This is the fourth part of our series about the menopause based on our booklet “Fast Facts for Patients: Menopause”, which is freely available online. This article gives advice and practical tips on the management of the most commons symptoms.

Heavy Bleeding

Irregular or heavy bleeding is often an early symptom of the menopause transition. You may have less of a gap between heavier periods, or you may go for several months without a period.

Bleeding is unacceptable if it is heavy for you, regardless of the amount of blood you lose or how much sanitary protection you require.

Practical Tips

  • Keep a track of your periods for discussion with your doctor. Make a note of: when they start, how long they last, how heavy they are, any spotting in between periods, and any abnormal bleeding, pain, discomfort or other symptoms.
  • Wear panty liners or protective underwear if the timing of your periods is unpredictable.
  • Use high-absorbency tampons or pads during your period and change them every 2–4 hours.
  • Keep using contraception if you are under the age of 55. You can get pregnant during the menopause transition.

Further Steps If Needed

  • Talk to your doctor if you are concerned about heavy bleeding to rule out other causes, such as fibroids.
  • Talk to your doctor if you are feeling tired or look paler than usual. You may have anaemia. Your doctor can do a blood test and may give you iron tablets.
  • Non-steroidal anti-inflammatory drugs, such as ibuprofen, can help with menstrual cramps and may reduce your flow by up to 30%.
  • An intrauterine system (IUS) that contains 52 mg of the progestogen levonorgestrel reduces bleeding in most women without changing the menstrual cycle. Only the Mirena IUS is licensed for use as part of hormone replacement therapy (HRT).

Hot Flushes

Hot flushes are a sudden feeling of intense heat that spreads throughout the body. They may last seconds or minutes, and may be accompanied by reddening of the skin, sweating and sometimes palpitations (rapid heart rate). Hot flushes can lead to embarrassment and anxiety.

Hot flushes are one of the most common and well-known symptoms of the menopause transition. In a national survey conducted on behalf of the British Menopause Society (BMS), 79% of women aged 45–65 experienced hot flushes.

In general, women get hot flushes for an average of 5 years, although it can be a lot longer than this. Some women experience very few, whereas others may get several hot flushes a day.

Hot flushes

Practical Tips

  • Wear several thin layers of clothing, and choose clothes that you can remove quickly and easily.
  • Carry a fan with you, or try neck-cooling scarves/bandanas.
  • Cool your face with cold water if you feel a hot flush coming on.
  • Avoid triggers such as spicy food, alcohol and caffeine.
  • Check whether any medicine you are taking increases the risk of hot flushes; talk to your doctor if you think this is an issue.
  • Use relaxation and breathing techniques to avoid stress and anxiety, as they can make hot flushes worse.

Further Steps If Needed

  • HRT is the recommended treatment for hot flushes and is highly effective.
  • Femal (bee pollen) has been shown to reduce hot flushes.
  • Your doctor may prescribe medications called SSRIs or SNRIs (selective serotonin- or norepinephrine-reuptake inhibitors). These medications are used to treat depression but can also reduce perimenopausal symptoms. An SSRI may be helpful if HRT is not an option.
  • Pregabalin, gabapentin and clonidine may also help to reduce hot flushes. All these medications have other uses.

Night Sweats

Night sweats are hot flushes that happen during the night. They can disturb your sleep pattern (and your partner’s), resulting in tiredness. Some women may have difficulty coping because of lack of sleep.

In the BMS survey, 70% of women reported having night sweats.

Night sweats

Practical Tips

  • Wear fewer and/or looser clothes at night.
  • Have two single duvets on your bed, so that you and your partner can each choose the level of warmth that works for you.
  • Try a cooling pillow.
  • Look out for triggers, such as spicy food, alcohol and caffeine.
  • Check whether any of your medications are associated with night sweats; talk to your doctor if you think this is an issue.
  • Try not to worry about how much sleep you are getting.

Further Steps If Needed

  • HRT is highly effective in controlling night sweats and improving sleep patterns.

Vaginal Dryness

Instead of being stretchy and well lubricated, the tissues of the vagina become dry and are more easily damaged. The terminology for this may be confusing but the author’s preferred term is “urogenital atrophy”.

Vaginal dryness is a very common symptom of the menopause transition, but women are often embarrassed to talk about it.

Urogenital atrophy may cause discomfort or pain during sex. It can also make a smear test difficult or painful.

In the BMS survey, 35% of women said they had experienced vaginal dryness, with 18% of those who had this symptom saying it was unexpected.

Practical Tips

  • Use lubricants during sex.
  • Try vaginal moisturisers, available from pharmacies.

