Menopause symptoms: recognition, diagnosis and treatment strategies

Menopause is a natural biological transition that signifies the end of ovarian follicular activity and the cessation of menstruation^​1​. It is defined retrospectively after 12 consecutive months of amenorrhoea without other pathological or physiological causes^​2​. The average age of natural menopause in the UK is 51 years, though the perimenopausal transition may begin up to ten years earlier^​3​. Around 13 million women in the UK are currently perimenopausal or postmenopausal, accounting for nearly one-third of the female population, with the vast majority experiencing symptoms that impact daily functioning, productivity and long-term health (e.g. the development of other health conditions). The wide-ranging impact of menopause on the quality of life of women cannot be understated^​4​.

Declining levels of oestrogen and progesterone, alongside age-related changes in androgen levels, underpin a range of systemic changes that can manifest as vasomotor instability, sleep disturbance, anxiety, mood changes, cognitive difficulties, genitourinary symptoms and musculoskeletal pain^​5,6​. Yet, despite these well-established physiological effects, menopause remains underdiagnosed and undertreated, particularly in primary care and community pharmacy settings^​7​. In October 2025, it was announced that menopause advice will be included in routine NHS health checks, to tackle this underdiagnosis and ensure that women experiencing symptoms of menopause get appropriate support at the correct time^​8​.

Public awareness of menopause has risen sharply in recent years, driven by national campaigns, evolving policy and an emphasis on workplace wellbeing^​9​. However, clinical practice continues to face significant challenges, including unequal access to trained menopause specialists, variation in prescribing confidence and ongoing HRT supply shortages that complicate continuity of care^​10​. Pharmacists can bridge this gap by offering accessible advice, medicines optimisation and person-centred support. Importantly, the results of a survey, conducted by the Royal Pharmaceutical Society and published in 2025, highlighted that 84% of respondents said they would welcome education, information and advice from pharmacists about managing menopausal symptoms^​11​.

National Institute for Health and Care Excellence (NICE) guidance and a British Menopause Society (BMS) consensus statement provide the foundation for consistent, evidence-based menopause care^​1,12​. Both highlight the importance of recognising the multisystem impact of menopause, requiring both pharmacological and lifestyle interventions, regular review and shared decision-making.

This article provides an overview of the recognition, diagnosis and management of menopause, focusing on how pharmacists across all sectors can apply national guidance, identify red flags and support women in navigating evidence-based treatment options to improve their quality of life and long-term health outcomes.

Factors influencing menopause start

The timing of menopause varies between women and is shaped by a mix of genetic, lifestyle and, in some cases, medical factors. While the average age of menopause in the UK is 51 years, it can happen anytime between 45 and 55 years and still being considered within the normal age range. Menopause before the age of 45 years is classed as early, while before the age of 40 years is classed as premature ovarian insufficiency (POI)^​1​. POI is beyond the scope of this article, see ‘Premature ovarian insufficiency: diagnosis and management’.

Some examples of factors that can influence the timing of menopause can be seen in Figure 1^{​13–24​}.

Figure 1: Factors that can influence the timing of menopause

The physiology of menopause

Menopause occurs when the ovaries stop releasing eggs and the production of oestrogen and progesterone falls to low levels. Age-related changes in testosterone may also occur during the menopausal transition. These hormonal changes lead to the symptoms and long-term health effects seen during perimenopause and post-menopause^​1​.

The transition happens gradually — often over several years — and is called perimenopause. During this time, hormone levels fluctuate unpredictably, which explains why symptoms can come and go or vary in severity^​25​.

Hormonal control and menstrual cycle changes

The menstrual cycle is regulated by the hypothalamic–pituitary–ovarian (HPO) axis. The hypothalamus releases gonadotrophin-releasing hormone (GnRH), which stimulates the pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinising hormone (LH). These hormones act on the ovaries to stimulate follicle development and ovulation, which in turn leads to oestrogen and progesterone production^​26​. Figure 2 shows how hormone levels may change over time^​26​.

Figure 2: Variations in hormones over time

These hormonal shifts cause cycle irregularity: shorter or longer cycles, missed periods and variable bleeding intensity, before menstruation ceases entirely^​26​.

