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Recommendations on women’s midlife health and menopause hormone therapy (MHT)

Governing principles on MHT

  • Throughout these recommendations, the term menopause hormone therapy (MHT) has been used to cover therapies including oestrogens, progestogens, and combined therapies. Alternative names are hormone therapy (HT) and hormone replacement therapy (HRT)
  • Menopause hormone therapy (MHT) remains the most effective therapy for vasomotor symptoms and urogenital atrophy:
    • other menopause-related complaints, such as joint and muscle pains, mood swings, sleep disturbances, and sexual dysfunction (including reduced libido) may improve during MHT
    • quality of life and sexual function may also improve
  • The administration of individualised MHT (including androgenic preparations when appropriate) may improve both sexuality and overall quality of life
  • Consideration of MHT should be part of an overall strategy including lifestyle recommendations regarding diet, exercise, smoking cessation, and safe levels of alcohol consumption for maintaining the health of peri- and postmenopausal women
  • MHT must be individualised and tailored according to symptoms and the need for prevention, as well as personal and family history, results of relevant investigations, the woman’s preferences and expectations:
    • the risks and benefits of MHT differ for women during the menopause transition compared with those for older women
  • Women experiencing a spontaneous or iatrogenic menopause before the age of 45 years and particularly before 40 years are at higher risk for cardiovascular disease and osteoporosis and may be at increased risk of affective disorders and dementia. MHT may reduce symptoms and preserve bone density and is advised at least until the average age of menopause
  • Counselling should convey the benefits and risks of MHT in clear and comprehensible terms, e.g. as absolute numbers rather than, or in addition to, percentage changes from baseline expressed as a relative risk
  • MHT should not be recommended without a clear indication for its use, i.e. significant symptoms or physical effects of oestrogen deficiency
  • Women taking MHT should have at least an annual consultation to include a physical examination, update of medical and family history, relevant laboratory and imaging investigations, a discussion on lifestyle, and strategies to prevent or reduce chronic disease. There is currently no indication for increased mammographic or cervical smear screening
  • There are no reasons to place mandatory limitations on the duration of MHT
  • Whether or not to continue therapy should be decided at the discretion of the well-informed woman and her health professional, dependent upon the specific goals and an objective estimation of ongoing individual benefits and risks
  • The dosage should be titrated to the lowest effective dose:
    • lower doses of MHT than previously used may reduce symptoms sufficiently and maintain quality of life for many women 
    • long-term data on lower doses regarding fracture or cancer risks and cardiovascular implications are still lacking

Diagnosis of menopause

  • Menopause is a natural and inevitable event that happens on average at age 51 years
  • Menopause is a retrospective clinical diagnosis, as the final menstrual period can only be defined if followed by 12 months of amenorrhoea
  • Menopause before the age of 40 years is considered to be premature, whether occurring naturally or as a result of surgery or some other intervention (e.g. chemotherapy). The clinical implications of menopause before age 40 are different from menopause after age 40. Treatment of premature menopause is typically considered more critical (see Premature ovarian insufficiency, below)

Midlife body changes

  • Weight management and prevention of weight gain are essential components in the care of postmenopausal women: 
    • an absolute increase in weight at midlife is not attributable to the menopause 
    • the hormonal changes that accompany menopause are associated with increases in total body fat and abdominal fat, even in lean women
    • maintenance of a healthy diet and avoidance of caloric excess combined with physical activity are important components of weight management
    • MHT can improve insulin sensitivity and is not associated with weight gain

Premature ovarian insufficiency

  • Premature ovarian insufficiency (POI) is defined as primary hypogonadism in women younger than 40 years who previously had menstrual cycles 
  • The diagnosis of POI is confirmed by the finding of FSH levels >40 IU/l on two occasions 4–6 weeks apart 
  • POI should be effectively treated to prevent an increase in the risk of cardiovascular disease, osteoporosis, cognitive decline, dementia, and Parkinsonism
  • Referral to a specialist is recommended for genetic and autoimmune testing
  • It is important to inform the woman of the diagnosis with empathy in a sensitive and caring manner. Women must be provided with adequate information and counselling 
  • The mainstay of treatment is hormone replacement with oestrogen, progesterone, and possibly testosterone, which needs to be continued at least until the average age of the natural menopause
  • MHT should not be regarded as being contraceptive
  • Ovarian stimulation with drugs such as clomiphene citrate and gonadotropin therapy should not be routinely used as they have no proven benefit
  • In vitro fertilisation (IVF) with donor oocytes/embryos has a high success rate but is not acceptable to all women with POI

