# Menopause and HRT

> Menopause for FMGE gynaecology: twelve-month diagnosis, Indian age of onset, FSH changes, HRT rules with an intact uterus and osteoporosis prevention.

- Canonical URL: https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/menopause-and-hrt
- Exam / course: FMGE · Subject: Obstetrics and Gynaecology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Menopause and HRT", PrepElephant, https://prepelephant.com/topics/fmge/obstetrics-and-gynaecology/menopause-and-hrt

## Direct answer

Menopause is the permanent cessation of menstruation from loss of ovarian follicles, diagnosed retrospectively after twelve consecutive months of amenorrhoea — around age 51 in Western series and commonly reported a few years earlier, in the mid-to-late forties, in Indian studies. The transition brings erratic cycles, vasomotor flushes and night sweats, and the hypo-oestrogen state thins the urogenital epithelium (genitourinary syndrome of menopause) and accelerates bone loss, making osteoporosis the key long-term risk. Diagnosis is clinical after 45; a raised follicle-stimulating hormone with low oestradiol confirms when needed. Hormone replacement therapy is the most effective treatment for vasomotor symptoms — oestrogen alone after hysterectomy, oestrogen plus progestogen with an intact uterus — at the lowest effective dose for the shortest duration, avoiding oral therapy with thrombotic risk and hormone-dependent cancer outright.

## What you must remember

- Diagnosis: twelve months of amenorrhoea with no other cause after about 45 years; a raised FSH (above about 25 to 30 IU/L) with low oestradiol supports ambiguous or early cases.
- Timing: average near 51 in Western data, with Indian studies commonly reporting the mid-to-late forties; menopause before 40 is premature ovarian insufficiency needing specialist care.
- Symptom clusters: vasomotor (flushes, night sweats), psychological (mood lability, sleep and memory complaints), urogenital (dryness, dyspareunia, recurrent urinary infection) and long-term bone and cardiovascular risks.
- Bone: loss is fastest in the first postmenopausal years, and osteoporosis is a T-score of minus 2.5 or less on DXA; protection needs calcium 1000 to 1200 mg daily, vitamin D, weight-bearing exercise and smoking cessation, with bisphosphonates when osteoporosis or fragility fracture is established.
- HRT rules: oestrogen alone if the uterus is removed; oestrogen plus adequate progestogen (or a levonorgestrel intrauterine system) if the uterus is intact — unopposed systemic oestrogen causes endometrial hyperplasia and carcinoma.
- HRT cautions: current or past hormone-dependent cancer, venous thromboembolism, active liver disease and unexplained bleeding are contraindications; transdermal oestrogen suits thrombotic or migraine risk by avoiding first pass; large trials link combined long-term therapy with small rises in breast cancer, stroke and clot risk.
- Non-hormonal options: cognitive behavioural therapy, SSRIs or SNRIs, gabapentin or clonidine for flushes; low-dose vaginal oestrogen and lubricants for genitourinary symptoms.

## Common confusion

The examinable trap is the progestogen rule — oestrogen alone in a woman with a uterus is the classic wrong answer, while combined therapy after hysterectomy is unnecessary. The second distinction: cycles may be erratic in the transition, but any bleeding after twelve months of amenorrhoea is postmenopausal bleeding demanding endometrial evaluation. Premature ovarian insufficiency before 40 differs from routine menopause and needs HRT until the natural menopausal age.

## Exam-focused takeaway

FMGE asks the twelve-month definition, the FSH direction, the oestrogen-plus-progestogen rule, transdermal preference with thrombotic risk, and the T-score of minus 2.5. Vignettes pair flushes with an HRT decision after risk assessment, or bleeding after menopause with biopsy-first sequencing. Answer 45 to 55 as normal, mid-forties average in Indian series, premature below 40.

## Frequently asked questions

### How is menopause diagnosed?

Clinically, by twelve consecutive months of amenorrhoea with no other cause in a woman past her mid-forties; a raised FSH with low oestradiol helps when the history is unclear.

### What is the average age of menopause in Indian women?

Indian studies commonly report the mid-to-late forties, somewhat earlier than the near-51 average of Western series; menopause before 40 is premature ovarian insufficiency.

### Why must progestogen accompany systemic oestrogen?

Unopposed oestrogen stimulates the endometrium, causing hyperplasia and carcinoma; a woman with an intact uterus needs both hormones, while after hysterectomy oestrogen alone suffices.

### Which women should avoid HRT?

Those with current or past breast or endometrial cancer, venous thromboembolism history, active liver disease, undiagnosed vaginal bleeding or uncontrolled cardiovascular risk.