MYTHS AND FACTS ABOUT THE MENOPAUSE, PLUS WAYS HORMONES MAY HELP

Myths, uncertainties and long-outdated assumptions mark the menopause like few other areas of medicine and health care.

This is particularly true of menopausal hormone therapy, or hormone replacement therapy (HRT), prescribed to help women handle some menopausal symptoms.

What to know

Menopause - what exactly is it?

The menopausal transition describes the change from the reproductive phase of a woman's life to permanent infertility and is associated with significant hormonal changes. Menopause or climacteric are terms used to describe the entire transition phase, which usually lasts 10 to 15 years.

The term is often used differently, but in fact "menopause" refers exclusively to the time of the last menstrual period and is determined retrospectively when no period has occurred for twelve months.

On average, menopause occurs at the age of 51, by when the supply of eggs created before birth is exhausted. The timing has remained unchanged, even though women today live significantly longer on average and are usually much fitter at 50 than their peers were 50 or 100 years ago.

What exactly happens?

"Most women think they don't have any menopause symptoms as long as their period comes reasonably on time," says DMG President Katrin Schaudig. However, the first changes in the cycle and symptoms such as mood swings can occur as early as the late 30s or early 40s – the first signs of the onset of the menopause.

During perimenopause, usually between the ages of 45 and 50, the cycle becomes increasingly irregular, with intermenstrual bleeding and longer breaks between periods. Fluctuations in both cycle-determining hormones (progesterone and oestrogen) characterise this phase.

"These are then spring tides and tsunamis in hormone levels instead of ebb and flow as before in the cycle," says Schaudig. Psychological problems can arise. Towards the end of perimenopause, oestrogen levels drop significantly. Symptoms such as hot flushes and sleep disorders become more frequent.

Postmenopause after menopause is characterised by increasingly low but more stable levels of both sex hormones. The risk of cardiovascular and bone diseases increases, and other long-term effects such as changes in the skin, mucous membranes and body composition are also typical.

Experts emphasise that symptoms and levels of discomfort vary greatly from person to person in each phase. In addition, the problems usually do not persist continuously, but flare up periodically.

Around a quarter of women experience severe symptoms, only mild symptoms, intermittent symptoms or no symptoms at all, says Olaf Ortmann from the University Clinic for Gynaecology and Obstetrics in Regensburg, Germany.

Menopause also has a highly unpleasant characteristic, namely "the earlier the symptoms start, the longer they usually last," says Ortmann. "It can take three years – but also 15 years." Sometimes certain symptoms persist in a milder form throughout life. "Hot flushes are – extremely rarely – still possible at the age of 80."

Menopause or ageing – is there a clear difference for each symptom?

No. Hot flushes, associated with heavy sweating, especially at night, are considered a classic symptom related to changes in hormone levels.

On average, women in the menopause experience hot flushes frequently – on more than six days within the last two weeks – for more than seven years, says the guideline "Peri- and Postmenopause – Diagnostics and Interventions" developed by professional associations in Germany.

Sleep disorders, depression, mood swings, anxiety, sexual problems and joint pain are symptoms that can have various causes, but according to Schaudig, they become more frequent and intense during menopause.

Gynaecologist Sheila de Liz also lists depression, anger attacks, hair loss, itchy skin or mysterious eczema, headaches, frequent bladder infections, nocturnal urinary urgency, hearing loss, weight gain and dizziness as possible menopausal symptoms in a book on the menopause.

In many cases, it is not possible to say clearly what is specifically attributable to the menopause – which is ultimately also part of the natural ageing process, says Ortmann. Stress and strain in everyday life also play a major role in the severity of symptoms – and can be particularly significant for women around the age of 50.

Socially disadvantaged women who are under great pressure and have little opportunity to create well-being and freedom for themselves are often severely affected, say researchers.

This is consistent with studies showing that menopausal symptoms play little or no role in societies where older people are highly respected – meaning among women who tend to enjoy a high level of well-being.

Will having my hormones checked provide more clarity?

Not generally. During perimenopause, hormone levels fluctuate greatly – according to experts, sometimes by a factor of 20 – and therefore do not accurately reflect the status during menopause. "The various phases of the menopausal transition can be diagnosed primarily on the basis of clinical criteria," say guidelines. "Hormone testing is generally not necessary."

However, Ortmann says that for certain problems such as palpitations, high blood pressure or depressive moods, it may well be useful to consider your hormone levels.

Time and again, women with sleep problems are prescribed sleeping pills or those with low moods are given antidepressants, or are sent to orthopaedic surgeons or rheumatologists for joint pain - without anyone considering the possibility of the menopause.

What can I do?

You can alleviate symptoms through diet, exercise, mindful behaviour and targeted relaxation exercises, say experts. "There are many things you can do yourself," says Ortmann. For hot flushes, for example, lowering the room temperature in the bedroom can help. Herbal remedies are also considered helpful by many.