Lifestyle, diet, and exercise

  • Regular exercise is advised to reduce cardiovascular and total mortality:
    • optimal exercise prescription is at least 150 minutes of moderate-intensity exercise per week. Two additional weekly sessions of resistance exercise may provide further benefit 
    • the recommended intensity of aerobic activity should take into account the older adult’s aerobic fitness
  • Weight loss of only 5–10% is sufficient to improve many of the abnormalities associated with the insulin resistance syndrome
  • The basic components of a healthy diet are: several servings/day of fruits and vegetables, whole grain fibres, fish twice per week, and low total fat (but the use of olive oil is recommended). Consumption of salt should be limited and the daily amount of alcohol should not exceed 30 g for men and 20 g for women
  • Smoking should be avoided


  • Symptoms such as vaginal dryness, soreness, dyspareunia, urinary frequency, nocturia, and urgency are extremely common in postmenopausal women 
  • Incontinence increases in prevalence with age
  • The loss of lubrication and hormonal changes may lead to sexual dysfunction. Treatment of this condition improves quality of life, not only for the woman but also for her partner. 
  • Urogenital symptoms respond well to oestrogens. Long-term treatment is often required as symptoms can recur on cessation of therapy. Systemic risks have not been identified with local low-potency/low-dose oestrogens
  • Use of systemic MHT does not seem to prevent urinary incontinence and is not preferable to low-dose local oestrogens in the management of urogenital atrophy or recurrent lower urinary tract infections 
  • Lifestyle changes and bladder retraining are recommended as first-line therapy for overactive bladder symptoms
  • Antimuscarinic drugs, combined with local oestrogens, constitute first-line medical treatment in postmenopausal women with symptoms suggestive of an overactive bladder
  • All women complaining of stress urinary incontinence will benefit from pelvic floor muscle training in the first instance
  • Duloxetine may work synergistically with conservative therapy. However, some women will ultimately undergo surgery, and retropubic and transobturator tapes are currently the most popular procedures 
  • There is currently no role for systemic oestrogen therapy in women with pure stress urinary incontinence

Postmenopausal osteoporosis

  • Osteoporosis is defined as a dual-energy X-ray absorptiometry-derived T-score ≤–2.5 or the presence of a fragility fracture
  • The 10-year probability of fracture in an individual can be estimated using the FRAX® model:
    • intervention thresholds for therapy can be based on 10-year fracture probability but will be country-specific
  • Alternatively, treatment can be given to all patients with a fragility fracture or a T-score of ≤–2.5 (osteoporosis), or a T-score of <–1.0 >–2.5 (osteopenia) with additional risk factors
  • An appropriate assessment of prevalent fractures and secondary causes of osteoporosis should precede any therapeutic decisions
  • Lifestyle changes should be part of treatment strategy and choice of pharmacological therapy should be based on a balance of effectiveness, risk, and cost 
  • MHT is the most appropriate therapy for fracture prevention in the early menopause in symptomatic women

Cartilage, connective tissues

  • Oestrogen has an effect on connective tissue throughout the whole body: 
    • cartilage degradation and the need for joint replacement surgery are reduced among users of MHT

Cardiovascular disease

  • Cardiovascular disease is the principal cause of morbidity and mortality in postmenopausal women 
  • In women <60 years old, who are recently menopausal and with no evidence of cardiovascular disease, the initiation of oestrogen-alone therapy reduces coronary heart disease (CHD) and all-cause mortality
  • It is not recommended to initiate MHT beyond age 60 years solely for primary prevention of CHD

Coagulation, venous thromboembolism disease and MHT

  • Oral oestrogen therapy is contraindicated in women with personal history of venous thromboembolism (VTE)
  • Transdermal oestrogen therapy should be the first choice in obese women suffering from climacteric symptoms
  • The risk of venous thrombosis increases with age and in the presence of other risk factors, including congenital or acquired thrombophilic disorders
  • A careful assessment of personal and family history of VTE is essential before prescribing hormone therapy
  • The risk of venous thromboembolic events increases with oral MHT but the absolute risk is rare below age 60 years 
  • Observational studies point to a lower risk with low-dose transdermal therapy associated with progesterone, underlined by a strong biological plausibility 
  • Population screening for thrombophilia is not indicated prior to MHT use
  • Selective screening may be indicated on the basis of personal and familial history

