Menopause: diagnosis and management

This guideline covers the diagnosis and management of menopause, including in women who have premature ovarian insufficiency. The guideline aims to improve the consistency of support and information provided to women in menopause.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including offlabel use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Individualised care
Adopt an individualised approach at all stages of diagnosis, investigation and management of perimenopause and 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-Mullerian hormone
inhibin A
inhibin B
-estradiol
antral follicle count
-varian 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 also recommendations on diagnosing and managing premature ovarian insufficiency).

# 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 1.3.2) 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 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 on the management of premature ovarian insufficiency).
Adapt a woman's treatment as needed, based on her changing symptoms.

## Vasomotor 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:
-estrogen and progestogen to women with a uterus
-estrogen 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.

## Psychological symptoms
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.In November 2015, this was an off-label use. See NICE's information on prescribing medicines

## Urogenital atrophy
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 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 NICE guideline on suspected cancer).
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 recommendations on complications of local treatment and menopausal symptoms in the NICE guideline on early and locally advanced breast cancer and recommendations on risk reduction and treatment strategies in the NICE guideline on familial 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

## Venous thromboembolism
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 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.

## Cardiovascular disease
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, 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).
Type of HRT
Current HRT users
Treatment duration <5 years
Treatment duration 510 years
5 years since stopping treatment
Women on oestrogen alone (RCT estimate)
fewer
(10 to 1)
No available data
No available data
fewer
(9 to 2)
Women on oestrogen alone (observational estimate)
fewer
(9 to 3)
No available data
No available data
No available data
Women on oestrogen plus progestogen (RCT estimate)
more
(3 to 18)
No available data
No available data
more
(1 to 11)
Women on oestrogen plus progestogen (observational estimate)
No available data
No available data
No available data
No available data
Notes: Thebaseline population risk in the UK over 7.5 years was 26.3 per 1,000 (results from Weiner 2008 were used for the baseline population risk estimation). For full source references, see Appendix M in the full guideline.
Randomised controlled trial (RCT)estimates based on women aged 5059 years at entry to the RCT.
Observational estimates based on cohort studies with several thousand women.
Type of HRT
Current HRT users
Treatment duration <5 years
Treatment duration 510 years
5 years since stopping treatment
Women on oestrogen alone (RCT estimate)
(5 to 10)
No available data
No available data
more
(4 to 9)
Women on oestrogen alone (observational estimate)
more
(1 to 8)
No available data
No available data
No available data
Women on oestrogen plus progestogen (RCT estimate)
more
(2 to 21)
No available data
No available data
more
(1 to 13)
Women on oestrogen plus progestogen (observational estimate)
more
(1 to 7)
No available data
No available data
No available data
Notes: The baseline population risk in the UK over 7.5 years was 11.3 per 1,000 (results from Weiner 2008 were used for the baseline population risk estimation). For full source references, see Appendix M in the full guideline.
Randomised controlled trial (RCT)estimates based on women aged 5059 years at entry to the RCT.
Observational estimates based on cohort studies with several thousand women.

## 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.

## Breast cancer
Using the MHRA risk table, 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.

## Osteoporosis
Give women advice on bone health and discuss these issues at review appointments (see the NICE guideline on osteoporosis: assessing the risk of fragility fracture).
Using table 3, 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 3, 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.
Type of estimate
Current HRT users
Treatment duration <5 years
Treatment duration 510 years
5 years since stopping treatment
RCT estimate
fewer
(10 to 33)
Baseline population risk: 69 per 1,000 women
(follow-up: 3.43 years)
fewer
(9 to 37)
Baseline population risk: 78 per 1,000 women (follow-up: 3.71 years)
No available data
No available data
Observational estimate
fewer
(15 to 18)
Baseline population risk: 15.4 per 1,000 women (follow-up: 2.8 years)
fewer
(11 to 17)
Baseline population risk: 15.4 per 1,000 women (follow-up: 2.8 years)
fewer
(15 to 20)
Baseline population risk: 15.4 per 1,000 women (follow-up: 2.8 years)
more
(19 to 27)
Baseline population risk: 106 per 1,000 women (follow-up: 5 years).
Notes: For full source references, see Appendix M in the full guideline.
Absolute risks calculated by using the baseline population risk in the control arm for each analysis, following GRADE methodology.
Randomised controlled trial (RCT)estimates based on women aged 5059 years at entry to the RCT.
Observational estimate based on cohort studies with several thousand women.