After 12 months without a natural period, a woman is considered postmenopausal. At this stage, oestrogen and progesterone remain low and stable. Symptoms may persist but often evolve — for example, vasomotor symptoms may lessen, while vaginal dryness and joint pain become more prominent; however, women can experience a variety of changing symptoms. But this is not the case for everyone^​26​. 

Oestrogen

Oestrogen is the main hormone affected by menopause. It plays an important role in many systems in the body, including temperature control, mood, sleep and bone strength, see Figure 3^​27,28​.

Progesterone

Progesterone levels start to fall during perimenopause when ovulation becomes irregular. Low progesterone can lead to:

• Heavier or unpredictable periods before they stop altogether;
• Sleep disturbance and anxiety, as progesterone has a mild calming, sedative effect^​29​.

Symptoms of menopause

Menopause affects multiple organ systems, leading to a wide range of symptoms that can vary in type and intensity^​26​. While many women experience classic vasomotor symptoms, such as hot flushes and night sweats, others may present with psychological, urogenital or musculoskeletal complaints that are less obviously hormone related. Recognising these presentations allows pharmacists to offer appropriate advice, support or referral. There is often resolution or improvement in these symptoms once hormone balance is restored through HRT or other management strategies^​1​.

See Figure 3 for a summary of the symptoms, classes and frequency of menopause^{​30–33​}.

Figure 3: Menopause symptoms, causes and frequency

Lesser-known symptoms

Many symptoms are less commonly associated with menopause and can lead to misdiagnosis or unnecessary investigations. These include:

• Tinnitus or ringing in the ears (exact estimates vary, but some estimate that up to one-third of menopausal women experience tinnitus);
• Heart palpitations (57%);
• Dry or itchy skin and hair thinning (58%);
• Altered body odour or taste (thought to be common but exact estimates are not available);
• Migraines or new headaches (52%);
• Burning mouth syndrome (estimates vary, some put it at 18–33%);
• Changes in digestion and bloating (65%);
• Loss of muscle tone or joint instability (70% of patients will experience musculoskeletal symptoms)^{​30,34–36​}.

Impact on quality of life

Symptoms of menopause can significantly affect daily functioning, relationships and work performance. In the UK, around one in four women experience symptoms they describe as severe, while one in ten report leaving employment owing to menopause-related difficulties^​37​.

Pharmacists and other members of the pharmacy team play a vital role in normalising conversations, offering evidence-based advice and signposting to appropriate care pathways such as review with a GP or other qualified healthcare professional, menopause clinics or occupational health support, see Box 1.

Diagnosis of menopause

Clinicians, including pharmacists across all practice settings, should focus on recognising symptoms, excluding alternative causes and identifying those who may benefit from further evaluation or referral^​1,12​. This approach aligns with NICE and BMS guidance^​1,12​.

Clinical assessment

In women aged over 45 years, a clinical diagnosis of perimenopause or menopause can be made when they report typical symptoms, such as vasomotor instability (e.g. hot flushes, night sweats), mood or cognitive changes, fatigue or sleep disturbance and altered menstrual patterns^​1,12​.

Routine biochemical testing is not required in this group, as fluctuating hormone levels provide little diagnostic clarity^​1,12​. Diagnosis should instead focus on symptom burden, quality of life and individual risk profile^​12​.

Diagnosis may be more complex in those using hormonal contraception, after endometrial ablation or post-hysterectomy with retained ovaries. In such cases, diagnosis should rely on a detailed symptom history, age and risk assessment, considering testing only where results would change management^​1,12​. 

Pharmacists may be the first point of contact for women experiencing these symptoms and can play an important role in recognising early perimenopausal signs, offering evidence-based advice and signposting to appropriate prescribers or specialist clinics^​11​.

Role of biochemical testing

FSH testing may be considered in situations where the diagnosis may be uncertain in women aged 40–45 years or to guide treatment in women post-hysterectomy with ovaries intact, presenting with menopausal symptoms^​1,12​.

Other hormone assays (e.g., oestradiol, LH, AMH) are not routinely recommended, owing to high intraindividual variability and poor diagnostic reliability^​1,12​.

Supporting investigations

Supporting investigations may be indicated to rule out alternative causes or establish baseline measures before initiating hormone therapy. Blood pressure and BMI are checked for cardiovascular risk assessment.

