Menopause and falling oestrogen: long-term bone and heart health risks

Menopause and perimenopause are a natural part of life. The NHS describes them as happening when periods change and eventually stop due to lower hormone levels. Perimenopause is the lead-up, menopause is when you have not had a period for 12 months, and after that it is called postmenopause.

Oestrogen does far more than regulate periods. It helps keep bones strong, supports the lining of the vagina and urinary tract and has effects on the heart, blood vessels, skin, mood and sleep. When levels drop, changes can appear across all of these areas, which is why the NHS lists symptoms as varied as hot flushes, sleep problems, mood changes, vaginal dryness, urinary tract infections, joint pains, palpitations and weakening bones.

Not everyone is affected in the same way. The NHS says you may get symptoms that have a big impact on daily life, or you may hardly have any symptoms at all, and that ethnic background can affect how severe symptoms are and how long they last.

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. The NHS says it develops slowly over several years and is often diagnosed only when a fall or sudden impact causes a fracture, most commonly of the wrist, hip or spinal bones.

Menopause is a key reason risk rises. The NHS notes that women lose bone rapidly in the first few years after the menopause, that women are more at risk than men, particularly if menopause begins early or the ovaries have been removed, and that other factors such as a family history of osteoporosis, long-term high-dose steroid tablets, a low body mass index, heavy drinking and smoking also increase the risk.

Doctors can estimate your future fracture risk using tools such as FRAX or QFracture and may refer you for a DEXA bone density scan. A T score below -2.5 is defined as osteoporosis, and between -1 and -2.5 as osteopenia, according to the NHS. Regular exercise, calcium-rich foods and a daily vitamin D supplement of 10 micrograms are advised, along with stopping smoking and cutting alcohol.

The NHS says early or premature menopause means a higher chance of developing osteoporosis and cardiovascular disease, and explains that it is important to replace missing hormones if menopause starts before 45 because of the higher chance of problems with bones and the heart. This is a statement about earlier menopause, not menopause at the usual age.

Urinary and vaginal changes are also common. The NHS lists vaginal dryness, burning or itching, painful sex, more urinary tract infections and urinary incontinence among menopause symptoms. Vaginal oestrogen helps with dryness, and the NHS says it does not increase the risk of breast cancer, blood clots or other conditions and is safe to use for a long time because very little reaches the rest of the body.

Weight gain around the stomach and upper body, loss of muscle strength and changes in mood and memory are also described. HRT can improve muscle strength, but the NHS stresses that exercise is also important.

The NHS says the main benefit of HRT is that it relieves most perimenopause and menopause symptoms such as hot flushes, night sweats, sleep problems, anxiety and low mood and vaginal dryness, and that it helps to prevent osteoporosis. It reports that the risks of serious side effects are usually very low and depend on the type of HRT, how long it is taken and your own health.

It lists the main risks: combined HRT slightly increases breast cancer risk, with around 5 extra cases in every 1,000 women who take it for 5 years, and the risk falls again after stopping. HRT tablets can increase the risk of blood clots and slightly increase the risk of stroke, but patches, gels and sprays do not increase clot risk. Research shows little or no effect on coronary heart disease risk.

Non-hormonal options exist for those who cannot or do not want HRT, including cognitive behavioural therapy and some medicines. The NHS notes that herbal remedies such as red clover and black cohosh have very little evidence for how well they work or how safe they are.

The NHS advises contacting a GP if you think you have menopause or perimenopause symptoms and want to know your options, if you have a fast heartbeat, if your bleeding pattern is heavier than before, or if you have had no period for 12 months and have any vaginal bleeding. Postmenopausal bleeding should always be checked, even if it is only once or only a small amount, because it can occasionally be a sign of cancer.

Menopause care is available through the GP and, where needed, specialist NHS menopause services. Private menopause clinics also exist and offer longer appointments, though the underlying treatments are the same. It is sensible to be cautious of unlicensed hormone products and to discuss any private hormone testing with your GP.