Menopause & HRT: Expert Care in London

Menopause is one of the most significant hormonal transitions a woman will experience, yet for generations it has been treated as something to simply get through rather than something that deserves proper medical attention. I believe that view is both outdated and unhelpful. In my practice, I see women who have been experiencing debilitating symptoms for years — symptoms that have affected their careers, their relationships, their sleep, and their sense of self — and who were told only to "wait and see." You deserve more than that. Menopause is a medical transition, and it warrants the same thorough, evidence-based approach as any other healthcare need.

What Is Perimenopause?

Perimenopause is the transitional phase that precedes the final menstrual period, and it can begin years — sometimes a decade — before menstruation stops entirely. During this time, ovarian function becomes increasingly erratic. Oestrogen levels fluctuate unpredictably: they do not simply decline in a smooth, linear way. Instead, they spike and crash, which is precisely why perimenopause can feel so destabilising and difficult to attribute to hormones.

Cycles may become shorter, then longer, then shorter again. They can become heavier or lighter. Some months you may not ovulate at all. These irregular patterns, combined with the biochemical effects of fluctuating oestrogen and progesterone, produce a constellation of symptoms that many women — and even some clinicians — fail to recognise as hormonal in origin.

Perimenopause typically begins in a woman's mid-to-late forties, though in some women it begins as early as the late thirties. Premature ovarian insufficiency (POI), in which ovarian function declines before the age of 40, is a distinct condition that requires especially prompt hormonal treatment.

Symptoms I Help With

One of the things I hear most often from patients is: "I didn't know all of these were connected." The hormonal changes of perimenopause and menopause affect almost every organ system in the body. The symptoms I regularly assess and treat include:

• Hot flushes and night sweats — vasomotor symptoms affecting up to 80% of women; can disrupt sleep, work, and social life
• Sleep disturbance — difficulty falling asleep, frequent waking, unrefreshing sleep, often worsened by night sweats
• Brain fog — problems with concentration, word-finding, memory, and cognitive sharpness, often profoundly distressing
• Mood changes — low mood, increased anxiety, irritability, emotional reactivity, and depressive episodes linked to oestrogen fluctuation
• Vaginal dryness and discomfort — the genitourinary syndrome of menopause (GSM), including dryness, thinning, and pain during intercourse
• Low libido — reduced sexual desire driven by declining oestrogen and testosterone
• Joint aches and muscle pain — often misattributed to ageing or arthritis; oestrogen plays an anti-inflammatory role
• Heart palpitations — episodes of racing or irregular heartbeat that can be frightening but are often hormonally driven
• Urinary symptoms — increased urinary urgency, frequency, or recurrent urinary tract infections due to urogenital atrophy
• Skin and hair changes — loss of collagen leading to dryness, thinning, and increased wrinkling; hair thinning or loss
• Weight redistribution — the shift to central adiposity that accompanies declining oestrogen

These symptoms can occur individually or in combination, and they frequently appear before periods become irregular — which means many women experiencing them do not realise hormones are the cause.

My Approach to HRT

Hormone replacement therapy remains the most effective treatment for menopausal symptoms, and in my practice I take an individualised approach rather than prescribing a single standard regimen. Every woman's hormonal profile, medical history, preferences, and goals are different — and her HRT should reflect that.

Where clinically appropriate, I prefer body-identical hormones: specifically, transdermal oestradiol (delivered via patch, gel, or spray) combined with micronised progesterone (Utrogestan) for women with a uterus. Body-identical hormones have the same molecular structure as the hormones your body naturally produces, and the evidence base for their safety and tolerability is now well-established.

The route of oestrogen delivery matters clinically. Transdermal oestrogen — absorbed through the skin — bypasses first-pass metabolism in the liver. This means it does not increase clotting factors in the way that oral oestrogen can, which translates to a safer thrombosis (blood clot) profile. For women with a personal or family history of venous thromboembolism, migraine with aura, or cardiovascular risk factors, the transdermal route is particularly important to consider.

Micronised progesterone, unlike older synthetic progestogens, has a more favourable safety profile — particularly in relation to breast cancer risk and cardiovascular health — and is also better tolerated by many women due to its mild sedative effect, which can actually support sleep.

Beyond Symptom Relief

While the relief of symptoms is often the immediate priority, HRT offers benefits that extend well beyond how you feel day to day. When started within ten years of the final menstrual period or before the age of 60 — what is known as the "early menopause window" — oestrogen therapy has a significant evidence base for:

• Bone protection: oestrogen is critical to bone density. The rapid bone loss that follows menopause is a leading cause of osteoporosis; HRT is one of the most effective interventions for its prevention
• Cardiovascular health: oestrogen has a beneficial effect on cholesterol, arterial flexibility, and insulin sensitivity. Starting HRT in the early menopause window is associated with a reduced risk of cardiovascular disease
• Cognitive health: emerging evidence suggests oestrogen therapy started early may reduce the risk of Alzheimer's disease, though research in this area continues to evolve
• Genitourinary health: local oestrogen used vaginally can be used long-term and is safe for the majority of women, including many with a history of certain cancers

Is HRT Right for Me?

This is a question I take seriously in every consultation. The safety of HRT was dramatically — and in many ways, unfairly — called into question by the Women's Health Initiative (WHI) study published in 2002. That study used oral conjugated equine oestrogen combined with medroxyprogesterone acetate (a synthetic progestogen), in women who were on average 63 years old and many years past menopause. Its findings cannot be straightforwardly applied to body-identical HRT started in younger, recently menopausal women.

The current evidence, summarised by both the NICE menopause guideline and the British Menopause Society, indicates that for the majority of women under 60 using body-identical HRT, the benefits outweigh the risks. The absolute increase in breast cancer risk with combined HRT is small and comparable to the risk associated with drinking one to two units of alcohol per day.

There are women for whom HRT requires careful consideration or may not be appropriate — those with a current or recent diagnosis of hormone-sensitive breast cancer, unexplained vaginal bleeding, or certain cardiovascular conditions. I always take a thorough personal and family history before making any recommendation.

What to Expect at Your Consultation

When you come to see me, I will begin with a detailed history covering your symptoms, their duration and severity, your menstrual pattern, your past medical and surgical history, and your family history. I use validated menopause scoring tools (such as the Greene Climacteric Scale or the Menopause Rating Scale) to help us both understand the full picture of how you are affected.

We will discuss your priorities — whether that is sleep, mood, vasomotor symptoms, long-term health, or all of the above — and I will explain the options available to you clearly and without pressure. If HRT is appropriate and you wish to proceed, I will write a bespoke prescription and arrange a follow-up appointment, typically at three months, to review how you are responding and adjust the dose or formulation as needed. Menopause care is not a single appointment; it is an ongoing partnership.

When to Seek Help

1. Your periods have become irregular, heavier, or more frequent and you are over 40
2. You are experiencing hot flushes, night sweats, or sleep disruption affecting your quality of life
3. You are noticing mood changes, anxiety, or low mood that feel different to your usual pattern
4. You have been experiencing symptoms for more than a few months without a clear explanation
5. You have tried HRT but feel it is not working well, or you are concerned about side effects
6. You had a premature or surgical menopause and have not yet been offered hormonal treatment
7. You want to understand your long-term health risks and how to manage them proactively

You do not need to be in full menopause to come and see me. Perimenopause is real, it is hormonal, and it is very much within my remit to help. If you have been dismissed, or told your blood tests are "normal" so there is nothing to be done, I would welcome the opportunity to take a proper, thorough look at what you are experiencing. Let us find a way forward together.