Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health (NCC-WCH) on behalf of the National Institute for Health and Care Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.
Adopt an individualised approach at all stages of diagnosis, investigation and management of menopause. Follow recommendations in the NICE guideline on Patient experience in adult NHS services .
Diagnosis of Perimenopause and Menopause
Diagnose the following without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms:
- Perimenopause based on vasomotor symptoms and irregular periods
- Menopause in women who have not had a period for at least 12 months and are not using hormonal contraception
- Menopause based on symptoms in women without a uterus
Take into account that it can be difficult to diagnose menopause in women who are taking hormonal treatments, for example for the treatment of heavy periods.
Do not use the following laboratory and imaging tests to diagnose perimenopause or menopause in women aged over 45 years:
- Anti-Müllerian hormone
- Inhibin A
- Inhibin B
- Antral follicle count
- Ovarian volume
Do not use a serum follicle-stimulating hormone (FSH) test to diagnose menopause in women using combined oestrogen and progestogen contraception or high-dose progestogen.
Consider using a FSH test to diagnose menopause only:
- In women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle
- In women aged under 40 years in whom menopause is suspected (see "Diagnosing and Managing Premature Ovarian Insufficiency" below)
Information and Advice
Give information to menopausal women and their family members or carers (as appropriate) that includes:
- An explanation of the stages of menopause
- Common symptoms (see recommendation below) and diagnosis
- Lifestyle changes and interventions that could help general health and wellbeing
- Benefits and risks of treatments for menopausal symptoms
- Long-term health implications of menopause
Explain to women that as well as a change in their menstrual cycle they may experience a variety of symptoms associated with menopause, including:
- Vasomotor symptoms (for example, hot flushes and sweats)
- Musculoskeletal symptoms (for example, joint and muscle pain)
- Effects on mood (for example, low mood)
- Urogenital symptoms (for example, vaginal dryness)
- Sexual difficulties (for example, low sexual desire)
Give information to menopausal women and their family members or carers (as appropriate) about the following types of treatment for menopausal symptoms:
- Hormonal, for example hormone replacement therapy (HRT)
- Non-hormonal, for example clonidine
- Non-pharmaceutical, for example cognitive behavioural therapy (CBT)
Give information on menopause in different ways to help encourage women to discuss their symptoms and needs.
Give information about contraception to women who are in the perimenopausal and postmenopausal phase. See guidance from the Faculty of Sexual & Reproductive Healthcare (FSRH) on Contraception for women aged over 40 years .
Offer women who are likely to go through menopause as a result of medical or surgical treatment (including women with cancer, at high risk of hormone-sensitive cancer or having gynaecological surgery) support and:
- Information about menopause and fertility before they have their treatment
- Referral to a healthcare professional with expertise in menopause
Managing Short-term Menopausal Symptoms
The recommendations in this section are not intended for women with premature ovarian insufficiency (see recommendations below for management of premature ovarian insufficiency).
Adapt a woman's treatment as needed, based on her changing symptoms.
Offer women HRT for vasomotor symptoms after discussing with them the short-term (up to 5 years) and longer-term benefits and risks. Offer a choice of preparations as follows:
- Oestrogen and progestogen to women with a uterus
- Oestrogen alone to women without a uterus
Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone.
Explain to women that there is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms. However, explain that:
- Multiple preparations are available and their safety is uncertain
- Different preparations may vary
- Interactions with other medicines have been reported
Consider HRT to alleviate low mood that arises as a result of the menopause.
Consider CBT to alleviate low mood or anxiety that arise as a result of the menopause.
Ensure that menopausal women and healthcare professionals involved in their care understand that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with depression (see the NICE guideline on Depression in adults ).
Altered Sexual Function
Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective. (At the time of publication [November 2015], testosterone did not have a UK marketing authorisation for this indication in women. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.)
Offer vaginal oestrogen to women with urogenital atrophy (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms.
Consider vaginal oestrogen for women with urogenital atrophy in whom systemic HRT is contraindicated, after seeking advice from a healthcare professional with expertise in menopause.
If vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause.
Explain to women with urogenital atrophy that:
- Symptoms often come back when treatment is stopped
- Adverse effects from vaginal oestrogen are very rare
- They should report unscheduled vaginal bleeding to their general practitioner (GP)
Advise women with vaginal dryness that moisturisers and lubricants can be used alone or in addition to vaginal oestrogen.
Do not offer routine monitoring of endometrial thickness during treatment for urogenital atrophy.
Complementary Therapies and Unregulated Preparations
Explain to women that the efficacy and safety of unregulated compounded bioidentical hormones are unknown.
Explain to women who wish to try complementary therapies that the quality, purity and constituents of products may be unknown.
Advise women with a history of, or at high risk of, breast cancer that, although there is some evidence that St John's wort may be of benefit in the relief of vasomotor symptoms, there is uncertainty about:
- Appropriate doses
- Persistence of effect
- Variation in the nature and potency of preparations
- Potential serious interactions with other drugs (including tamoxifen, anticoagulants and anticonvulsants)
Review and Referral
Discuss with women the importance of keeping up to date with nationally recommended health screening.
Review each treatment for short-term menopausal symptoms:
- At 3 months to assess efficacy and tolerability
- Annually thereafter unless there are clinical indications for an earlier review (such as treatment ineffectiveness, side effects or adverse events)
Refer women to a healthcare professional with expertise in menopause if treatments do not improve their menopausal symptoms or they have ongoing troublesome side effects.
