Menopause care in Mumbai is provided by Dr. Vaishali Joshi, FRCOG, Senior Consultant Obstetrician & Gynaecologist at Kokilaben Dhirubhai Ambani Hospital, Andheri West. Menopause is not an illness, but its symptoms are treatable and its long-term effects on bone and cardiovascular health are worth taking seriously. Too many women endure years of disruptive symptoms because they were told, or assumed, that nothing could safely be done. That is no longer an accurate picture of the evidence.
Menopause is defined retrospectively: it is the point twelve months after a woman's last period. The years of hormonal fluctuation leading up to it — the perimenopause — are where most symptoms occur, and they can begin several years before periods actually stop. Many women in their mid-forties are told their symptoms cannot be menopausal because they are still menstruating. They very often can be.
The average age of natural menopause in India is generally reported as somewhat earlier than in Western populations. Menopause before the age of 40 is termed premature ovarian insufficiency and is a different clinical situation requiring specific management, not simply an early version of the same thing.
What are the symptoms of menopause?
Vasomotor symptoms
Hot flushes and night sweats — the best-known symptoms, and for many women the most disruptive. They can persist for several years.
Sleep and mood
Insomnia, often driven by night sweats but also independently; irritability, anxiety, low mood and difficulty concentrating. These are frequently misattributed to stress alone.
Genitourinary symptoms
Vaginal dryness, discomfort during intercourse, urinary urgency and recurrent urinary infections. Unlike hot flushes, these do not improve with time and tend to worsen if untreated.
Musculoskeletal
Joint aches and stiffness, which are common and surprisingly often the presenting complaint.
Cycle changes
In perimenopause, periods typically become irregular — closer together, further apart, lighter or heavier — before stopping.
Bleeding after the menopause is never normal. Any bleeding twelve months or more after your last period needs prompt assessment, even if it is a single episode and even if it is light. Most causes are benign, but this is the symptom that detects endometrial cancer early, and it should not be waited on.
Is hormone replacement therapy safe?
This deserves a direct answer, because a generation of women was frightened away from HRT by the early reporting of the Women's Health Initiative study in 2002, and much of that fear has outlived the evidence that produced it.
What has changed in the understanding since then:
- Age and timing matter enormously. The original study population was substantially older than the women who typically start HRT. For most women who begin HRT under the age of 60, or within ten years of their menopause, the balance of benefit and risk is favourable.
- The type and route matter. Oestrogen given through the skin, as a patch or gel, does not carry the increased risk of venous thrombosis associated with oral oestrogen. Micronised progesterone appears to have a more favourable profile than older synthetic progestogens.
- The breast cancer risk was widely misreported. There is a small increase in breast cancer risk with combined HRT, which relates to duration of use and which declines after stopping. In absolute terms it is comparable to lifestyle factors that attract far less alarm. Oestrogen-only HRT, used by women who have had a hysterectomy, does not show the same association.
- There are real benefits beyond symptom relief, including protection against osteoporosis and fracture.
None of this means HRT is right for every woman. It is genuinely contraindicated in some — a personal history of breast cancer, active liver disease, unexplained vaginal bleeding, or a history of oestrogen-dependent cancer or recent thromboembolism among them. And some women simply prefer not to take it, which is a perfectly reasonable position.
What it does mean is that the decision should be an informed individual discussion of your own symptoms, medical history and preferences — not a blanket refusal based on a study reported two decades ago.
What are the non-hormonal options?
For women who cannot take HRT or choose not to, several approaches genuinely help.
- Vaginal oestrogen for genitourinary symptoms. This is worth separating out: it is a local preparation with minimal systemic absorption, and it is suitable for many women who cannot take systemic HRT. It is by far the most effective treatment for vaginal dryness and recurrent urinary infections after menopause, and it is greatly underused.
- Non-hormonal vaginal moisturisers and lubricants, used regularly rather than only before intercourse.
- Certain non-hormonal prescription medicines can reduce hot flushes, though generally less effectively than HRT.
- Cognitive behavioural therapy, which has reasonable evidence for hot flushes, sleep disturbance and mood.
- Lifestyle measures — regular weight-bearing exercise, limiting alcohol and caffeine, stopping smoking, keeping the bedroom cool and managing weight. Modest individually, worthwhile together.
A word of caution on supplements. Many products are marketed for menopause with claims that outrun their evidence, and “natural” does not mean inert — some interact with prescribed medication. Compounded “bio-identical” hormone preparations from unregulated sources are not the same as regulated body-identical HRT and are not recommended. Tell your doctor what you are taking.