## Dementia
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 46 weeks apart.
Do not diagnose premature ovarian insufficiency on the basis of a single blood test.
Do not routinely use anti-Mullerian 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.

# Terms used in this guideline
Compounded bioidentical hormones Unregulated plant-derived hormonal combinations similar or identical to human hormones that are compounded by pharmacies to the specification of the prescriber.
Fragility fracture Fractures that result from mechanical forces that would not ordinarily result in fracture (such as a fall from a standing height or less). Reduced bone density is a major risk factor for fragility fractures, which occur most commonly in the spine, hip and wrist.
Low mood Mild depressive symptoms that impair quality of life but are usually intermittent and often associated with hormonal fluctuations in perimenopause.
Menopause A biological stage in a woman's life that occurs when she stops menstruating and reaches the end of her natural reproductive life. Usually it is defined as having occurred when a woman has not had a period for 12 consecutive months (for women reaching menopause naturally). The changes associated with menopause occur when the ovaries stop maturing eggs and secreting oestrogen and progesterone.
Menopausal women This includes women in perimenopause and postmenopause.
Perimenopause The time in which a woman has irregular cycles of ovulation and menstruation leading up to menopause and continuing until 12 months after her final period. The perimenopause is also known as the menopausal transition or climacteric.
Postmenopause The time after menopause has occurred, starting when a woman has not had a period for 12 consecutive months.
Premature ovarian insufficiency Menopause occurring before the age of 40 years (also known as premature ovarian failure or premature menopause). It can occur naturally or as a result of medical or surgical treatment.
Urogenital atrophy Thinning and shrinking of the tissues of the vulva, vagina, urethra and bladder caused by oestrogen deficiency. This results in multiple symptoms such as vaginal dryness, vaginal irritation, a frequent need to urinate and urinary tract infections.
Vasomotor symptoms Menopausal symptoms such as hot flushes and night sweats caused by constriction and dilatation of blood vessels in the skin that can lead to a sudden increase in blood flow to allow heat loss. These symptoms can have a major impact on activities of daily living.# Context
Menopause is when a woman stops having periods as she reaches the end of her natural reproductive life. This is not usually abrupt, but a gradual process during which women experience perimenopause before reaching postmenopause. The average age of menopause in the UK is 51. However, this varies widely and 1 in 100 women experience premature ovarian insufficiency (menopause occurring before the age of 40 years).
Oestrogen depletion associated with menopause causes irregular periods and has many other effects on the body. The most common symptoms are hot flushes and night sweats. Other symptoms include mood changes, memory and concentration loss, vaginal dryness, a lack of interest in sex, headaches, and joint and muscle stiffness. Quality of life may be severely affected.
Most women (8 out of 10) experience some symptoms, typically lasting about 4 years after the last period, but continuing for up to 12 years in about 10% of women. Prolonged lack of oestrogen affects the bones and cardiovascular system and postmenopausal women are at increased risk of a number of long-term conditions, such as osteoporosis.
Around a million women in the UK use treatment for their menopausal symptoms. The advice and support available is variable, and use of hormone replacement therapy (HRT)  a highly successful treatment for common symptoms of menopause  varies with socioeconomic and cultural factors. The number of prescriptions for HRT almost halved after the publication of 2 large studies: the Women's Health Initiative (2002) and the Million Women Study (2003). These studies focused on the use of HRT in chronic disease prevention and potential long-term risks rather than considering the benefits in terms of symptom relief. One of the aims of this NICE guideline was to clarify the balance of benefits and risks of HRT use for both women and their healthcare providers. Note that at the time of publication (November 2015), the MHRA is consulting with marketing authorisation holders on amending the existing warning about the risk of ovarian cancer in the Summary of Product Characteristics (SPC) information for HRT products. The current core SPC states that longterm use of oestrogenonly and combined oestrogenprogestogen HRT has been associated with a slightly increased risk of ovarian cancer.
This guideline addresses the diagnosis and management of menopause. It covers women in perimenopause and postmenopause, and the particular needs of women with premature ovarian insufficiency and women with hormone-sensitive cancer (for example, breast cancer). The guideline concentrates on the clinical management of menopause-related symptoms, considers both pharmaceutical and non-pharmaceutical treatments, includes a health economic analysis, and reviews the benefits and adverse effects of HRT. It applies to all settings in which NHS services are provided.# Recommendations for research
The Guideline Development Group has made the following recommendations for research. The full set of research recommendations is detailed in the full guideline.

