Question & Context

Menopausal symptoms – what is supported by evidence?

In brief

Against hot flashes and night sweats, hormone therapy is the most effective remedy there is, and for healthy women in the years around menopause it is safer than its reputation. If you do not want to take hormones or are not allowed to, there are now two approved hormone-free active substances and behavioral therapy as options. Strength training, enough protein and good sleep hardly relieve hot flashes, but they protect bones, muscles and heart in a phase in which metabolism changes noticeably. Which path suits you is best decided together with your gynecologist.

What matters first

Take symptoms seriously

Hot flashes, sleep problems, mood swings and concentration problems are typical companions of menopause and can noticeably burden everyday life. The draft of the new German S3 guideline from 2026 provides that women with distressing symptoms should be offered hormone therapy after being informed, if there is nothing against it. So you do not have to grit your teeth and bear it.

Keep an eye on heart and blood lipids

Around the last menstrual period, total cholesterol and LDL rise markedly. In the American SWAN study with over a thousand women, this was the only risk factor directly tied to menopause, while blood pressure and blood sugar rose rather evenly with age. A check of blood lipids, blood pressure and blood sugar in this phase therefore makes particular sense.

Lift heavy weights

Strength training is the most important tool for bones and muscles. In the LIFTMOR study, 101 postmenopausal women with already low bone density trained intensively under supervision twice a week for eight months. Bone density at the lumbar spine rose by 2.9 percent; in the comparison group with light home training, it fell by 1.2 percent.

Secure protein and sleep

With age, muscle needs more protein per meal to respond equally strongly. A protein-conscious diet supports the training. A cool bedroom protects deep sleep, which helps especially with night sweats.

When you should have this checked by a doctor

Any bleeding after menopause, that is, when your period had already stopped for a year, is a warning sign and should be checked by a gynecologist, because it is the most common early sign of uterine cancer. Medical advice is also important if you have persistent low mood, thoughts of not wanting to live any more, a racing heart or chest pain, and bone fractures after minor falls. Before hormone therapy, thromboses, breast cancer, liver and vascular diseases in your own or your family’s history need to be put on the table. Not every bit of tiredness or weight gain in midlife comes from hormones; the thyroid, an iron deficiency or sleep apnea can also be behind it.

What hormone therapy achieves

A Cochrane analysis of 24 studies with 3,329 women shows how large the effect is: on estrogen, hot flashes were 75 percent less frequent than on placebo. The placebo effect is also remarkable, as hot flashes also decreased by almost 58 percent in the placebo groups.

The great uncertainty stems from the Women’s Health Initiative, whose combination arm was stopped early in 2002. However, the women studied there were mainly older, 63 years on average, and were treated for prevention, not because of symptoms. In the long-term analysis over 18 years, all-cause mortality was practically the same at 27.1 percent on hormones and 27.6 percent on placebo. In the estrogen-alone arm, in women without a uterus, breast cancer was even less common after more than 20 years.

The route of administration also matters. In the French ESTHER study, the risk of thrombosis was roughly quadrupled with estrogen as a tablet, but not increased with estrogen through the skin. The 2026 draft guideline recommends informing women about exactly this. Hormone therapy is, however, not suitable for preventing heart disease or dementia.

If you want to manage without hormones

Fezolinetant has been approved in the EU since December 2023, and elinzanetant since November 2025. Both act on the temperature center in the brain and work without hormones. For fezolinetant, there has been a Dear Doctor letter (Rote-Hand-Brief) since January 2025: liver values should be checked before and during treatment.

Cognitive behavioral therapy helps above all to cope better with distressing symptoms and is mentioned in the draft guideline for quality of life. Exercise is valuable for heart, bones and mood, but against hot flashes themselves, a Cochrane review of five studies with 733 women found no clear effect. That is no reason to give up exercise, just an honest assessment of what it is good for.

What the database says

Sorted by strength of evidence. The BK-Score rates the state of knowledge, not the substance.

Menopausal hormone therapy Evidence 9/10 · Well supported, heavily overhypedHormone therapy is the most effective remedy for hot flashes. The page explains why the fear after 2002 was too great and what age, preparation and use via patch or gel mean for the risk.
Strength training 3× per week Evidence 9/10 · Well supportedStrength training is one of the best-supported single measures in the database and especially valuable during menopause for bones, muscles and metabolism.
Creatine monohydrate Evidence 9/10 · Well supportedIn combination with strength training, creatine increased lean mass and leg strength in women after menopause. Bone density, on the other hand, did not change in the meta-analysis.
Vitamin D3 Evidence 8/10 · Well supported, heavily overhypedA vitamin D deficiency should be corrected, especially with regard to the bones. In the large VITAL study without selection for deficiency, however, taking it did not reduce the number of bone fractures.
Sleep & sleep hygiene Evidence 7/10 · Supported, with caveatsSleep problems are among the most distressing symptoms of menopause. The page shows what sleep hygiene and behavioral therapy for insomnia can do.
Adjusting protein to age Evidence 7/10 · Supported, with caveatsOlder muscles need more protein per meal for the same response. The page puts into context which amounts professional societies recommend and where the longevity scene goes beyond them.
Meditation 10 min daily Evidence 6/10 · Supported, with caveatsMindfulness and meditation show small to moderate effects on anxiety, stress and mood in meta-analyses. A gentle complement for the emotional side of the transition.
Bedroom at 16–18 °C Evidence 6/10 · Supported, with caveatsHeat costs deep sleep; a cool room protects it. With night sweats, this is a simple first lever.

Frequently asked questions

At what age does menopause begin?

From about the mid-40s, the body gradually produces less estrogen, often first noticeable through more irregular cycles. If menstrual bleeding stops completely for a year, the last bleeding was very probably the menopause, on average at age 51. The timing varies greatly from woman to woman.

Is hormone therapy dangerous?

In the large WHI long-term analysis over 18 years, all-cause mortality was practically the same on hormones and placebo, and for women in their fifties the balance was more favorable than for women around 70. According to the data so far, estrogen through the skin increases the risk of thrombosis less than tablets. The individual weighing-up belongs at your gynecologist’s practice.

What helps against hot flashes without hormones?

Two hormone-free active substances are approved in the EU, fezolinetant and elinzanetant, both prescription-only. Behavioral therapy helps to cope better with the symptoms. Cool rooms and clothing in layers are simple everyday aids.

Why do I gain weight during menopause?

The scale does not rise faster during the transition than before, but body composition changes. In the SWAN study, fat gain doubled at the start of the transition while muscle mass was lost, until about two years after the last period. Strength training and enough protein address exactly that.

Do I need food supplements now?

Not automatically. It makes sense to specifically check for and correct a deficiency in vitamin D, iron or vitamin B12. Creatine can support muscle strength in combination with strength training, but does not replace the training.

Can exercise really strengthen the bones?

Yes, especially heavy, supervised strength training with jumping elements. In a study of women after menopause, bone density at the lumbar spine rose with intensive training, while it fell in the comparison group. If you already have osteoporosis, you should build up the training under expert guidance.