Perimenopause, Menopause & MHT: A 2026 Guide for Women in George and the Garden Route
Medically reviewed by Dr Claudia Lakay, MBChB (Stellenbosch University)This article is educational content based on current peer-reviewed guidelines. It is not personalised medical advice. Decisions about hormone therapy and menopause treatment depend on an individual woman's symptoms, health history, and preferences, and should be made in consultation with a doctor.
Quick answer
Menopause is the permanent end of menstrual periods, with a mean age of 51.4 years. The transition before it — perimenopause — typically lasts 4 to 8 years, and causes hot flushes, sleep problems, mood changes, and cognitive symptoms in most women. Menopausal hormone therapy (MHT) is the most effective treatment for troublesome symptoms. Recent 2024–25 re-analysis and the November 2025 FDA removal of the black-box warning have substantially clarified who benefits — particularly women under 60 or within 10 years of menopause. Dr Claudia Lakay — a female GP at NeoHealth in George Central — offers menopause consultations and MHT review, serving the Garden Route.
Key points
- Menopause symptoms span more than hot flushes — sleep, mood, cognition, joints, genitourinary, and metabolic changes all matter.
- MHT is the most effective treatment for moderate-to-severe symptoms. For women under 60 or within 10 years of menopause, excess risks are generally under 1 event per 1,000 women per year.
- Transdermal oestrogen (patches, gels) has lower clot risk than oral — relevant for many women.
- Micronised progesterone appears to have a more favourable breast cancer risk profile than synthetic progestogens.
- Dr Claudia Lakay offers menopause and MHT consultations at NeoHealth in George Central, with patients from Wilderness, Sedgefield, Mossel Bay, Knysna, and across the Garden Route.
Want to discuss menopause and MHT with a female GP in George?
Book with Dr LakayIn this guide
- What perimenopause and menopause actually are
- The full symptom picture — it's more than hot flushes
- The shift in understanding MHT
- The timing hypothesis and the 2024–25 WHI reanalysis
- Oral vs transdermal oestrogen — the route matters
- The progestogen question — not all are equal
- Vaginal oestrogen for GSM — safer than many people think
- Non-hormonal options
- The FDA November 2025 removal of the black-box warning
- The South African context
- When MHT is not recommended
What perimenopause and menopause actually are
Menopause is the single point in time when a woman has gone 12 consecutive months without a period. The mean age is 51.4 years, and 90% of women reach menopause between ages 45 and 56.
Perimenopause is the transitional phase leading up to menopause, plus the 12 months following the final period. It often starts in the early to mid forties. Cycles become irregular (a 7-day or greater difference between consecutive cycle lengths signals the early transition), and later in the transition, gaps of 60 days or more between periods become common. Perimenopause typically lasts 4 to 8 years.
Postmenopause is the phase after menopause — roughly 40% of a woman's adult life. Symptoms, cardiovascular risk, bone health, and genitourinary changes in this phase are not an endurance test. They are medical phenomena with treatment options.
The full symptom picture — it's more than hot flushes
Vasomotor symptoms (hot flushes and night sweats) affect 50–80% of women. In roughly half of women, they persist for more than 7 years.
Genitourinary syndrome of menopause (GSM) affects 45–77% of postmenopausal women — vaginal dryness, painful intercourse, burning, itching, urinary urgency, and recurrent urinary tract infections. Unlike hot flushes, GSM typically worsens over time without treatment.
Sleep disturbance, mood changes, cognitive symptoms (brain fog, memory, concentration), musculoskeletal symptoms (joint pain), metabolic and cardiovascular changes, and sexual function changes are all well-recognised. A recent large study of >145,000 symptom logs found that fatigue, headache, anxiety, and brain fog are prevalent across all phases of the menopausal transition.
The shift in understanding MHT
Between 2002 and 2024, attitudes to menopausal hormone therapy went through a full cycle. The Women's Health Initiative (WHI) trials published in 2002 appeared to show increased risks of breast cancer, heart disease, stroke, and clots. MHT prescription dropped from roughly 40% of postmenopausal women in their 50s to just 7% in the US by 2010 — with similar drops worldwide.
Over the next two decades, careful re-analysis of the WHI data, combined with new trials, gradually clarified what the original findings meant. The resulting timing hypothesis is now well established.
The timing hypothesis and the 2024–25 WHI reanalysis
The timing hypothesis holds that MHT initiated close to menopause — before age 60, or within 10 years of the final period — has a favourable benefit-risk profile in most women without contraindications. MHT initiated significantly later, particularly after 70, carries a less favourable profile.
A 2024 JAMA review and a 2025 JAMA Internal Medicine reanalysis of WHI data confirmed: for younger menopausal women, the absolute excess risks of adverse events are less than 1 per 1,000 women per year, and MHT is the most effective treatment for moderate-to-severe vasomotor symptoms.
