Menopause and perimenopause: symptoms, treatment and expert advice in Tirana

01What is menopause and what is perimenopause?

Menopause is a woman’s final menstrual period, and it can only be confirmed once 12 consecutive months have passed without a period and without any other obvious cause. It happens because the ovaries gradually stop working and oestrogen levels fall. According to the World Health Organization (WHO), menopause is a natural part of life, not a disease.

Perimenopause is the transition before and around menopause. According to the WHO, it starts with the first signs, usually changes in the menstrual cycle, and lasts until one year after the final period. It can last several years, and it is often the time when symptoms are most unpredictable, because hormone levels rise and fall erratically.

The three terms you will hear most often:

• Perimenopause: the transition years, with irregular cycles and symptoms that come and go.
• Menopause: the final period, confirmed after 12 months without one.
• Postmenopause: the whole period after menopause, when some symptoms settle but care for your bones, heart and intimate health becomes more important.

Menopause can also be induced, for example after surgical removal of both ovaries or after some cancer treatments (chemotherapy, radiotherapy). In these cases symptoms can start suddenly and be more intense, so early advice matters even more.

The most important thing to know: menopause symptoms are real, common and treatable. You do not have to put up with them in silence.

02What age does menopause start? Early and premature menopause

Most women reach natural menopause between 45 and 55 (WHO), with an average age of around 51 (NHS, United Kingdom). Perimenopausal symptoms can begin several years earlier, often in the mid-40s.

The age of menopause is influenced by several factors:

• Genetics: the age at which your mother or sisters reached menopause is often a good guide.
• Smoking: linked to earlier menopause.
• Ovarian surgery, chemotherapy or pelvic radiotherapy.
• Some autoimmune or genetic conditions.

Definitions by age:

• Premature menopause, or premature ovarian insufficiency (POI): when the ovaries stop working before the age of 40. It has traditionally been estimated to affect about 1 in 100 women, and the 2024 international POI guideline (ESHRE, ASRM, IMS) cites even higher estimates.
• Early menopause: between 40 and 45.
• Usual menopause: between 45 and 55.

Why does early menopause matter? When oestrogen is missing for many years before the average age, the long-term risk of osteoporosis and heart disease rises. For this reason, international guidelines (ESHRE, NICE) recommend that women with POI who have no contraindications take hormone replacement at least until the average age of natural menopause. Here hormone therapy is not just about symptoms: it protects your health.

If you are under 40 and your periods have become infrequent or stopped, or you have hot flushes, do not assume it is menopause without being seen. Other causes (thyroid problems, prolactin, pregnancy, severe stress or weight loss) need to be ruled out.

03What are the symptoms of menopause and perimenopause?

Menopause symptoms vary enormously from one woman to another: some have few or none, others have severe symptoms that last for years (WHO). The first sign of perimenopause is usually a change in your cycle: shorter or longer cycles, lighter or heavier periods, or skipped months.

Vasomotor symptoms (hot flushes):

• Hot flushes: a sudden feeling of heat in the face, neck and chest, often with flushing, sweating and a racing heart, usually lasting a few minutes.
• Night sweats: hot flushes during sleep that wake you up and soak your nightclothes or sheets.
• According to The Menopause Society (USA), up to around 3 in 4 women have hot flushes during the transition. The SWAN study (JAMA Internal Medicine, 2015) found that they last around 7 years on average, and longer for some women.

Sleep, mood and mind:

• Insomnia, frequent waking or unrefreshing sleep, often linked to night sweats.
• Irritability, anxiety, low mood or a feeling of not being yourself.
• Brain fog: difficulty concentrating, forgetting words or small things. This is common in perimenopause and often improves over time.
• Tiredness and low energy.

The body:

• Joint and muscle aches, morning stiffness.
• Headaches or changes in migraine.
• Palpitations.
• Skin and hair changes: drier skin, thinner hair.
• A shift in where fat is stored, especially around the waist.

Genitourinary syndrome of menopause (vaginal dryness):

• Vaginal dryness, burning or itching.
• Pain during sex.
• Needing to pass urine often or urgently, recurrent urinary infections, mild leakage.
• Unlike hot flushes, these symptoms usually do not go away on their own and often get worse over the years, so they are worth treating.

Sex drive: low libido is common and usually has several causes at once (hormones, tiredness, sleep, pain, the relationship, mood). Talk about it openly: it is a normal part of the consultation.

If you are not sure whether a symptom is related to menopause, keep a short diary for 2–4 weeks (cycle, hot flushes, sleep, mood). It makes the consultation much more precise.

04How does menopause affect bones, heart and long-term health?

Falling oestrogen does not only cause day-to-day symptoms; it also changes your long-term health. The good news is that most of these risks can be reduced with simple measures and timely check-ups.

