenopause’, when ovarian hormone fluctuations start to produce symptoms, even though cycles may still be regular. In fact, symptoms often intensify in the premenstrual days, and many women find this stage the most challenging.

Perimenopause typically lasts 4 – 8 years. In Australia, the average age of menopause is 51, with a normal range between 45 and 56 years.

How long do symptoms last?

There is no reliable way to predict how long menopausal symptoms will continue for an individual woman. Patterns vary widely:

• For most women, symptoms resolve within 2 – 5 years
• 10 – 20% of women experience symptoms for up to 12 years
• Some symptoms may appear only in specific contexts: for example, vaginal dryness may be most noticeable during intercourse

Symptom duration depends on hormonal patterns, health factors, and life circumstances. While the variability can be frustrating, understanding the range helps set realistic expectations.

What is More Important: the diagnosis of menopause, or symptom severity?

From a clinical perspective, symptom severity is far more important than the formal diagnosis of menopause. Menopause itself is a clinical diagnosis, and in most cases, we do not need — nor benefit from — blood tests to confirm it.

Hormone levels such as FSH and estradiol fluctuate significantly, sometimes day-to-day, during the menopausal transition. Blood tests are particularly unhelpful when a woman is already taking menopausal hormone therapy (MHT) or the oral contraceptive pill (OCP), as these medications alter hormone levels and make interpretation meaningless.

We doctors are far more interested in symptoms than laboratory numbers, because treatment is offered to address how a woman feels, not to “treat” peri/menopause itself.

What are the Symptoms of Menopause?

I like to group them in 4 main categories, as follows:

Vasomotor symptoms

Hot flushes and night sweats are the hallmark symptoms of menopause. They are a major contributor to sleep disturbance, which in turn can negatively affect daily functioning, work performance, mood stability, and relationships.

Genitourinary syndrome

Vaginal dryness, burning, irritation, reduced lubrication with sexual activity, painful intercourse, and increased susceptibility to urinary tract infections. Many women experience these symptoms silently, often not realising they are treatable.

Psychological and cognitive symptoms

Mood changes, anxiety, irritability, forgetfulness, difficulty concentrating, and trouble making decisions. These cognitive symptoms are often described as “brain fog” and can be particularly distressing during perimenopause.

Skin changes

Dryness and thinning of the skin are common. Some women report itchiness or a sensation of crawling under the skin, reflecting changes in collagen and skin hydration associated with declining estrogen levels.

What are the Management Options?

Management of menopausal symptoms can be grouped into: hormonal; non-hormonal; complementary approaches; and lifestyle changes.

The website mymenoplan.org (written by US-based menopause clinicians and scientists) has a wonderful tool where you can create your ‘Menoplan’ based on your most significant menopausal symptoms. This produces a table of management options, for each of your chosen symptoms. You can then click each management option (eg. ‘acupuncture’, ‘hormone therapy’) to read more details about what this entails.

Menopausal Hormone Therapy (MHT)

Menopausal hormone therapy (MHT) remains the most effective treatment for vasomotor symptoms, and for many women it can significantly improve quality of life. Modern MHT uses lower doses than previously, and current evidence shows that for most healthy women within ten years of menopause, the benefits outweigh the risks. During perimenopause, combined oral contraceptive pills can offer similar symptom control when there are no contraindications, with the added advantage of reliable contraception.

MHT can be offered as estrogen only treatment for women who have had a hysterectomy, or as combined MHT (estrogen plus progestogen) for women with a uterus, where the progestogen provides essential endometrial protection.

Combined MHT can be given cyclically, allowing predictable withdrawal bleeding, or continuously, where bleeding should not occur. In general, cyclical therapy suits women who are still having periods or whose last period was less than twelve months ago. Starting continuous therapy too early can lead to bothersome, unscheduled bleeding and unnecessary investigations.