Other tests that may be done to inform treatment safety, include:

• Lipid profile and HbA1c/glucose, if metabolic risk factors present;
• Thyroid function tests, to rule out thyroid disease;
• Full blood count, if fatigue or heavy bleeding present;
• Liver function tests, if oral HRT considered^{​1,12,40​}.

Differential diagnosis

Because symptoms can overlap with other conditions, alternative or concurrent diagnoses should be considered, see Table 1^​41​. It should be noted that these are a selection of examples, not an exhaustive list.

Table 1: An overview of menopause symptoms and potential differential diagnoses

A structured history and review of current medications can support accurate assessment, facilitate referral, where appropriate, and avoid unnecessary investigations.

Referral to registered menopause specialists

Some women experience significant menopausal or perimenopausal symptoms but they do not meet NICE diagnostic thresholds or have inconclusive results. In these cases, referral to a registered menopause specialist — as defined by the BMS — is appropriate^​42​.

Specialist review is recommended for:

• Complex clinical presentations or contraindications to HRT;
• Women with ongoing symptoms despite initial management;
• Diagnostic uncertainty (e.g. irregular bleeding patterns, hormone therapy intolerance)^​1,12​.

Access to menopause specialists varies widely across the UK, with significant regional differences in NHS provision. As a result, specialist referral may occur via NHS or private services, while inequities in access can affect the timeliness and quality of care available to women^​43​.

Treatment strategies

Effective management of menopausal and perimenopausal symptoms requires a person-centred, evidence-based approach, tailored to each woman’s individual symptoms, health risks, preferences and treatment goals^​1,5​.

Women do not need to wait until they are postmenopausal or to have a confirmed diagnosis to be offered treatment^​12​. Early intervention during this stage can improve quality of life, support sleep and mood, as well as reduce longer-term health risks^​12​.

Symptomatic women in the perimenopausal stage can and should be offered appropriate support, including lifestyle advice, pharmacological interventions and referral, where indicated^​12,44​.

Management should aim to:

• Alleviate current symptoms;
• Prevent or manage long-term health risks associated with oestrogen deficiency (e.g. osteoporosis, cardiovascular disease);
• Promote holistic wellbeing through lifestyle and psychosocial support^​45​.

The choice of therapy depends on:

• Symptom type and severity;
• Personal and family medical history;
• Patient preference, contraindications and route of administration;
• HRT type is determined by uterine status and menopausal stage, rather than age alone, in line with NICE guidance^​1,12​.

HRT 

HRT remains the most effective treatment for vasomotor symptoms (e.g. hot flushes, night sweats) and improves mood, sleep, vaginal dryness and overall quality of life^​46​.

Evidence considered by NICE and the BMS confirms that for most healthy women aged under 60 years, or within 10 years of menopause, the benefits of HRT outweigh the risks^{​1,12,47​}.

See Table 2 for a summary of the types of HRT^{​1,12,47–49​}.

Table 2: Types of HRT

Oestrogen doses should be adjusted, if inadequate relief or if side effects (e.g. breast tenderness, bloating) occur^​1,12​.

Transdermal oestrogen should be used if oral preparations cause gastrointestinal (e.g. constipation) or cardiovascular side effects (e.g. changes in blood pressure or lipids)^​50​.

Transdermal oestrogen (i.e. patches, gels, sprays) is often preferred in women with increased venous thromboembolism (VTE) risk because transdermal HRT is not associated with an increased VTE risk and has a lower VTE risk than oral HRT. This is likely because transdermal oestrogen avoids first-pass hepatic effects seen with oral oestrogen. It is also suitable for use in women with migraine, obesity or raised blood pressure^​51,52​. Additionally, there is greater scope for individualising treatment, including dose titration and route selection. 

Where symptom control is inadequate, skin irritation occurs or the individual finds the preparation difficult to use, switching between transdermal formulations is appropriate and supported by national menopause guidance^​1,53​.

For more information on different presentations for HRT consultations, see ‘Case-based learning: menopause and HRT consultations‘.