Bones and osteoporosis:

• Oestrogen protects bone density. According to the International Osteoporosis Foundation (IOF), women can lose up to around 20% of their bone density in the first 5–7 years after menopause.
• The IOF estimates that around 1 in 3 women over 50 will have an osteoporotic fracture in their lifetime.
• Osteoporosis has no symptoms until a fracture happens, so assessing your risk matters: previous fractures, family history, low body weight, smoking, corticosteroids, early menopause.

Heart and blood vessels:

• According to the WHO, the relative protection women have against heart disease diminishes after oestrogen falls.
• After menopause, LDL cholesterol, blood pressure and abdominal fat often rise. Cardiovascular disease is the leading cause of death in women worldwide.
• Checking blood pressure, cholesterol, blood sugar and weight becomes even more important after 50.

Pelvic floor and intimate health:

• The WHO notes that pelvic support structures weaken, which can increase the risk of pelvic organ prolapse and urinary leakage.
• Pelvic floor exercises and treating genitourinary symptoms help a great deal.

Menopause is therefore a good moment for a full check-up: it is not just about hot flushes, but about building your health for the next 30 years.

05How is menopause diagnosed? Do you need hormone blood tests?

In most women, menopause is diagnosed from age and symptoms, not from blood tests. The UK NICE guideline NG23 (updated in November 2024) recommends that in women over 45 with typical symptoms, perimenopause or menopause is diagnosed clinically, without laboratory tests.

Why not always test? In perimenopause, hormones such as FSH and oestradiol fluctuate widely from day to day and month to month. A single normal result does not rule out perimenopause, and a single high result does not confirm it.

When tests are useful:

• Under 40, when premature menopause (POI) is suspected: FSH is usually measured and repeated a few weeks later, together with other tests as needed.
• Between 40 and 45, with symptoms and a change in cycle: FSH may be considered (NICE).
• To rule out other causes: thyroid, prolactin, anaemia, pregnancy.
• Before some treatments, or when there are other medical conditions.

Note: hormonal contraception and some other treatments can make FSH unreliable. That is why test results are always interpreted by the doctor, looking at the full picture.

A full assessment at the consultation usually includes:

1. Your cycle and symptom history.
2. Your medical and family history (heart disease, blood clots, breast cancer, osteoporosis).
3. Blood pressure and weight.
4. A gynaecological examination when needed, with ultrasound and a Pap/HPV test if due.
5. Blood tests only when they genuinely help the decision.

06What helps naturally? Lifestyle, diet and menopause weight gain

Lifestyle will not make every symptom disappear, but it is the foundation of any treatment and protects your bones and heart for years. Here is what the evidence supports:

• Regular physical activity: around 150 minutes a week of moderate activity (the WHO recommendation for adults), plus strength exercises twice a week. Weight-bearing and strength exercise help bones and muscles.
• A balanced diet rich in vegetables, fruit, whole grains, pulses, fish and olive oil (Mediterranean style).
• Enough calcium and vitamin D, ideally from food; supplements only when your doctor recommends them.
• Stopping smoking and cutting down on alcohol: both affect bones, heart and hot flushes.
• Good sleep habits: a cool bedroom, light nightwear, a consistent routine, less screen time before bed.
• Identifying hot-flush triggers: caffeine, alcohol, spicy food, hot rooms and stress.
• Relaxation techniques and slow breathing.

Menopause weight gain: many women notice they put on weight, especially around the waist, even without changing what they eat. This comes from a combination of age, loss of muscle mass, poor sleep and hormonal changes that shift fat towards the abdomen. The strategies that work best are strength training to preserve muscle, enough protein at every meal, slightly smaller portions and better sleep. Hormone therapy is not a weight-loss treatment, but it may help indirectly by improving sleep and energy.

Menopause-specific cognitive behavioural therapy (CBT) is recommended by NICE (2024) as an option for hot flushes, low mood and sleep problems, either instead of or alongside hormone therapy.

Herbs and supplements: many products are sold as natural menopause remedies. The evidence for them is inconsistent, product quality varies and some can interact with other medicines. The Menopause Society (2023) does not recommend most of them for hot flushes. If you use any, always mention it at your consultation.

07Menopausal hormone therapy (HRT/MHT): benefits, risks and myths

Menopausal hormone therapy (HRT or MHT) is the most effective treatment for hot flushes and night sweats. NICE (2024) describes it as first-line treatment for vasomotor symptoms, and The Menopause Society (2022) states that for women under 60 or within 10 years of menopause, without contraindications, the benefit–risk ratio is favourable for treating symptoms and preventing bone loss.