Further Steps If Needed

  • Your doctor can prescribe vaginal moisturisers, which can be used twice weekly to reduce vaginal dryness.
  • Your doctor can also prescribe treatments that deliver low doses of oestrogen directly to the vagina. These are available as pessaries, creams or a vaginal ring.
  • Another treatment option is prasterone, a pessary inserted into the vagina on a daily basis. It releases a precursor hormone (dehydroepiandrosterone or DHEA), which is converted in the lining of the vagina to oestrogen and testosterone with virtually no absorption into the bloodstream. Both oestrogen and testosterone are important for tissue quality.
  • In general, urogenital atrophy is best managed with treatments that are delivered directly to the vagina.
  • If these treatments do not work, your doctor may prescribe a drug called ospemifene. It is taken by mouth and improves tissue quality. It should be used alone, not added to HRT.
  • It is important to keep using whatever your doctor has prescribed for vaginal dryness for several months. Some products can be used for life.
  • If you are due for a smear test, use of these treatments for 3–6 months beforehand will help make the procedure easier. (It is important that you continue to have regular smear tests.)

Bladder Problems

During the menopause transition you may experience a sudden or constant need to pass urine (urge incontinence), leakages during exercise or when laughing or coughing (stress incontinence), or both of these (mixed incontinence). You may also find that it is painful to pass urine.

A lack of oestrogen causes the tissues in your vagina and urethra (the tube that carries urine out of the body) to lose their elasticity. The pelvic floor may also weaken.

  • Getting older also has various debilitating effects on the pelvic organs and tissues.
  • When you are standing, most of your bodyweight bears down on the pelvic floor, so being overweight makes this worse.
  • Pregnancy and childbirth put pressure on the pelvic floor, especially if a baby was large, labour was prolonged or instruments were used to help the delivery.
  • Coughing and constipation can also stress the pelvic floor.
  • Some women have poor-quality tissue for genetic reasons.
  • The bladder tissues are also affected by oestrogen, so bladder problems can occur during and after the menopause transition.
  • Overactive bladder can increase the need to pass urine, including during the night, which disrupts sleep.

Pelvic muscles

Practical Tips

  • Pelvic floor exercises (also called Kegel exercises) strengthen the pelvic floor and can therefore help with bladder control. These exercises can also increase sexual pleasure.
  • You can identify the muscles of your pelvic floor by squeezing around your back passage as though trying to stop wind and at the same time squeezing at the front as if trying to stop passing urine. The front and back contract at the same time.
  • Exercising these muscles can help to prevent bladder problems and reduce problems that already exist.
  • Many resources and apps are available to help you learn how to do these exercises and to remind you to do them (forever). For example, the NHS Apps Library recommends the inexpensive “Squeezy” app.
  • Ask your doctor to refer you to a specialist physiotherapist if you feel that you need more help.
  • Other forms of exercise can strengthen the pelvic floor, particularly yoga and Pilates.
  • Have your last drink at least 1 hour before going to bed.
  • Try to reduce your intake of caffeine and alcohol, as these can worsen symptoms.
  • Try to avoid spicy foods as these may also irritate the bladder.

Further Steps If Needed

  • Your doctor can prescribe various treatments to improve urogenital tissue quality in addition to a medication for overactive bladder.
  • Additional oral medication may be required for women with overactive bladder or mixed incontinence.

Effects on Your Mood And Mind

You may experience changing emotions (emotional lability) at this time of life for many reasons, but the changes in hormones during the menopause transition may make this worse.

Common emotional issues include irritability, such as snapping for no apparent reason, low mood, anxiety, difficulty coping, lack of motivation, tearfulness and worsening phobias.

Lack of sleep – because of anxiety or night sweats – can make these symptoms worse.

Some women also report becoming more forgetful, poor concentration and “brain fog”.

Women who are prone to mood changes are more likely to experience emotional lability during the menopause transition. Premenstrual symptoms may be worse during the menopause transition.

Brain fog

Practical Tips

  • Look after your general health and wellbeing. This will help improve your mood.
  • Try to exercise regularly; it is a particularly good way to improve your mood, as is being outdoors.
  • Try relaxation techniques, breathing exercises and/or mindfulness. These can all help.
  • Take time to look after yourself, away from the stresses of life and the demands of others.
  • Tell your partner and family why you are feeling irritable. They are likely to be more supportive if they understand what you are going through.
  • If these (or other symptoms) are affecting your work, talk to your human resources team.
  • Get support by talking to your friends and other women.

Further Steps If Needed

If mood changes are affecting your quality of life, contact your doctor for help. There are a variety of treatments, including HRT and antidepressants (SSRIs and SNRIs), that you can discuss.


Please check out the previous and the next post of our series here:


Information based on Fast Facts for Patients: Menopause (Karger, 2021).

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