Bone health after menopause
Oestrogen protects bone. When it falls at menopause, bone density declines relatively rapidly in the following years, and osteoporosis is largely silent until a fracture happens. In India, low vitamin D levels are widespread and dietary calcium intake is frequently inadequate, which compounds the problem.
- Weight-bearing and resistance exercise — the single most useful thing most women can do, and it needs to include resistance work, not walking alone.
- Adequate calcium and vitamin D, from diet where possible and supplementation where levels are low. Vitamin D deficiency is worth testing for rather than assuming.
- Stopping smoking and moderating alcohol, both of which independently accelerate bone loss.
- Bone density (DEXA) assessment where there are risk factors — early menopause, long-term steroid use, low body weight, a family history of hip fracture, or a previous fragility fracture.
- Specific treatment where osteoporosis is confirmed. HRT itself protects bone, which is part of the calculation for younger postmenopausal women.
Cardiovascular and metabolic health
Cardiovascular risk rises after menopause, and cardiovascular disease is a leading cause of death in women — a fact that receives far less attention than it deserves. The menopause consultation is a good opportunity to check blood pressure, lipids and glucose, and to address weight and activity. For many women it is the first structured health review they have had in years.
Continuing gynaecological care
Menopause does not end the need for gynaecological review. Cervical screening continues to the recommended age. Any postmenopausal bleeding needs assessment. Breast awareness and mammography continue according to local guidance. And genitourinary symptoms, which so many women accept as an inevitable part of ageing, remain treatable at any stage — it is never too late to raise them.
Frequently asked questions
At what age does menopause usually happen?
Menopause is defined as twelve months after the last period, and the average age in India is generally reported as somewhat earlier than in Western populations. The perimenopause — the years of hormonal fluctuation beforehand — can begin several years earlier, and this is when most symptoms occur. Menopause before the age of 40 is termed premature ovarian insufficiency and needs specific assessment and management rather than being treated as simply an early version of the same process.
Is HRT safe?
For most women who begin HRT under the age of 60 or within ten years of their menopause, the balance of benefit and risk is favourable. Much of the widespread fear traces to early reporting of a 2002 study whose population was substantially older than typical HRT users. Understanding has since changed: oestrogen given through the skin avoids the thrombosis risk of oral oestrogen, and the breast cancer risk with combined HRT is small, related to duration of use, and declines after stopping. HRT is genuinely contraindicated in some women, so the decision should be an individual discussion rather than a blanket answer either way.
Can I take HRT if I cannot take systemic hormones?
Often, yes — for genitourinary symptoms specifically. Vaginal oestrogen is a local preparation with minimal systemic absorption and is suitable for many women who cannot take systemic HRT. It is by far the most effective treatment for vaginal dryness, discomfort during intercourse and recurrent urinary infections after menopause, and it is considerably underused. Discuss your particular history with your gynaecologist, as suitability depends on the reason systemic HRT is unsuitable.
What can I take for hot flushes if I do not want HRT?
Certain non-hormonal prescription medicines can reduce hot flushes, though generally less effectively than HRT. Cognitive behavioural therapy has reasonable evidence for hot flushes, sleep disturbance and mood. Lifestyle measures — limiting alcohol and caffeine, stopping smoking, keeping the bedroom cool, regular exercise and weight management — are modest individually but worthwhile together. Be cautious with marketed supplements: claims often outrun evidence, and some interact with prescribed medication.
Is bleeding after the menopause ever normal?
No. Any bleeding twelve months or more after your last period needs prompt assessment, even a single light episode. Most causes turn out to be benign — vaginal atrophy or a polyp, for instance — but postmenopausal bleeding is the symptom that detects endometrial cancer at an early and highly treatable stage. It should never be watched and waited on.
How do I protect my bones after menopause?
Weight-bearing and resistance exercise is the single most useful measure, and it needs to include resistance work rather than walking alone. Ensure adequate calcium and vitamin D — deficiency is widespread in India and worth testing for rather than assuming. Stop smoking and moderate alcohol, both of which accelerate bone loss independently. Bone density (DEXA) assessment is advised where there are risk factors such as early menopause, long-term steroid use, low body weight, or a previous fragility fracture. HRT itself protects bone, which forms part of the decision for younger postmenopausal women.
Related reading
Written & medically reviewed by Dr. Vaishali Joshi, FRCOG CCT MD DNB DGO FCPS — Senior Consultant Obstetrician & Gynaecologist, Kokilaben Dhirubhai Ambani Hospital, Mumbai.
Last reviewed . This article is general information and is not a substitute for individual medical advice. Please discuss your own circumstances at consultation.