# Women with breast cancer
What is the safety and effectiveness of alternatives to systemic hormone replacement therapy (HRT) as treatments for menopausal symptoms in women who have had treatment for breast cancer?
Why this is important
Women with a history of breast cancer are rarely offered hormonal treatment for menopausal symptoms but the available alternatives are less effective. There is limited evidence from randomised controlled trials on the safety and effectiveness of options such as non-hormonal treatments, ospemifene, conjugated equine estrogen/bazedoxifene (CEE/BZA) or local vaginal oestrogen for menopausal symptoms in women who have had treatment for breast cancer. There is insufficient evidence on the efficacy and safety of non-pharmaceutical treatments in women with breast cancer and other hormone-sensitive conditions. Randomised controlled trials or large cohort studies are needed to understand the effects of these treatments in women with breast cancer, and to investigate if there is a difference in breast cancer recurrence, mortality and tumour aggression with different types of treatment.

# Effects of HRT on breast cancer risk
What is the difference in the risk of breast cancer in menopausal women on HRT with progesterone, progestogen or selective oestrogen receptor modulators?
Why this is important
Fear of breast cancer deters many women from taking HRT, even in the presence of debilitating menopausal symptoms. There is a lack of evidence from randomised controlled trials directly comparing the risk of breast cancer in menopausal women on HRT with progesterone, progestogen or selective oestrogen receptor modulators. There is a need for a national registry of women with breast cancer.
Optimising the riskbenefit profile of HRT will potentially reduce morbidity and mortality from breast cancer in women who need HRT over the long term because of continuing menopausal symptoms.

# Effects of HRT on venous thromboembolism risk
How does the preparation of HRT affect the risk of venous thromboembolism (VTE)?
Why this is important
An increase in the risk of VTE (deep vein thrombosis  or pulmonary embolism ) is a significant side effect of HRT, particularly because PEs can be fatal. This risk appears to be greater with oral than transdermal HRT. DVT risk increases with age and BMI, among other risk factors.
The progestogen component of HRT may also influence the risk of a DVT, which may be greater with androgenic synthetic progestogens than natural progesterone (but findings from observational studies need confirmation). Most women in the UK take oral HRT comprising oestrogen combined with a synthetic progestogen, and the use of progesterone is less common.
Randomised controlled trials are needed to compare oral with transdermal HRT, and HRT containing different types of progestogens. These trials should measure coagulation factors and the incidence of VTE in women at increased risk of VTE for whom transdermal oestrogen is indicated.

# Effects of HRT on dementia risk
What are the effects of early HRT use on the risk of dementia?
Why this is important
Concern about the prospect of dementia in older age is increasing and any beneficial effect on the future risk of dementia will be important to women who are considering using HRT. There is a need for good-quality observational studies controlling for the effect of important confounders on how early HRT use affects dementia risk in women with early natural menopause, including women with premature ovarian insufficiency.

# Premature ovarian insufficiency
What are the main clinical manifestations of premature ovarian insufficiency and the short- and long-term impact of the most common therapeutic interventions?
Why this is important
Women with premature ovarian insufficiency can experience the effects of menopause for most of their adult life. This can lead to reduced quality of life and an increased risk of osteoporosis, cardiovascular disease and possibly dementia. There is uncertainty about the diagnosis, time course and management of premature ovarian insufficiency. For example, it is possible that different interventions produce different outcomes in terms of quality of life, and bone, cardiovascular and brain protection. Combined oral  contraceptives are often prescribed when this might not be the best treatment in terms of quality of life and preservation of bone density and cardiovascular health. Short- and long-term outcomes of HRT versus combined hormonal contraceptives in women with premature ovarian insufficiency therefore need to be investigated.
Development of a collaborative premature ovarian insufficiency registry would allow the collection of high-quality demographic, biobank (genomic) and clinical data in order to clarify:
the diagnosis and presentation of premature ovarian insufficiency
the impact of therapeutic interventions such as combined hormonal contraceptives, HRT and androgens
the long-term impact of premature ovarian insufficiency on bone density and fracture, and cardiovascular and cognitive health
the long-term risk of cancer, which can be determined by linking with relevant cancer and mortality registries.# Finding more information and resources
You can see everything NICE says on menopause in the NICE Pathway on menopause.
To find out what NICE has said on topics related to this guideline, see our web page on gynaecological conditions.
For full details of the evidence and the guideline committee's discussions, see the full version. You can also find information about how the guideline was developed, including details of the committee.
NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting NICE guidelines into practice, see resources to help you put guidance into practice.