Consider referring women to a healthcare professional with expertise in menopause if:
- They have menopausal symptoms and contraindications to HRT or
- There is uncertainty about the most suitable treatment options for their menopausal symptoms
Starting and Stopping HRT
Explain to women with a uterus that unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3-month review appointment, or promptly if it occurs after the first 3 months (see recommendations on endometrial cancer in the NGC summary of the NICE guideline Suspected cancer: recognition and referral).
Offer women who are stopping HRT a choice of gradually reducing or immediately stopping treatment.
Explain to women that:
- Gradually reducing HRT may limit recurrence of symptoms in the short term
- Gradually reducing or immediately stopping HRT makes no difference to their symptoms in the longer term
Women with, or at High Risk of, Breast Cancer
For advice on the treatment of menopausal symptoms in women with breast cancer or at high risk of breast cancer, see Section 1.3 of the NICE guideline Early and locally advanced breast cancer and the NGC summary of the NICE guideline Familial breast cancer: classification and care of people at risk of familial breast cancer and management of breast cancer and related risks in people with a family history of breast cancer.
Offer menopausal women with, or at high risk of, breast cancer:
- Information on all available treatment options
- Information that the SSRIs paroxetine and fluoxetine should not be offered to women with breast cancer who are taking tamoxifen
- referral to a healthcare professional with expertise in menopause
Long-term Benefits and Risks of Hormone Replacement Therapy
Explain to women that:
- The risk of venous thromboembolism (VTE) is increased by oral HRT compared with baseline population risk
- The risk of VTE associated with HRT is greater for oral than transdermal preparations
- The risk associated with transdermal HRT given at standard therapeutic doses is no greater than baseline population risk
Consider transdermal rather than oral HRT for menopausal women who are at increased risk of VTE, including those with a body mass index (BMI) over 30 kg/m2.
Consider referring menopausal women at high risk of VTE (for example, those with a strong family history of VTE or a hereditary thrombophilia) to a haematologist for assessment before considering HRT.
Ensure that menopausal women and healthcare professionals involved in their care understand that HRT:
- Does not increase cardiovascular disease risk when started in women aged under 60 years
- Does not affect the risk of dying from cardiovascular disease
Be aware that the presence of cardiovascular risk factors is not a contraindication to HRT as long as they are optimally managed.
Using Tables 1 and 2 in the original guideline document, explain to women that:
- The baseline risk of coronary heart disease and stroke for women around menopausal age varies from one woman to another according to the presence of cardiovascular risk factors
- HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease
- HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease
Explain to women that taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke. Also explain that the baseline population risk of stroke in women aged under 60 years is very low (see Table 2 in the original guideline document).
Type 2 Diabetes
Explain to women that taking HRT (either orally or transdermally) is not associated with an increased risk of developing type 2 diabetes.
Ensure that women with type 2 diabetes and all healthcare professionals involved in their care are aware that HRT is not generally associated with an adverse effect on blood glucose control.
Consider HRT for menopausal symptoms in women with type 2 diabetes after taking comorbidities into account and seeking specialist advice if needed.
Using Table 3 in the original guideline document, explain to women around the age of natural menopause that:
- The baseline risk of breast cancer for women around menopausal age varies from one woman to another according to the presence of underlying risk factors
- HRT with oestrogen alone is associated with little or no change in the risk of breast cancer
- HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer
- Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT
Give women advice on bone health and discuss these issues at review appointments (see the NGC summary of the NICE guideline Osteoporosis: assessing the risk of fragility fracture).
Using Table 4 in the original guideline document, explain to women that the baseline population risk of fragility fracture for women around menopausal age in the UK is low and varies from one woman to another.
Using Table 4 in the original guideline document, explain to women that their risk of fragility fracture is decreased while taking HRT and that this benefit:
- Is maintained during treatment but decreases once treatment stops
- May continue for longer in women who take HRT for longer
Explain to menopausal women that the likelihood of HRT affecting their risk of dementia is unknown.
Loss of Muscle Mass and Strength
Explain to women that:
- There is limited evidence suggesting that HRT may improve muscle mass and strength
- Muscle mass and strength is maintained through, and is important for, activities of daily living
Diagnosing and Managing Premature Ovarian Insufficiency
Diagnosing Premature Ovarian Insufficiency
Take into account the woman's clinical history (for example, previous medical or surgical treatment) and family history when diagnosing premature ovarian insufficiency.
Diagnose premature ovarian insufficiency in women aged under 40 years based on:
- Menopausal symptoms, including no or infrequent periods (taking into account whether the woman has a uterus) and
- Elevated FSH levels on 2 blood samples taken 4 to 6 weeks apart
Do not diagnose premature ovarian insufficiency on the basis of a single blood test.
Do not routinely use anti-Müllerian hormone testing to diagnose premature ovarian insufficiency.
If there is doubt about the diagnosis of premature ovarian insufficiency, refer the woman to a specialist with expertise in menopause or reproductive medicine.
Managing Premature Ovarian Insufficiency
Offer sex steroid replacement with a choice of HRT or a combined hormonal contraceptive to women with premature ovarian insufficiency, unless contraindicated (for example, in women with hormone-sensitive cancer).
Explain to women with premature ovarian insufficiency:
- The importance of starting hormonal treatment either with HRT or a combined hormonal contraceptive and continuing treatment until at least the age of natural menopause (unless contraindicated)
- That the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age and is very low in women aged under 40
- That HRT may have a beneficial effect on blood pressure when compared with a combined oral contraceptive
- That both HRT and combined oral contraceptives offer bone protection
- That HRT is not a contraceptive
Give women with premature ovarian insufficiency and contraindications to hormonal treatments advice, including on bone and cardiovascular health, and symptom management.
Consider referring women with premature ovarian insufficiency to healthcare professionals who have the relevant experience to help them manage all aspects of physical and psychosocial health related to their condition.