Oral vs transdermal oestrogen — the route matters
- Oral oestrogen carries roughly a four-fold increased risk of VTE compared with non-users.
- Transdermal oestrogen (patches, gels) bypasses the liver and shows no increased VTE risk in observational studies.
Transdermal oestrogen also has more favourable effects on triglycerides and metabolic markers. For women with VTE risk factors, obesity, elevated triglycerides, or migraine, transdermal delivery is generally preferred.
The progestogen question — not all are equal
Women with an intact uterus need a progestogen alongside oestrogen to protect the endometrium. Which progestogen matters.
Micronised progesterone (the body-identical form) appears to have a more favourable breast cancer risk profile than synthetic progestogens in observational studies. Current guidance from major menopause societies now typically preferences micronised progesterone where available and affordable. The hormonal IUD is also increasingly used to provide the progestogen component of combined MHT — particularly useful for perimenopausal women managing heavy bleeding.
Vaginal oestrogen for GSM — safer than many people think
Low-dose vaginal oestrogen — delivered as tablets, creams, or rings — has minimal systemic absorption. There is no increased risk of coronary heart disease, stroke, VTE, endometrial cancer, or breast cancer with low-dose vaginal oestrogen, and no progestogen is needed for endometrial protection when using it.
Vaginal oestrogen is first-line treatment for moderate-to-severe GSM not relieved by moisturisers and lubricants. Symptom improvement is 60–80%.
Non-hormonal options
For women who cannot or prefer not to take MHT, options include SSRIs and SNRIs (10–65% reduction in VMS), fezolinetant (new neurokinin-3 receptor antagonist, approved 2023), gabapentin, CBT, and clinical hypnosis — none match MHT's efficacy but all have evidence.
The FDA November 2025 removal of the black-box warning
On 10 November 2025, the US FDA removed the black-box warning on all menopausal hormone therapy products after 22 years. The class-wide warning was replaced with product-specific labelling, the old "lowest dose, shortest duration" mandate was removed, and new guidance on optimal timing (within 10 years of menopause or before age 60) was incorporated.
The South African context
Public sector: The Essential Medicines List contains limited MHT options, and menopause care is not generally prioritised in primary healthcare.
Private sector: A broader range is available, including oral and transdermal oestrogens, multiple progestogens (including micronised progesterone, MPA, and dydrogesterone), tibolone, vaginal oestrogens, and non-hormonal options.
For women in George and the Garden Route who want evidence-based menopause care, a private-sector GP with menopause training — like Dr Claudia Lakay at NeoHealth — is often the most accessible path.
When MHT is not recommended
MHT is not recommended for primary or secondary prevention of cardiovascular disease, prevention of dementia, or osteoporosis prevention as the sole indication.
MHT is generally avoided or requires careful individualisation in women with: a history of breast cancer or oestrogen-sensitive cancer; active or recent VTE; active or recent liver disease; undiagnosed vaginal bleeding pending investigation; active coronary artery disease.
Talk to Dr Lakay about menopause in George
If you'd like to discuss perimenopause, menopause, or MHT, book a consultation with Dr Claudia Lakay at NeoHealth, George Central. As one of the few female GPs in George offering dedicated menopause care — including evidence-based MHT review, non-hormonal options, and cardiovascular and bone health assessment — Dr Lakay's menopause consultation is a proper discussion, not a prescription pad.
Book a consultationImportant: This article provides general information on menopause and hormone therapy based on current peer-reviewed guidelines and is intended for educational purposes only. It is not personalised medical advice.
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Frequently Asked Questions
Am I in perimenopause?
Perimenopause is suggested by increasing cycle variability, followed later by longer gaps, typically starting in the early to mid forties. A doctor can help interpret the pattern alongside any relevant blood tests.
Should I have my hormones tested?
For most women in the typical age range, routine hormone testing is not required to diagnose menopause — the pattern of periods and symptoms is usually sufficient.
Is MHT safe?
For most women under 60 or within 10 years of menopause, with no contraindications, current evidence supports a favourable benefit-risk profile. Absolute excess risks in this group are generally under 1 event per 1,000 women per year.
What about breast cancer risk?
Combined MHT is associated with a small increase in breast cancer risk; oestrogen-only MHT (in women without a uterus) may be associated with a small reduction. Micronised progesterone appears to carry less risk than synthetic progestogens.
Do I need to stop MHT at a certain age?
No arbitrary stopping age. MHT should be used for as long as its benefits outweigh its risks, with periodic review.
Where can I see a female GP about menopause in George?
NeoHealth is located in Suite 12, Prince Vintcent Square, Gloucester Ave, George Central. Dr Claudia Lakay offers menopause consultations, with patients from Wilderness, Sedgefield, Mossel Bay, Knysna, and across the Garden Route.