Testosterone

Testosterone is produced by the ovaries and adrenal glands, and levels decline with age. Current national guidance does not recommend routine measurement. In addition, the principal evidence-based indication for therapy is persistent low sexual desire in postmenopausal women despite adequate oestrogen replacement^​1,54​. However, in clinical practice, some specialists report additional benefits in selected individuals, including improvements in energy, mood and cognitive symptoms, although high-quality evidence to support these broader indications remains limited and it is not currently guideline endorsed^​54,55​.

Initiating HRT

When initiating HRT, an individualised discussion of risks and benefits is needed, which includes breast cancer, VTE, and cardiovascular risk. NICE has produced a decision aid for discussing these risks with patients, which can help these conversations. A summary of the decision aid can be seen in Table 3^​1​.

Table 3: Overview of the risk versus benefit for HRT

The following steps should be followed when initiating HRT:

• Start with the lowest effective dose and titrate to symptom control;
• Review after three months, then annually or sooner if issues, such as intolerable side effects, arise;
• Adjust route, dose or regimen based on response and side effects^​50​.

Duration of HRT

There is no fixed time limit for HRT use. An annual HRT review is advised, to assess symptom control, side effects and consider ongoing risks vs benefits^​1,12​. 

HRT can be continued as long as benefits outweigh risks and the woman wishes to remain on therapy^​1,12​.

Non-hormonal treatments

Non-hormonal treatments have a place in the management of menopause symptoms, vaginal moisturisers and lubricants should be offered alongside HRT. For women unable (e.g. in the case of hormone sensitive cancer) or unwilling to use HRT, several non-hormonal options can reduce vasomotor or mood-related symptoms, see Table 4^​1,56​.

However, it should be noted that — with the exception of vaginal moisturisers/lubricants and fezolinetant — the use of the non-hormonal options listed in Table 4 are off-label^​56​.

Table 4: Non-hormonal pharmacological options

Endometrial protection

It is important to ensure there is an adequate progestogen component in women with an intact uterus^​48​.

Unscheduled bleeding is common in the first three to six months; however, persistent or heavy bleeding warrants investigation, as it could indicate underlying endometrial pathology.

Micronised progesterone (body-identical) or licensed synthetic progestogens should be prescribed in appropriate doses and regimens. A 52mg levonorgestrel intrauterine system (LNG-IUS) can be used in combination with oestrogen as part of HRT to provide endometrial protection for up to five years^​1​.

Lifestyle and complementary strategies

Lifestyle interventions can significantly improve symptoms and overall wellbeing^​1​.

Individualised lifestyle counselling, emphasising modifiable factors that also reduce long-term disease risk should be provided, see Box 2^​12​.

Cognitive behavioural therapy (CBT) has demonstrated benefits for vasomotor and mood symptoms. It is also recommended by NICE, either in addition to HRT or as an alternative for those who prefer not to take it or if it is contraindicated^​1​. CBT may be beneficial in helping women manage the psychological impact of menopausal symptoms, including low mood, anxiety and sleep disturbance. CBT does not treat the underlying hormonal changes of menopause but may help women develop coping strategies for symptoms such as mood disturbance and insomnia.

Some women explore herbal or complementary therapies (e.g. black cohosh, red clover, soy isoflavones)^​59,60​. It is important that pharmacists consider drug interactions with these therapies and should be aware of patients OTC medicines use when checking for interactions. 

Pharmacists should discuss complementary therapies openly and without judgement, noting that:

• These treatments are unavailable on the NHS;
• Evidence is limited or inconsistent;
• Product quality and safety vary widely;
• Herbal preparations should not be combined with HRT without medical advice^​61​.

Safety and monitoring

Safe and effective menopause management depends on individualised care, ongoing monitoring and clear communication^​5​. Monitoring should focus on symptom control, treatment safety and long-term health promotion^​62​.

All women commencing treatment should have an initial review after three months, to:

• Evaluate symptom relief and adverse effects;
• Confirm adherence and correct use, especially for transdermal products;
• Address any bleeding patterns, side effects or safety concerns;
• Adjust dose or formulation as needed^{​1,12,47​}.

If therapy is well-tolerated, subsequent reviews can occur annually, unless earlier assessment is indicated. Annual review should include:

• Current symptom assessment and overall wellbeing;
• Blood pressure and BMI measurement;
• Discussion of breast and cardiovascular health;
• Confirmation that the patient understands how and when to seek medical review (e.g. unscheduled bleeding, new contraindication)^​1,12​.

