In short: The menopause is a natural stage of life, but its symptoms can be anything but gentle. It happens in stages, beginning with the perimenopause, when symptoms appear while periods are still happening, and is confirmed once you have gone twelve months without a period. Hormone replacement therapy (HRT) is the most effective treatment for most people, but it is far from the only option. If you cannot take HRT, or would rather not, there are well-established alternatives. This guide explains the stages, the symptoms to recognise, and the full range of treatments, so you can have an informed conversation about what is right for you.
If you have found your way to this page, there is a fair chance you have spent a while wondering whether what you are feeling is “just stress”, “just getting older”, or something with a name. Disrupted sleep, a shorter fuse than usual, a memory that suddenly feels less reliable, periods that have become unpredictable: these changes can be unsettling, and they are too often dismissed or endured in silence. The reassuring truth is that they usually have a clear explanation, and there is a great deal that can be done to help.
At 108 Harley Street, our Women’s Health consultants support women through this transition every week. Below we explain what the menopause actually is, the stages it moves through, the symptoms worth recognising, and the treatments available, including what your options are if HRT is not right for you.
What the menopause actually is
The menopause is the point at which your ovaries stop releasing eggs and your periods stop, driven by a natural fall in the hormone oestrogen. According to the NHS, it usually affects women between the ages of 45 and 55, though it can happen earlier or later. In the UK the average age is around 51.
The menopause can also happen for reasons other than the natural passage of time. Surgery to remove the ovaries, a hysterectomy, or cancer treatments such as chemotherapy can bring it on, sometimes suddenly. When it begins before the age of 40 it is known as premature menopause, or premature ovarian insufficiency, which is assessed and managed differently and warrants specialist input. Unlike in women over 45, blood tests do have a role here, with the diagnosis made after two tests taken four to six weeks apart.
The stages: perimenopause, menopause and postmenopause
One of the most common points of confusion is the language. These three terms describe different stages of the same journey.
- Perimenopause. This is the lead-in, when hormone levels begin to fluctuate and fall. Crucially, you are still having periods, even if they have become irregular, and you can still experience the full range of symptoms. The NHS notes these symptoms can begin years before your periods actually stop. The perimenopause is where most people first notice that something has changed.
- Menopause. Strictly speaking, the menopause is a single point in time: the day you have gone a full twelve months without a period. It is diagnosed looking backwards, once those twelve months have passed.
- Postmenopause. This is the time after that point. Many symptoms ease over the following years, but some can continue, and the lower level of oestrogen has longer-term implications for bone and heart health that are worth being aware of.
If you are over 45 and have typical symptoms, NHS and NICE guidance is clear that you do not usually need a blood test to diagnose the menopause; the diagnosis is made on your symptoms and your pattern of periods. Blood tests have a clearer role in younger women, where the picture can be less obvious.
The symptoms worth recognising
Menopausal symptoms vary enormously from one person to the next. Some people sail through with little disruption, while others find their daily life significantly affected. The following are among the most commonly reported, drawing on NHS guidance.
Physical symptoms
- Hot flushes and night sweats (known medically as vasomotor symptoms), often the most recognisable sign.
- Changes to your periods, which typically become irregular before they stop altogether.
- Vaginal dryness, discomfort or itching, and discomfort during sex.
- Urinary symptoms, including needing to pass urine more often or discomfort when you do.
- Disrupted sleep, whether from night sweats or difficulty settling and staying asleep.
- Joint and muscle aches, headaches, and palpitations.
Emotional and cognitive symptoms
- Mood changes, including low mood, irritability and anxiety.
- “Brain fog”, problems with memory and concentration that can be particularly worrying at work.
- Reduced interest in sex (low libido), which can have several overlapping causes.
None of these symptoms in isolation proves you are perimenopausal, and several can have other causes that deserve attention in their own right. That is exactly why a proper assessment is valuable: it puts the whole picture together rather than guessing from a single symptom.
How the menopause is treated
This is the part most people are really searching for. The encouraging headline is that effective help exists, and the right approach depends on your symptoms, your medical history and your own preferences. Below we set out the main routes, beginning with HRT and then, importantly, the options for those who cannot or would rather not take it.
Hormone replacement therapy (HRT)
HRT works by replacing the oestrogen your body is no longer producing, and it is recognised by NICE as the most effective treatment for the hot flushes and night sweats that trouble so many people. It can also help with mood, joint aches and vaginal dryness, and it offers protection against osteoporosis.
