Menopause Awareness Month: Interview with Dr Priyanka Mehta

The International Menopause Society was founded in 1978, in hopes of raising awareness and improving the lives of women around the world. The organisation offers evidence-based education on women’s health and hopes to advance menopause research. However, menopause is still significantly under-researched. According to Harvard School of Medicine, over 75% of age-related diseases are likely influenced by menopause in one way or another. Despite this, 99% of preclinical ageing studies ignore menopause. This lack of research can leave women unsure or confused about their symptoms or treatment options. To help women understand the biological mechanisms in menopause, the symptoms, the possible severity levels and treatment options, we interview Dr Priyanka Mehta. Dr Mehta is a menopause, perimenopause and hormone health specialist situated in Britain.

In Conversation with Dr Priyanka mehta

Why does perimenopause often begin before women realise what is happening?

Because it usually doesn’t start with one obvious symptom. Many women are still having periods when the first changes begin.
They may notice that they are not sleeping as well, they feel more anxious or irritable, their concentration is not the same, or they suddenly struggle with brain fog or fatigue. Very often they put it down to work, children, stress or simply getting older.

Perimenopause can begin several years before the final period, and hormone levels can fluctuate quite a lot during this time. That is why women often say, “I just don’t feel like myself,” long before they realise hormones may be part of the picture.

What are the menopause and perimenopause symptoms women are least prepared for, beyond hot flashes?

I think the symptoms that surprise women most are the ones affecting the brain and mood. Brain fog, poor concentration, forgetfulness, anxiety, irritability and disturbed sleep can be very unsettling, especially for women who have always been highly organised and capable. There can also be joint pains, headaches, palpitations, changes in skin and hair, vaginal dryness, painful sex and reduced libido.

Many women also notice that their body composition changes. They may lose muscle more easily and gain fat around the abdomen even though their weight has not changed dramatically. So menopause is really much broader than hot flushes.

Which symptoms are normal during this transition, and which should always be discussed with a doctor?

Irregular periods, hot flushes, night sweats, sleep disturbance, mood changes, brain fog, joint pains and vaginal dryness are all common during perimenopause and menopause. But we should not assume that every symptom is caused by menopause.

Heavy or prolonged bleeding, bleeding after sex, or any bleeding after 12 months without a period should always be checked.

The same applies to a new breast lump, nipple changes, persistent palpitations, unexplained weight loss, severe fatigue, chest pain, breathlessness or significant changes in mood. Sometimes menopause and other conditions such as thyroid problems, iron deficiency or metabolic issues can exist at the same time.

What is actually happening hormonally in the body during perimenopause and menopause?

It is not simply that estrogen gradually falls. During perimenopause, ovulation becomes less predictable. Progesterone may fall or fluctuate, while estrogen can go up and down quite dramatically. That is why symptoms can feel inconsistent. A woman may feel fine for a few weeks and then suddenly have poor sleep, anxiety, breast tenderness or hot flushes.

As menopause approaches, ovarian estrogen production eventually falls more consistently and FSH rises. These hormones influence much more than periods. They affect sleep, mood, temperature control, bones, metabolism, vaginal health and even how we feel cognitively. This is also why one blood test does not always tell the whole story in perimenopause.

How can women distinguish menopause-related symptoms from stress, ageing, depression or other health issues?

There is a lot of overlap. Stress can disturb sleep, concentration and mood. Thyroid problems can cause fatigue and palpitations. Iron deficiency can cause exhaustion and hair loss. Depression can affect sleep, motivation and cognition.

So we look at the overall pattern. If a woman is in her forties, her periods are changing, and she is also developing hot flushes, night sweats, vaginal symptoms or several new symptoms at the same time, perimenopause becomes more likely. The important thing is not to blame everything on menopause, but also not to dismiss everything as stress or ageing.

What lifestyle changes have the strongest scientific evidence behind them?

Strength training is probably one of the most important things women can do in midlife. We naturally lose muscle as we age, and this can accelerate around menopause. Muscle is important not only for strength, but also for bone health, metabolism and maintaining independence later in life. I usually recommend a combination of resistance exercise, regular walking or aerobic activity, adequate protein, plenty of fibre and a mostly whole-food diet. Sleep also matters enormously.

Alcohol can worsen sleep and hot flushes, and smoking has a very clear negative effect on cardiovascular and bone health. I would not recommend extreme menopause diets. The basics done consistently are far more useful.

What should women know today about hormone replacement therapy? Who may benefit, what are the risks, and why has the medical conversation around HRT changed?

The biggest change is that we now understand HRT in a much more individualised way.
It is not simply “HRT is good” or “HRT is dangerous.” We look at the woman’s age, symptoms, medical history, family history, whether she still has a uterus, and the type and route of hormones being used. For many healthy women with significant menopausal symptoms, particularly when treatment is started around the time of menopause, HRT can be very effective. It remains the most effective treatment for hot flushes and night sweats and also helps with vaginal symptoms and prevention of bone loss.

If a woman has a uterus, progesterone or another progestogen is needed alongside systemic estrogen to protect the lining of the womb. We also increasingly use estrogen through the skin, such as patches or gels, because this can have advantages for some women compared with oral estrogen.
The conversation has changed because we are much better at understanding absolute risk, timing, dose and individual risk factors rather than treating every woman the same way.

What non-hormonal treatments or alternatives currently have solid evidence?

There are several options. Menopause-specific cognitive behavioural therapy can help women with hot flushes, sleep and the psychological impact of symptoms.

There are also non-hormonal prescription medicines that can help with hot flushes, including some antidepressants, gabapentin and newer medicines such as fezolinetant.

For vaginal dryness, moisturisers and lubricants can be useful, and local vaginal estrogen is very effective for many women. Where I am more cautious is with supplements marketed as “natural hormone balancing.” Some may be harmless, some may interact with medication, and many have much less evidence than women are led to believe. Natural does not automatically mean safe or effective.

At what point should a woman seek specialised medical advice?

You do not need to wait until symptoms become unbearable. If menopause symptoms are affecting sleep, work, relationships, sexual health, mood or quality of life, that is a reasonable time to seek help. Women who experience menopause before the age of 45 should be assessed, and anyone under 40 with suspected premature ovarian insufficiency needs proper medical evaluation. Women with a history of breast cancer, blood clots, cardiovascular disease or more complex medical or gynaecological issues may also benefit from specialist menopause advice. And if someone has been told simply to “put up with it” despite significant symptoms, it is reasonable to seek another opinion.

What do you wish women knew about menopause before they reached their forties?

I wish women understood that menopause does not begin on the day their periods stop. Perimenopause often starts years earlier. I also wish women saw their forties as a time to invest in the next 30 or 40 years of health. Build muscle. Protect your bones. Know your blood pressure and cholesterol. Look after your sleep. Understand your breast health. Pay attention to vaginal and sexual health.

And learn about hormones before you are in the middle of symptoms and trying to work out what is happening. For me, menopause should not be presented as decline.

It is a transition, and for many women it can be a very useful point to reassess their health and decide how they want to feel and function in the decades ahead. I often call it a midlife reset.