The main types (without going into product names or doses, which are decided only after assessment):

• Oestrogen only: for women who have had a hysterectomy.
• Oestrogen plus a progestogen: for women who still have a womb. The progestogen protects the endometrium (womb lining) from thickening.
• Route: tablets, or transdermal (patch, gel or spray on the skin). According to international guidance (NICE, IMS, EMAS), transdermal oestrogen carries a lower risk of blood clots than tablets and is preferred for some women with risk factors.
• Cyclical regimens (with a monthly bleed) or continuous regimens (no bleed), depending on your stage.

Possible benefits:

• A clear reduction in hot flushes and night sweats.
• Better sleep and mood for many women.
• Protection of bone density and a lower risk of fractures.
• Improvement in vaginal dryness.
• For women with premature menopause, replacing hormones the body would naturally produce.

Risks, according to current guidance:

• Breast cancer: according to NICE, oestrogen-only therapy is associated with little or no change in risk, while oestrogen with a progestogen can increase the risk; the increase is related to how long it is used and falls after stopping.
• Blood clots: increased with oral oestrogen; not the same with the transdermal route.
• Risks differ by type, dose, route, duration and the age at which therapy starts (The Menopause Society, 2022). The balance is less favourable when therapy starts after 60 or more than 10 years after menopause.

The myth after the WHI study: in 2002 the US Women’s Health Initiative (WHI) study was widely reported as proof that hormone therapy is dangerous, and many women stopped overnight. Later analyses showed that participants were on average over 60 and many years past menopause, that absolute risks were small, and that the profile is much more favourable when therapy starts close to menopause. Today, guidelines see hormone therapy neither as dangerous for everyone nor as right for everyone: it is an individual decision. NICE also notes that HRT is unlikely to affect life expectancy.

Who usually should not use it without specialist assessment: women with a history of breast cancer or other hormone-dependent cancers, unexplained vaginal bleeding, a previous blood clot or embolism, active liver disease, or certain cardiovascular conditions.

For how long? There is no fixed age at which therapy must stop. Guidelines recommend reviewing it at least once a year to check that the benefits still outweigh the risks for you.

08How is vaginal dryness treated? Vaginal oestrogen and non-hormonal options

Vaginal dryness and the urinary symptoms of menopause (genitourinary syndrome) respond very well to treatment, even if you do not want or cannot take systemic hormone therapy.

Vaginal oestrogen:

• Applied locally as a cream, gel, vaginal tablet, pessary or ring, at low doses.
• NICE (2024) recommends offering it to women with genitourinary symptoms, including alongside systemic HRT, and continuing for as long as needed to relieve symptoms.
• Absorption into the bloodstream is minimal, so its safety profile is very different from tablets or patches.
• Improvement is usually felt within a few weeks to a few months; symptoms often return if treatment stops.
• For women with a history of breast cancer, the decision is made together with the oncologist.

Non-hormonal options for intimate symptoms:

• Vaginal moisturisers used regularly, several times a week.
• Lubricants during sex.
• Pelvic floor exercises for urinary leakage.
• Avoiding harsh soaps and vaginal douching.

Non-hormonal options for hot flushes:

• Cognitive behavioural therapy (CBT) and clinical hypnosis (The Menopause Society, 2023; NICE, 2024).
• Some prescription non-hormonal medicines, such as certain low-dose antidepressants (SSRIs/SNRIs), gabapentin or oxybutynin, which reduce hot flushes even without depression.
• Newer medicines that act directly on the brain’s temperature-control centre (NK3 receptor antagonists), where available and appropriate.
• These options are especially important for women who cannot take hormones, for example after breast cancer.

Every medicine, hormonal or not, has its own benefits and side effects. That is why the choice is always made after an examination, taking into account your symptoms, medical history and preferences.

09Can you get pregnant during perimenopause? Contraception after 40

Yes. Even when cycles are irregular, ovulation can still happen from time to time, so pregnancy during perimenopause is possible. The WHO advises using contraception until 12 consecutive months without a period.

Widely used practical rules (FSRH, United Kingdom), for women not using hormonal methods:

• If your last period is after 50: contraception for 1 more year after it.
• If your last period is before 50: contraception for 2 more years after it.
• After 55, natural pregnancy is considered very unlikely and contraception can usually be stopped.

Important points:

• Menopausal hormone therapy is not a contraceptive. If you are perimenopausal and taking HRT, you may also need contraception.
• Some hormonal methods mask the signs of menopause (such as periods), so the timing for stopping is decided with your doctor.
• Some contraceptive methods can also help with the heavy periods of perimenopause.
• Even after menopause, the risk of sexually transmitted infections continues (WHO), so protection still matters with new partners.

At the consultation we discuss the most suitable method for your age, health and plans.