Estrogen can be delivered via oral tablets, gels, or patches, and progestogen options include oral preparations, patches, or the IUD — all of which can be mixed and matched to suit individual needs. Before prescribing MHT, clinicians assess personal risk factors and overall suitability, and discuss the balance of benefits with potential risks, particularly those related to breast cancer, cardiovascular health, venous thromboemboli, and gallbladder disease, noting that risk varies with the person, the type of therapy, and the duration of use.

Non-hormonal therapy

Non-hormonal therapy can be a useful option for women who cannot use menopausal hormone therapy. It is important to recognise that these treatments primarily target hot flushes and night sweats, rather than the broader range of menopausal symptoms. Several medications can be considered on an individual basis — including certain antidepressants, gabapentin, and oxybutynin — although are used “off-label.”

Two medications are formally approved for vasomotor symptom management: fezolinetant and clonidine.

All non-hormonal options should be prescribed by a women’s health GP or gynaecologist after a thorough assessment and discussion of safety, expected benefits, and individual suitability.

Complementary approaches

Many women are curious about complementary therapies, often viewing herbal remedies as more “natural” options. While products such as Black cohosh, Red clover, Siberian rhubarb, Evening primrose oil, and Flaxseed have been explored in small clinical trials, the evidence for both effectiveness and safety remains limited. Some may offer modest relief of vasomotor symptoms, but they are best considered only after a full medical review to ensure its safe use.

Lifestyle changes

Lifestyle changes can play a meaningful role in helping women manage menopausal symptoms, and I often emphasise that these strategies can empower you to optimise your environment and wellbeing. Even small increases in body temperature can trigger a hot flush, so practical adjustments, as outlined below, can make symptoms less frequent or more manageable:

• Choosing natural fibres
• Wearing sleeveless or layered clothing
• Using fans
• Drinking cold beverages
• Lowering the bedroom temperature
• And / or keeping a cold pack nearby at night
• Avoiding common triggers like alcohol, smoking, spicy foods, and hot caffeinated drinks may also help

Many experts highlight the benefits of a Mediterranean style diet, rich in fruit, vegetables, olive oil, nuts, and fish, with limited red meat and minimal artificial additives, for cardiovascular and cognitive health. Regular physical activity supports thermoregulation and overall quality of life, with aerobic exercise and resistance training and yoga all showing benefit.

Prioritising sleep and practising good sleep hygiene is equally important for mental, metabolic, and cardiovascular health. Finally, recognising the impact of stress – especially during a life stage when many women juggle caring responsibilities and new physical changes – is essential; social connectedness, healthy relationships, mindfulness and cognitive behavioural therapy have all been shown to improve symptom experience.

Additional routine health checks

Managing risk is an important part of menopausal hormone therapy, and this includes routine breast checks and mammography for women over 50, an annual review of the MHT regimen, and earlier cessation if complications or new contraindications arise.

Management of genito-urinary symptoms

Lastly, genitourinary syndrome of menopause (GSUM) can be managed with both non-hormonal and hormonal options.

Non-hormonal approaches include vaginal moisturisers, such as polycarbophil gel or 0.2% hyaluronic acid gel, which help maintain hydration and improve comfort with regular use. A wide range of lubricants is also available: water-based products are generally the most affordable; silicone-based lubricants last longer; and oil-based lubricants (which should not be used with condoms if barrier contraception is required). For women who do not require barrier contraception, coconut oil or olive oil can be a cheap and safe alternative to commercial lubricants.

Hormonal treatments, including vaginal estrogens and vaginal DHEA, are highly effective in reducing bothersome dryness and discomfort, and are often recommended when symptoms persist despite non hormonal measures.

Conclusion

Menopause is a highly individual experience, and the goal of care is always to support women in feeling well, informed, and empowered. A wide range of options — hormonal, non-hormonal, complementary, and lifestyle-based — can be tailored to each person’s symptoms, health background, and preferences. What matters most is recognising that effective help exists and reaching out for support is an important first step toward feeling better.