Breast cancer

  • The degree of association between breast cancer and MHT remains controversial:
    • breast cancer risk should be evaluated before MHT prescription
  • The increased risk of breast cancer is primarily associated with the addition of a synthetic progestogen to oestrogen therapy (conjugated equine oestrogen + medroxyprogesterone acetate continuous combined therapy) and related to the duration of use
  • The risk may be lower with micronised progesterone or dydrogesterone than with other synthetic progestogens
  • The risk of breast cancer attributable to MHT is small and the risk decreases progressively after treatment is stopped
  • The risk of breast cancer may be decreased by providing education about preventive lifestyle measures (reducing body weight, alcohol intake, and increasing physical activity)

Endometrial safety and bleeding

  • Postmenopausal bleeding is ‘endometrial cancer until proven otherwise’, although only 1–14% of such patients will actually have cancer
  • Licensed doses of micronised progesterone are 200 mg per day for 12–14 days in sequential therapy and 100 mg per day for continuous combined therapy 
  • Higher doses of progesterone may be required for endometrial protection when higher doses of oestradiol are used, or in women with high body mass index (BMI)
  • Unopposed oestrogen therapy is associated with a duration- and dose-related increase in risk of endometrial hyperplasia and cancer
  • Endometrial protection requires an adequate dose and duration of progestogen

General and sexual quality of life in the menopause

  • Hormonal and non-hormonal treatments and/or psychosexual strategies should be individualised and tailored according to a woman’s history and current needs, taking into account also the partner’s availability, general and sexual health of the partner, and quality of the intimate relationship
  • Consider age, type, and time since menopause; vasomotor and mood symptoms; general health, including medications for chronic conditions; as well as intrapersonal and interpersonal factors when addressing the issue of quality of life and sexual well-being 
  • Do not believe that sex is not important for elderly women and try always to ‘break the ice’ in clinical practice with very simple open questions to facilitate the dialogue on sexual health
  • Diagnose signs and symptoms of genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA) to reduce discomfort and pain during sexual intercourse

Complementary therapies, non-pharmacological, and lifestyle interventions

  • The role of complementary therapies in the management of the menopause, both for symptomatic relief and avoidance of long-term complications, remains controversial 
  • Women should be counselled that complementary therapies have limited evidence for efficacy and safety and are not regulated by the medicines agencies
  • Paced respiration, cognitive behavioral therapy, mindfulness training, acupuncture, hypnosis, and stellate ganglion blockade may be useful techniques to consider when treating vasomotor symptoms

Vasomotor symptoms: pharmacologic treatments

  • The mechanisms underlying vasomotor symptoms are still not well understood:
    • head-to-head comparisons with hormone therapy or between non-hormonal agents are limited. Each pharmacological strategy has specific side-effects
  • Venlafaxine, desvenlafaxine, paroxetine, citalopram, and escitalopram are effective in reducing hot flushes in postmenopausal women
  • Paroxetine should be avoided in women receiving tamoxifen
  • Gabapentin is as effective but has more side-effects compared with selective serotonin reuptake inhibitors/serotonin–norepinephrine reuptake inhibitors

Postmenopausal vulvovaginal atrophy

  • Healthcare providers should be proactive in order to help their patients to disclose the symptoms related to VVA and to seek adequate treatment when vaginal discomfort is clinically relevant
  • Treatment should be started early, before irrevocable atrophic changes have occurred, and needs to be continued to maintain the benefits
  • The principles of treatment in women with established VVA are both restoration of urogenital physiology and alleviation of symptoms; when VVA is the sole symptom, local oestrogen treatment should be the first choice
  • The choice of modality for local oestrogen administration should be guided by patient preference
  • Local oestrogen therapy minimises the degree of systemic absorption and, although vaginal administration can increase plasma levels of oestrogens during chronic administration, the observed levels are rarely above the normal range of ≤20 pg/ml for postmenopausal women
  • Additional progestogen is not indicated when appropriate low-dose, local oestrogen is used, although long-term data (more than 1 year) are lacking
  • When local oestrogen is being considered in women on tamoxifen or aromatase inhibitors, the patient should be referred to a menopause specialist. The discussion should involve the patient’s oncology team


full guideline available from…


Baber R, Panay N, Fenton A, the IMS Writing Group. 2016 IMS recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016; 19 (2): 109–150.
First included: June 2017.