Menopause is the permanent end of menstrual periods — defined as 12 consecutive months without a period, occurring on average at age 51 in high-income countries (natural range 45-55 years). It results from the depletion of ovarian follicles and the consequent decline in oestrogen, progesterone and inhibin B production. The years before the final period (perimenopause) typically bring irregular periods, fluctuating hormones and emerging symptoms. Post-menopause is the rest of a woman's life after this event. With global life expectancy increasing, most women now spend one-third to one-half of their lives post-menopausal.

What are the symptoms of menopause?

Menopause can cause a wide spectrum of symptoms: Vasomotor symptoms (most common): hot flushes (sudden waves of heat, often with sweating and heart pounding, lasting 1-5 minutes); night sweats (hot flushes during sleep causing disrupted sleep and fatigue). Approximately 75-80% of women experience these, with most lasting 7-10 years. Genitourinary (GSM): vaginal dryness, dyspareunia (painful sex), vaginal itching/burning, urinary urgency, recurrent UTIs. Sleep disturbance: difficulty falling/staying asleep. Mood: anxiety, irritability, low mood — distinct from but can be confused with clinical depression. Cognitive: difficulty concentrating, memory lapses ("brain fog" — often distressing but usually mild and temporary). Musculoskeletal: joint aches, early morning stiffness. Long-term: osteoporosis; cardiovascular risk increase.

What is menopausal hormone therapy and is it safe?

Menopausal hormone therapy (MHT, also called HRT) uses hormones (oestrogen + progesterone/progestogen for women with a uterus; oestrogen alone for women without a uterus) to replace the declining hormones of menopause. It is the most effective treatment for vasomotor symptoms (approximately 80% reduction in hot flush frequency) and GSM. The safety question: the 2002 WHI trial caused mass abandonment of MHT by incorrectly extrapolating risks found in older women (60+) with existing heart disease to all women on MHT. The current consensus (BMS, NICE, IMS — all 2023): for symptomatic women under 60 or within 10 years of menopause, the benefits of MHT (symptom relief, bone protection, possible cardiovascular protection) clearly outweigh the risks. Absolute risks are small.

What about breast cancer risk?

Combined MHT (oestrogen + progestogen) is associated with a small increased breast cancer risk — approximately 1 extra case per 1,000 women per year of use. To put this in perspective: this risk is similar to drinking 1-2 units of alcohol daily, or being overweight, or having an obese BMI. Oestrogen-only MHT (for hysterectomised women) has no significant breast cancer risk increase, and in the WHI trial the oestrogen-only arm showed no increase. Vaginal oestrogen (for GSM only): negligible systemic absorption; no measurable breast cancer risk — safe even in women with a history of breast cancer, per ASCO 2023 and NICE 2023. The risk from combined MHT returns to baseline within 5 years of stopping.

What non-hormonal options exist for menopause?

For women who cannot or prefer not to use MHT: Fezolinetant (Veoza, approved 2023): a neurokinin 3 receptor antagonist — the first non-hormonal treatment specifically targeting the hypothalamic mechanism of hot flushes; reduces frequency by approximately 60%. SSRIs/SNRIs: venlafaxine, escitalopram, paroxetine — reduces hot flush frequency by approximately 40-60%; evidence also supports mental health benefit. Gabapentin/pregabalin: effective for vasomotor symptoms, especially night sweats disrupting sleep. Clonidine: modest benefit. For GSM: vaginal moisturisers (hyaluronic acid) for daily symptoms; lubricants for sexual activity; local vaginal oestrogen (negligible systemic absorption).

How does GMJ News cover menopause?

GMJ News covers WHO menopause data, the WHI trial misinterpretation and MHT rehabilitation, vasomotor symptoms, GSM, fezolinetant 2023, the timing hypothesis, POI, long-term consequences (bone, cardiovascular), and vaginal oestrogen safety in breast cancer survivors. Menopause — affecting every woman who lives beyond middle age — is directly relevant to PHIG's women's health programme and Georgia's reproductive health policy.

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Menopause

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Menopause — the permanent cessation of menstruation from ovarian follicle depletion (defined as 12 consecutive months of amenorrhoea, average age 51 in HICs) — affects every woman who lives long enough, with an estimated 1.1 billion post-menopausal women globally by 2025, yet remains one of the most systematically under-managed conditions in medicine despite effective treatments, and despite the fact that vasomotor symptoms (hot flushes and night sweats) severely impair quality of life in approximately 75-80% of menopausal women for a median of 7-10 years (WHO). The 2023 guidelines from the British Menopause Society, NICE, and International Menopause Society have rehabilitated menopausal hormone therapy (MHT/HRT) as the most effective treatment for menopausal symptoms — with benefits clearly outweighing risks for most symptomatic women under 60 or within 10 years of menopause — correcting the widespread over-reaction to the 2002 WHI trial that left millions of women undertreated for over two decades.

Key messages

1.1B post-menopausal women by 2025 — most undertreated

1.1 billion women will be post-menopausal by 2025. Despite effective treatments, the majority of symptomatic menopausal women remain undertreated — largely due to the aftermath of the 2002 WHI trial that wrongly frightened clinicians and patients away from MHT for over 20 years (WHO/IMS 2023).

MHT/HRT — rehabilitated as first-line treatment

2023 guidelines (British Menopause Society, NICE, IMS) confirm: MHT is the most effective treatment for menopause symptoms and benefits clearly outweigh risks for most symptomatic women under 60 or within 10 years of menopause. The 2002 WHI panic was based on misinterpretation of data from older women with existing CVD.