HRT comes in several forms, tablets, skin patches, gels and sprays, and the right type depends partly on whether you still have your womb. If you do, you need a progestogen alongside the oestrogen to protect the womb lining; this can be a tablet, a combined patch, or the hormonal coil. If you have had a hysterectomy, oestrogen alone is usually appropriate.
For vaginal dryness and urinary symptoms specifically, a low-dose vaginal oestrogen (as a cream, tablet, pessary or ring) can be used on its own. It acts locally, is not absorbed into the bloodstream in any meaningful amount, and can be used long term, including alongside standard HRT.
As with any treatment, HRT carries some risks as well as benefits. Current NICE and NHS guidance is that for most people the risks are small and are usually outweighed by the benefits, but this genuinely depends on your individual history. It is a conversation to have with a clinician who can weigh up your particular circumstances rather than a decision to make from a headline.
If you cannot, or would rather not, take HRT
HRT is not suitable or wanted by everyone, and a good menopause service should be just as comfortable discussing the alternatives. The options below are recognised in UK guidance.
- Lifestyle measures. Regular, sustained aerobic exercise such as swimming or running can help with several symptoms, and reducing alcohol and caffeine may lessen hot flushes and night sweats for some people. These are rarely a complete answer on their own, but they are a genuine part of the toolkit.
- Cognitive behavioural therapy (CBT). NICE specifically recognises menopause-focused CBT as an option, not only for low mood and anxiety but also for the hot flushes and night sweats themselves. It can be used whether or not you also take medication.
- Non-hormonal medicines. Several prescription medicines can help with hot flushes and night sweats where HRT is unsuitable. In 2026, NICE recommended fezolinetant as an option for moderate to severe hot flushes and night sweats when HRT cannot be used, adding a newer, non-hormonal route to the existing choices a specialist can discuss.
- Treatments for specific symptoms. Low mood linked to the menopause may respond to HRT or CBT; where there is a diagnosis of depression, antidepressants have a role. Vaginal moisturisers and lubricants can ease dryness for those not using vaginal oestrogen.
- Testosterone for low libido. Where low sex drive persists and is troubling, a menopause specialist may consider testosterone, used off-licence, as the NHS describes. It is one part of a fuller assessment rather than a first step.
What matters is that “beyond HRT” does not mean “without help”. There is a real menu of options here, and the right one is the one that fits your symptoms and your circumstances.
Don’t overlook the longer term
Because the menopause lowers your oestrogen level for good, it has implications that reach beyond symptom relief. A lower oestrogen level can increase the risk of osteoporosis (thinning of the bones) and has a bearing on heart health. This is not a cause for alarm, but it is a good reason to think about bone and cardiovascular health as part of the picture, through weight-bearing exercise, maintaining muscle strength, and a conversation with your clinician about your individual risk. Encouragingly, the menopause is now being formally included in the NHS Health Check from 2026, a sign of how seriously this stage of life is finally being taken.
A note on contraception
It is a common misconception that perimenopause means you can no longer become pregnant. Until you have reached the menopause proper, pregnancy is still possible, and contraception is still relevant. If this applies to you, it is worth raising at your appointment, and you can read more about the options on our family planning and contraception page.
When to seek specialist assessment
There is no need to simply endure menopausal symptoms. It is worth arranging a proper assessment if:
- Your symptoms are affecting your daily life, your work, your relationships or your sleep.
- You are unsure whether what you are experiencing is the menopause or something else.
- You would like to understand your treatment options, including HRT, in the context of your own medical history.
- You are under 45, and particularly under 40, and experiencing menopausal symptoms, which warrants earlier specialist input.
One symptom that should always be checked rather than assumed: any bleeding after you have gone through the menopause, or unexpected bleeding, deserves prompt medical assessment in its own right.
How we can help at 108 Harley Street
Menopause care at 108 Harley Street is led by our consultant gynaecologist, Mr Mahantesh Karoshi, within our Women’s Health Clinic. Rather than a one-size-fits-all approach, he takes a full history, talks through your symptoms, and explains the evidence-based options available to you, so that any treatment plan is one you have chosen with a clear understanding of the benefits and risks. Where HRT is the right route, you can read more about it on our Women’s (HRT) Clinic page. Where it is not, we are just as ready to discuss the alternatives.
With a consultant available almost every weekday, you have the reassurance of expert assessment when you want clarity rather than guesswork.
The bottom line
The menopause is a natural transition, but difficult symptoms are not something you simply have to put up with. Understanding the stages, recognising the symptoms, and knowing that there is a genuine range of treatments, HRT and otherwise, puts you in a far stronger position to get the help that suits you. If your symptoms are affecting your life, or you would simply like to understand your options, the most useful step is to talk them through with someone who can see the whole picture.