Some risk factors of HRT necessitate additional monitoring, see Table 5 for more information^​1,12​.

Table 5: Monitoring considerations for HRT risk factors

Patient empowerment and shared care

By reinforcing self-monitoring and preventative care, pharmacists can help patients feel informed, supported and confident in managing their menopause symptoms. Pharmacists can encourage patients to:

• Track symptoms using a diary or tracking apps to monitor changes;
• Attend regular reviews and recommended screening (e.g. breast, cervical, bone health);
• Report any new, unusual or worsening symptoms promptly, as well as any suspected side effects from treatments. Early reporting allows timely assessment and adjustment of therapy;
• Understand the difference between normal perimenopausal fluctuation (e.g. irregular periods, vasomotor symptoms) and signs requiring review (e.g. persistent pelvic pain)^​45​.

Pharmacists can contribute to the safe and effective management of menopause symptoms by:

• Ensuring continuity of supply, which may involve addressing shortages and advising on alternatives;
• Reinforce adherence and correct use of transdermal products, additional information about use of transdermal products can be found via SPS;
• Promoting lifestyle changes, such as smoking cessation, healthy diet and exercise, to reduce long-term health risks.

Communication and person-centred care

Person-centred care is at the core of modern menopause management. Pharmacists and clinicians across all settings play a pivotal role in creating an environment where women and all individuals experiencing menopause or menopausal symptoms feel heard, understood and supported.

Empathetic, inclusive communication improves adherence, builds trust and ensures equitable access to treatment.

Menopause discussions are often emotionally charged. Stigma, embarrassment or misinformation can prevent people from seeking help^​63​.

Approaches that can help this include:

• Providing a space for open discussion and active listening;
• Avoiding assumptions about age, gender or lifestyle;
• Normalise the conversation using clear, non-medical language when appropriate^​64​.

Pharmacists may be the first point of contact and can make a profound difference by validating experiences and offering practical, evidence-based advice.

Shared decision-making

Shared decision-making ensures that care reflects each individual’s preferences, values and health goals, which involves:

• Presenting balanced information on benefits and risks of all treatments;
• Discussing options for both hormonal and non-hormonal management;
• Exploring personal priorities symptom relief, bone health, libido, cognitive function or lifestyle impact;
• Encouraging ongoing dialogue and review, emphasising that treatment decisions can evolve over time^​1,65​.

Patients may benefit from signposting to reputable information sources including NHS menopause guidance, Women’s Health Concern factsheets and advocacy organisations (e.g. The Menopause Charity and menopausesupport.co.uk), which provide accessible explanations of symptoms, treatment options and support pathways.

Equality, diversity and inclusion

Menopause affects individuals from all backgrounds differently. A truly person-centred approach must address cultural, religious, gender and social diversity to ensure care is equitable and accessible^​66​. Promoting equity means recognising these barriers and actively working to remove them through inclusive language, flexible service design and representation in health education materials. Some examples of additional considerations that can affect engagement with healthcare professionals and use of medicines to manage symptoms can be seen in Figure 4^{​1,12,43,67–72​}.

Figure 4: Additional considerations that can affect engagement with healthcare professionals and use of medicines to manage symptoms

Holistic and multidisciplinary support

Menopause can affect every aspect of life, work, relationships, mental health and self-esteem. As part of holistic menopause care, referral/signposting for the following may be needed: 

• Psychological wellbeing and screening for depression or anxiety;
• Sexual and relationship health, including discussion of libido, comfort and communication;
• Occupational impact and workplace adjustments under the Equality Act 2010;
• Signposting to physiotherapy, counselling or pelvic floor therapy when relevant^​1,12​.

Conclusion

Pharmacists can support women to manage their menopause symptoms by recognising the range of symptoms, understanding the available treatment options — including lifestyle measures, non-hormonal therapies and HRT — and providing evidence-based advice to improve patient outcomes.

Pharmacists can address misconceptions about menopause treatments, support women with informed decision-making and identify when referral to other healthcare professionals is needed. Creating a supportive and open environment for conversations about menopause can help reduce stigma and encourage women to seek the help they need.