Vasomotor symptoms — 75-80% of women, lasting 7-10 years

Hot flushes and night sweats affect approximately 75-80% of menopausal women; the average duration of moderate-severe vasomotor symptoms is 7-10 years (not "a few months" as historically taught). Night sweats cause sleep deprivation with downstream effects on mood, cognition and cardiovascular health.

Genitourinary syndrome of menopause — underreported, treatable

GSM (vaginal dryness, dyspareunia, vaginal atrophy, urinary frequency and urgency) affects approximately 50-60% of post-menopausal women but fewer than 25% seek treatment. Local vaginal oestrogen — with negligible systemic absorption — is safe and effective even for women with breast cancer history (per NICE 2023/ASCO).

Long-term consequences — bone and heart

Oestrogen decline after menopause accelerates bone loss (2-3%/year for 5-10 years) → osteoporosis. Women's cardiovascular risk approaches men's after menopause — heart disease becomes the leading cause of death in post-menopausal women. MHT started within 10 years of menopause is cardioprotective (the timing hypothesis).

Fezolinetant — first non-hormonal vasomotor treatment (2023)

Fezolinetant (Veoza, Astellas) — a neurokinin 3 receptor antagonist blocking the KNDy neuron pathway that drives hot flushes — was FDA/EMA approved in 2023 as the first non-hormonal, non-SSRI/SNRI treatment specifically targeting the mechanism of vasomotor symptoms. Effective for women who cannot or prefer not to use hormones.

Key statistics

1.1B

women globally will be post-menopausal by 2025 (WHO)

WHO/IMS 2023

75-80%

of menopausal women experience vasomotor symptoms

WHO/BMS 2023

7-10yr

average duration of moderate-severe vasomotor symptoms

SWAN/IMS

Age 51

average age of natural menopause in HICs (range 45-55 normal)

WHO

2023

year BMS/NICE/IMS rehabilitated MHT as first-line treatment

BMS/NICE/IMS 2023

prevalence of premature ovarian insufficiency (menopause <40 years)

WHO/ESHRE

Menopause symptoms — prevalence in symptomatic women (WHO/IMS)

Source: WHO/IMS. Vasomotor symptoms most prevalent; GSM often underreported. All respond to MHT.

Glossary of key terms

Menopause and perimenopause
WHO/IMSMenopause: permanent cessation of menstruation — defined retrospectively after 12 consecutive months of amenorrhoea without pathological cause. Average age 51 (range 45-55 normal). Perimenopause (menopausal transition): irregular periods, fluctuating hormones, emerging symptoms — beginning 5-10 years before the final period. Post-menopause: from the menopause date onward (lasting the rest of life).

MHT/HRT composition
BMS/NICE 2023Combined MHT: oestrogen + progestogen (required for women with a uterus — to prevent endometrial hyperplasia from unopposed oestrogen). Oestrogen-only MHT: for women post-hysterectomy. Micronised progesterone (Utrogestan) — the preferred progestogen — has a more favourable safety profile than synthetic progestins (no increased breast cancer risk at 5 years; possible cardioprotective effect). Routes: oral, transdermal patch, gel, spray — transdermal preferred for lower VTE risk.

The WHI trial and its misinterpretation
JAMA/BMSThe Women's Health Initiative (WHI) 2002 randomised trial of conjugated equine oestrogen + synthetic progestin (medroxyprogesterone acetate) found a small increase in breast cancer and cardiovascular events — and was misinterpreted to apply to all MHT in all women. Subsequent analyses showed: the risks were predominantly in women aged 60-79 (not 50-59); older formulations in older women; and the arm with oestrogen alone (hysterectomised women) showed no breast cancer increase and even reduced CVD. The timing hypothesis: MHT started within 10 years of menopause is safe and potentially cardioprotective.

Breast cancer risk from MHT
BMS/NICE/Lancet 2019Combined oestrogen + progestogen MHT: small increased breast cancer risk — approximately 1 extra case per 1,000 women per year of use (equivalent to drinking 1-2 units of alcohol daily or being overweight). Risk returns to baseline within 5 years of stopping. Oestrogen-only MHT: no significant breast cancer risk increase. Vaginal oestrogen (local only): negligible systemic absorption; no measurable breast cancer risk — safe even in breast cancer survivors (per ASCO/NICE 2023).

Genitourinary syndrome of menopause (GSM)
IMS/NAMSThe preferred term for vulvovaginal atrophy and associated urinary symptoms — replacing the previous terms "atrophic vaginitis" and "vulvovaginal atrophy." Includes: vaginal dryness, itching, burning, dyspareunia, shortened/narrowed vaginal canal; urinary urgency, frequency, recurrent UTIs, dysuria; reduced lubrication. Progressive and worsening over time without treatment. Unlike vasomotor symptoms, GSM does NOT resolve spontaneously. Treatment: local vaginal oestrogen (cream, pessary, ring) — safe, highly effective, negligible systemic absorption.

Premature ovarian insufficiency (POI)
ESHRE/WHOMenopause occurring before age 40 — affecting approximately 1% of women. Causes: genetic (Turner syndrome, Fragile X premutation); autoimmune (autoimmune oophoritis); iatrogenic (chemotherapy, pelvic radiotherapy, bilateral oophorectomy); idiopathic (majority). Women with POI have significantly higher risks of cardiovascular disease, osteoporosis, premature cognitive decline and premature mortality. HRT/MHT is strongly recommended until the natural age of menopause (approximately 51) to protect bone, cardiovascular and neurological health.