"However, herbal remedies are not very effective if the symptoms are severe," says Ortmann. Hot flushes every few hours or weeks of sleep deprivation can be so distressing that they significantly impair quality of life and ability to work. Some women even retire earlier than planned because of this, says Schaudig. With the right hormone therapy, this can often be avoided. "The quality of life of many women is unnecessarily poor."

Menopausal hormone therapy, known as MHT, is particularly effective for hot flushes and sleep problems. The term is still quite new; for decades, the treatment was known as hormone replacement therapy (HRT).

The new name aims to focus more on the normal decline in hormones during the menopause and avoid the misunderstanding that hormones that should actually be present need to be replaced, Ortmann says. That would be the case say with an underactive thyroid, but not with the menopause.

In Germany, oestradiol administered through the skin is predominantly used to alleviate symptoms, though treatment varies from one country to the next.

Progesterone is often prescribed in capsule form as a supplement to protect the lining of the uterus from excessive growth caused by oestrogen. It can also be used to alleviate sleep disorders.

Will that give me breast cancer?

The widespread concern that hormone therapy significantly increases the risk of breast cancer stems, among other things, from the WHI (Women's Health Initiative) study published in 2002. The study was terminated prematurely because a slightly increased risk of breast cancer was found in one subgroup.

The participants were mainly older women who had gone through the menopause and were given oral oestrogen in combination with a specific progestin. Subsequent evaluations showed that when therapy is started early – a maximum of 10 years after the menopause or at a maximum age of 60 – the beneficial effects often outweigh the potential negative consequences.

"With adequate therapy, the risks are comparatively low," says Ortmann. However, a misinterpretation of the WHI results meant that hormone therapy, which had previously been widely used, was prescribed significantly less for decades. There are still doctors who are very hesitant to prescribe it, partly because of the high cost of consultation, says Schaudig. "However, there are also those who prescribe it very lightly."

According to experts, there has been less research in this field since the WHI study, which is one reason why many correlations are only suspected but not considered proven.

Apart from breast cancer, there is hardly any reliable information on the interactions of hormone therapy with existing diseases. German medics are revising the guideline, coordinated by Vanadin Seifert-Klauss from the Technical University of Munich. It is set to include MHT for pre-existing conditions as a new chapter, expected by year end.

Does MHT have any positive long-term effects beyond reduced symptoms?

Yes. Menopausal hormone therapy has been shown to reduce the risk of osteoporosis, coronary heart disease and heart attacks, explains Ortmann. There are indications of a link with a reduced risk of diabetes, but no clear evidence as yet.

Will I live longer with hormone therapy?

No, says Ortmann. Studies have shown no associated increase in life expectancy – which could be because the benefits and risks balance each other out in the long term. Nor can any evidence of a reduced risk of dementia be derived from the data available to date. However, experts say that the therapy may enable older people to live with fewer complaints and signs of ageing.

Shouldn't all women undergo hormone therapy?

Some books and articles on the subject that promote the idea, giving the impression that it would be foolish not to take this magic remedy for countless ailments.

After all, your hair may look better and you might have fewer wrinkles, and for some women, this may even be more important than reducing health risks. But Schaudig and Ortmann warn that hormone therapy is not suitable as a lifestyle product. General, purely prophylactic hormone therapy is not recommended and women should take the risks seriously.

More serious risks are known to exist, particularly in cases of high blood pressure and certain existing cardiovascular and tumour diseases. In most cases, hormone therapy is not recommended for those affected, Ortmann says.

But aren't bioidentical hormones supposed to be completely harmless?

This is what you read in some forums and articles, but it is incorrect. The term "bioidentical" is often assumed to mean that it is a natural substance, says Ortmann. However, it only means that the active ingredient is structurally similar or identical to the oestrogen produced in the human body.

On the other hand, equine oestrogens, which are produced from mares' urine, are structurally slightly different. "They are no worse than bioidentical oestrogens and do not pose any higher or different risks when taken in the same way," says Ortmann.

The main difference is whether the active ingredients are administered as tablets or via the skin – in the form of a gel, patch or spray.

Transdermal absorption avoids initial processing in the liver, known as the first-pass effect: oral oestrogen administration promotes the formation of coagulation factors there, which in turn increases the risk of venous thrombosis and stroke, Ortmann says.

But the effects mediated by the liver are also stronger for other processes – possibly including the desired effects, say scientists. Overall, the long-term side effects are less severe than with tablets – but it is feared that this also applies to the effect on osteoporosis risk.

How long should I take the hormones?

Menopausal hormone therapy is usually given for several years, says Ortmann. The therapy should be continued for as long as it is necessary to treat moderate or severe menopausal symptoms. The limit is a matter of judgement, says Schaudig, who, together with presenter Katrin Simonsen, produces a podcast on the issue in Germany.

Some people continue the therapy for a long time, sometimes until retirement, partly as symptoms can become more severe again once you stop taking the hormones.

2025-10-30T12:24:20Z