10What happens at a menopause consultation at Klinika Gjata?

A menopause consultation at Klinika Gjata is an open conversation and a full medical assessment, ending with a treatment plan built around you. Step by step:

1. Booking: call +355 4 234 0059. If you have previous tests, scans or reports, bring them with you.
2. Talking about your symptoms: cycle, hot flushes, sleep, mood, concentration, aches, intimate and sexual health. A short symptom diary helps a lot.
3. Medical and family history: heart disease, blood clots, migraine, breast or ovarian cancer in the family, fractures, the medicines and supplements you take.
4. Basic measurements: blood pressure and weight.
5. Gynaecological examination and ultrasound when needed, plus a Pap/HPV test if you are due one.
6. Blood tests only when they help: for example under 45, when other causes are suspected, or before some treatments.
7. Explaining the options: lifestyle, hormone therapy, vaginal oestrogen, non-hormonal options, with the benefits and risks of each in your case.
8. A shared decision: you choose, fully informed. No treatment is compulsory, and you can choose not to take any medicine.
9. Follow-up: usually a few months after starting treatment, to check the effect and any side effects, then a review at least once a year.
10. Referral when needed: for mammography, bone densitometry or other specialists.

11Which check-ups do you need after menopause, and what if you bleed after menopause?

After menopause, regular gynaecological check-ups remain important, even when you no longer have periods and have no complaints. The main check-ups:

• Gynaecological check-up: usually once a year, or as your doctor advises. It includes an examination, a conversation about symptoms and, when needed, an ultrasound.
• Pap test and HPV test: cervical screening continues after menopause, up to the age and at the interval set by the screening programme and your history. Both Pap and HPV tests are performed at Klinika Gjata.
• Gynaecological ultrasound: assesses the womb, endometrium and ovaries, especially when there are symptoms or bleeding.
• Breast screening: European guidelines (European Commission Initiative on Breast Cancer) recommend mammography every 2 years for women aged 50–69, with options also for ages 45–49 and 70–74. We advise you and refer you for mammography according to your age and risk.
• Bone health: assessment of osteoporosis risk factors and referral for bone densitometry (DXA) when needed, especially after early menopause or with other risk factors.
• Heart and metabolism: blood pressure, cholesterol and blood sugar checked regularly, in cooperation with your family doctor.

Practical tip: combine your annual gynaecological check-up with the review of any menopause treatment you take. One visit then covers both.

Any vaginal bleeding after menopause, meaning after 12 months without a period, should be checked by a doctor promptly, even if it is only light spotting and even if it happens only once. Most cases have benign causes, such as thinning of the vaginal lining or polyps, but endometrial cancer must be ruled out, and that is best done early. The UK NICE guidance treats postmenopausal bleeding in women over 55 as a reason for urgent referral.

Book a visit as soon as possible if you have:

• Bleeding, spotting or blood-stained discharge after menopause.
• Unexpected bleeding on hormone therapy, especially if it continues beyond the first months or starts after it had stopped.
• Very heavy periods with clots, or bleeding between periods or after sex during perimenopause.
• Periods that stop, or menopause symptoms, before 40.
• A breast lump or changes in the skin or nipple.
• Pelvic pain or abdominal bloating that does not go away.
• Very low mood, severe anxiety or thoughts of harming yourself: in this case seek help immediately.

Even without any of these signs, it is worth coming in if menopause symptoms are disrupting your sleep, work, relationships or quality of life. That alone is reason enough for a consultation.

12Where to get menopause advice in Tirana, and what does it cost?

Klinika Gjata on Rruga Hasan Sufa, Tirana, has offered menopause counselling and treatment since 2009 as part of complete gynaecological care.

Why women choose us:

• An experienced specialist: Assoc. Prof. Dr Elinda Gjata, MD, Dr. Sc., an obstetrician-gynaecologist with more than 25 years’ experience and Associate Professor at the University of Medicine, Tirana.
• Care based on international guidelines (NICE, The Menopause Society, IMS, EMAS), tailored to each woman.
• Everything in one place: consultation, gynaecological examination, ultrasound, Pap test and HPV test.
• Time to talk: menopause symptoms, including intimate and emotional ones, are discussed openly and without judgement.
• Continuity: the same doctor follows you from perimenopause into the years after menopause.

What does it cost? We do not publish fixed prices online, because the cost depends on what you need:

• Whether it is a first consultation or a follow-up.
• Whether a gynaecological examination and ultrasound are needed in the same visit.
• Whether a Pap test and/or HPV test is done.
• Whether blood tests or other examinations by referral are needed.
• The cost of any prescribed medicines, paid separately at the pharmacy.

For accurate information and to book, call +355 4 234 0059. We will explain beforehand what the visit includes.