Menopause is the natural end of your reproductive years. You have reached menopause when you have not had a period for 12 months in a row. In Australia, this usually happens between the ages of 45 and 55, and the average age is 51.

Perimenopause is the stage leading up to menopause. It often begins in your 40s. During this time, your ovaries slowly make less oestrogen and progesterone. Your hormone levels rise and fall, which can make your periods irregular and bring on other symptoms. This stage lasts about 4 to 6 years on average, and it ends 12 months after your final period. Many of the symptoms people call “menopause symptoms” actually start during perimenopause.

Menopause before the age of 45 is called early menopause. Before the age of 40 it is called premature menopause, also known as premature ovarian insufficiency. This can happen naturally, or as a result of surgery to remove both ovaries, or after some cancer treatments. If you think you may be going through menopause early, it is worth seeing your doctor, as there are extra things to consider for your long-term health.

Until you have gone 12 months without a period, you can still become pregnant. If you do not wish to fall pregnant, you still need contraception during perimenopause — even when your periods are irregular. How long to keep using it depends on your age (see the common questions below).

Everyone experiences menopause differently. About 1 in 2 women have mild to moderate symptoms, around 1 in 4 have symptoms severe enough to affect daily life, and around 1 in 4 have no symptoms at all. If you do have symptoms, they usually start in perimenopause and may last several years.

As your hormone levels change, you may notice:

• Periods that are shorter, longer or irregular
• Lighter or, at times, heavier bleeding
• Longer gaps between periods

• Hot flushes
• Night sweats
• Trouble sleeping
• Tiredness
• Mood changes, irritability or low mood
• Trouble with memory or concentration
• Aches and pains
• Headaches
• Reduced sex drive
• Vaginal dryness or discomfort during sex
• Needing to pass urine more often
• Crawling or itching sensations on the skin

If any of these symptoms are affecting your quality of life, you do not have to put up with them. Symptoms can often be managed well.

Many women manage menopause well with lifestyle changes, and some choose not to have any medical treatment. Steps that can help include:

• Eating a balanced diet, with enough calcium for bone health, and limiting caffeine and alcohol
• Regular exercise, including weight-bearing and strength activities, which help keep your bones strong and improve balance
• Looking after your mental health and reducing stress
• Getting good-quality sleep, and keeping your bedroom cool with light bedding
• Noticing and avoiding your own hot-flush triggers
• Not smoking, which lowers your risk of osteoporosis and heart disease

If your symptoms are harder to manage, Dr Mahadik can talk you through medical options, including menopausal hormone therapy.

Menopausal hormone therapy (MHT), previously called hormone replacement therapy (HRT), tops up the hormones your body makes less of during menopause. It works very well for hot flushes and night sweats. It can also help with vaginal dryness and protect your bones.

MHT is not the same for everyone, and whether it suits you depends on your symptoms, your age, your health history and your own preferences. For most women whose symptoms are hard to manage, starting MHT in their 50s or within 10 years of menopause, the benefits outweigh the small risks. Dr Mahadik will go through the benefits and risks with you so you can make a decision that is right for you, and review it with you over time.

MHT comes in several forms, so it can be matched to you:

• Tablets
• Skin patches or gels
• Vaginal creams or pessaries, mainly for vaginal and urinary symptoms

If you still have your uterus, MHT includes a second hormone (a progestogen) to protect the lining of your uterus. One option for this is a hormonal IUD (Mirena), which can provide this part of MHT while also managing heavy periods during perimenopause.

If you have gone through early or premature menopause, MHT is usually recommended at least until around the age of 51 (the average age of menopause), unless there is a health reason to avoid it. Please do not start or stop MHT without medical advice.

MHT is not suitable for everyone — for example, if you have had certain cancers, blood clots or heart disease. If MHT is not an option for you, there are other ways to manage symptoms. Depending on your situation, your doctor may suggest:

• Non-hormonal prescription medicines that can reduce hot flushes
• Treatments for specific symptoms, such as vaginal moisturisers for dryness
• Support for mood and sleep

Your doctor will help you find an approach that fits your health and your symptoms. Please do not stop any prescribed medicine without medical advice.

Once you have gone 12 months without a period, your periods have stopped for good. Any bleeding or spotting after that is not normal, and you should have it checked. It often has a harmless cause, but it is important to see your doctor so the cause can be found. When a cause is picked up early, most conditions behind bleeding after menopause can be treated.

Bleeding after menopause can be caused by:

• Thinning or soreness of the vaginal lining (this is part of what doctors now call genitourinary syndrome of menopause, or GSM)
• Thinning of the lining of the uterus
• Polyps or fibroids in the cervix or uterus, which are usually not cancer
• A thickened uterine lining, which can be related to MHT
• Changes in the cervix or uterus
• In a small number of cases, cancer of the uterus or cervix

To find the cause, your doctor may arrange a physical examination, blood tests, an ultrasound, a cervical screening test, or a small sample of the uterine lining (a biopsy). Sometimes a hysteroscopy is used to look inside the uterus. Treatment then depends on the cause — for example, medicine, removing a polyp, or a referral for further care if needed.

After menopause, lower oestrogen levels can affect your health in the long term, so a few regular checks become more important. These include a higher risk of osteoporosis (thinning bones) and heart disease.

• Cervical screening: If you are aged 25 to 74 and have a cervix, you still need a cervical screening test every 5 years, even after menopause. You can choose to collect the sample yourself or have your doctor collect it.
• Breast screening: BreastScreen Australia offers a free mammogram every 2 years for women aged 50 to 74. Women aged 40 to 49 and over 74 are also eligible, but are not sent an invitation.

Weight-bearing exercise, enough calcium and vitamin D, not smoking and limiting alcohol all help protect your bones and heart after menopause. Dr Mahadik can talk with you about your individual risk and whether any further checks are useful for you.