Menopause is a natural part of life, but that doesn’t mean it’s easy. Hot flushes, brain fog, mood swings, and sleepless nights can affect everything from your work to your relationships. To celebrate Menopause Awareness Month, we sat down with Dr Fiona MacRae, one of our leading menopause specialists at the Marion Gluck Clinic, for a Q&A about navigating this stage of life.

With her compassionate, whole-person approach, Dr MacRae has helped hundreds of women feel like themselves again. Here, she shares how bioidentical hormone replacement therapy (BHRT) can make a world of difference during menopause.

Menopause seems to come with such a range of experiences. What are the most common challenges women tell you about?

Dr MacRae: “The most common are the vasomotor symptoms – hot flushes, night sweats and the sleep disruption that often follows. However, it is rarely just those. Many women describe brain fog, difficulty concentrating, irritability or low mood.

“There are also the genitourinary changes – vaginal dryness, painful intercourse and urinary urgency or recurrent infections – which can be overlooked. Some experience joint aches, weight gain around the middle, and a loss of libido. Added to work and family responsibilities, the whole transition can feel overwhelming.”

We are hearing more about menopause in the media and in the workplace. How has the conversation shifted in recent years?

Dr MacRae: “The change has been remarkable. For decades, menopause was something women endured in silence. Today, it is discussed far more openly: employers are introducing menopause-friendly policies, public figures share their experiences, and women expect to have an informed conversation with their doctor.

“We have moved away from a one-size-fits-all approach. There is also a more balanced view of hormone therapy, particularly about transdermal estrogen and micronised progesterone. We now recognise that menopause care is not only about hormones; it also includes mental health, pelvic health, relationships, and lifestyle.”

The role of BHRT

Bioidentical hormone replacement therapy is often in the headlines. What benefits do you see for women during menopause?

Dr MacRae: “For most women, BHRT significantly eases flushes and sweats and improves sleep. Many notice clearer thinking, better mood, and relief from vaginal dryness. It also helps protect bone density, which becomes increasingly important with age.

“Transdermal estrogen is usually neutral, and sometimes beneficial, for cholesterol and blood pressure. For women who experience loss of libido after menopause, carefully prescribed testosterone can help restore sexual wellbeing. Treatment is always individualised.”

Are there any myths about BHRT that you would like to clear up?

Dr MacRae: “Yes, several. The most persistent is that all hormone therapy dramatically raises the risk of breast cancer. The reality is more nuanced. Estrogen-only therapy, traditionally used in women who have had a hysterectomy, does not increase breast cancer risk and may even reduce it slightly.

“If a woman still has her uterus, she needs a progestogen to protect the lining of the womb. The combination of estrogen and synthetic progestogen carries a small increase in risk. Evidence suggests that micronised progesterone is associated with a more favourable profile than synthetic progestins.

“Due to NICE guidance, there is a misconception that progesterone is not needed post-hysterectomy. Progesterone has lovely benefits: soothing anxiety, stabilising mood, and helping sleep (through its effect on GABA brain receptors) and through its mineralocorticoid effects, reducing fluid retention. These benefits are missed when following traditional guidelines.

“Another misconception is that patches and gels carry the same risk of blood clots as tablets. In fact, it is mainly oral estrogen that increases that risk. A fourth is that BHRT is completely risk-free because it is described as ‘natural.” It is still an active medication, and its benefits and risks need to be assessed for each individual.

“Finally, there is no fixed time limit, such as five years or a mandatory stopping age. Many women continue safely for longer, as long as the benefits outweigh the risks and they have regular reviews.”

A tailored approach

What does personalised BHRT look like in practice?

Dr MacRae: “It starts with a detailed consultation to understand a woman’s symptoms, goals, medical and family history. I almost always begin with transdermal estradiol – as a patch, a gel or a spray – and adjust the dose to achieve relief without unnecessary excess.

“Women with a uterus require progesterone for endometrial protection. I generally recommend micronised progesterone taken in a cyclical pattern if she is still having periods, or continuously once she is post-menopausal. A hormonal intra-uterine system is another excellent option. For genitourinary symptoms, we can add local vaginal estrogen at any time.

“If, after optimising all other aspects, a woman still has a distressing loss of libido, we may consider a low-dose testosterone with careful monitoring. Treatment is a partnership. We review symptoms, side-effects, and health screening regularly, and adjust the plan as needed.”

Lifestyle as a foundation

Lifestyle medicine is another area you emphasise at the Marion Gluck Clinic. How does it fit alongside hormones?

Dr MacRae: “It is integral. Hormones are rarely the whole story. We encourage a Mediterranean-style diet with good quality protein, fibre, and plenty of plant foods. We advise regular resistance and balance training to protect bones and muscles, as well as cardiovascular activity for heart and metabolic health.

“Sleep and stress management are crucial. We help women improve sleep hygiene and, if needed, use structured approaches such as cognitive-behavioural therapy. We advise on natural supplements to lower cortisol levels. We also address alcohol, smoking, and weight management.”

What would you say to women who are unsure whether BHRT is for them?

Dr MacRae: “Begin by tracking your symptoms for a few weeks so that you can bring a clear record to a consultation. Then have a balanced discussion with a knowledgeable clinician who will explain the options and assess your personal risk profile.

“Treatment is not a lifelong commitment. We often start with a low dose and review progress. Many women notice improvement within a few weeks. You can always adjust or stop if it does not suit you.”

A message for Menopause Awareness Month

Finally, what is the one key message you would like women to hear during Menopause Awareness Month?

Dr MacRae: “You do not have to’just put up with it’. There are safe, evidence-based options – both hormonal and non-hormonal – that can help you feel well and protect your long-term bone, brain, heart, and sexual health. The most important step is to reach out and begin the conversation.

“Menopause doesn’t have to mean losing your sense of self. With the right medical support and a personalised BHRT plan, you can move through this chapter feeling in control of your symptoms.”

If you’re ready to take the next step towards feeling like yourself again, our expert doctors are here to help.

Book an online appointment with the Marion Gluck Clinic and start your journey to better hormonal balance today.  

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