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Principles of Managing Menopause


There are several basic principles supported by consensus from numerous international medical societies that should be followed when diagnosing and managing menopausal symptoms. Many of the principles for treatment pertain to prescription Hormone Replacement Therapy; however, nonhormone and/or nonprescription options for menopause management also exist.

Lifestyle, Diet, and Exercise
recommendations supporting the overall health and well-being of peri- and postmenopausal women

Core Recommendations Regarding Hormone Replacement Therapy
a general overview of the type of hormone therapy to consider—systemic versus local—based on an individual patient’s needs

Appropriate Candidates for Hormone Replacement Therapy
description of women who may benefit from Hormone Replacement Therapy and those for whom therapy is contraindicated

Benefit-Risk Profile of Hormone Replacement Therapy
evidence illustrating the benefits and risks of hormone therapy, and how to put the risks into context for patients

Bioidentical” Hormone Therapy
rationale for why international medical societies do not recommend prescribing custom-compounded bioidentical hormone therapy

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Lifestyle, Diet and Exercise

Healthy lifestyle recommendations are a fundamental part of an overall strategy for maintaining the health and well-being of peri- and postmenopausal women.1

Key messages include the following:

  • Consume a healthy diet that includes:1
    • Several daily servings of fruits, vegetables, and whole grains
    • Fish twice per week
    • Low amounts of total fat (ie, good fats in moderation)
    • Limited amounts of salt
  • Adults should not regularly drink more than 14 units of alcohol per week. For adults who drink as much as 14 units per week, it is best to spread this evenly over 3 days or more.2
  • Exercise regularly to reduce the risk of cardiovascular disease and premature death.1
    • At least 150 minutes of moderate-intensity exercise per week is optimal (eg, 30 minutes 5 days a week).1
    • Adding strength training 2 times per week may provide further benefit, especially for patients at risk of osteoporosis.1
  • Avoid smoking.1
  • Socialise with friends and family, and partake in activities that promote physical and mental activity.1

Core Recommendations Regarding Hormone Replacement Therapy

  • Hormone Replacement Therapy (HRT) is the most effective treatment for menopause-related vasomotor symptoms across women of all ages. In addition, treatment benefits are more likely to outweigh risks for symptomatic women < 60 years or < 10 years from menopause onset.3,4 
    • Oestrogen as a single systemic agent is appropriate in women after hysterectomy.3,4
    • The addition of progestogen is required for women who still have their uterus. 3,4
  • Local low-dose oestrogen therapy is preferred for women whose menopausal symptoms are limited to vaginal dryness or dyspareunia, or for preventive purposes in post-menopausal women who experience recurrent urinary tract infections.3
    • The addition of progestogen is not required for women who still have their uterus when oestrogen is applied locally.4
  • HRT can be initiated in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other products approved for the prevention of osteoporosis before they reach the age of 60 or within 10 years after menopause onset.3
  • The type, dose, and duration of HRT should be individualised to match a patient’s treatment goals and any potential safety issues.3,4
    •  The choice of formulation and route of administration of HRT should be decided in concert with the patient.4
    •  In general, the dosage of HRT should be titrated to the lowest effective dose.1


Appropriate Candidates for Menopausal Hormone Therapy

The option of whether to use HRT is a decision that needs to be made by each individual woman based on:3

  • quality of life
  • health priorities
  • personal risk factors such as:
    • Age
    • Time since menopause
    • risk of venous thromboembolism, stroke, ischemic heart disease, and breast cancer
HRT should not be recommended without a clear indication for its use.3

The benefits of treatment outweigh the risks for most healthy, symptomatic women < 60 years or < 10 years within 10 years after menopause onset.4

In general, oestrogen therapy is not appropriate for individuals with any of the following conditions (please note this is not an exhaustive list and individual product SmPCs should be consulted for full details):4
  • Undiagnosed abnormal genital bleeding
  • Known, suspected, or history of breast cancer, except in appropriately selected patients being treated for metastatic disease
  • Known or suspected oestrogen-dependent neoplasia
  • Active deep vein thrombosis, pulmonary embolism, or a history of these conditions
  • Active arterial thromboembolic disease (eg, stroke, myocardial infarction), or a history of these conditions
  • Known anaphylactic reaction or angioedema with hormone therapy
  • Known liver impairment or disease
  • Known protein C, protein S or antithrombin deficiency, or other known thrombophilic disorders
  • Known or suspected pregnancy
For women at increased risk of venous thromboembolism, some guidelines recommend a non-oral (ie, transdermal) route of oestrogen administration at the lowest effective dose (if not contraindicated) and an appropriate progesterone (for women with a uterus).1,3,4


Benefit-Risk Profile of Hormone Replacement Therapy

Understanding of the benefits and risks of menopausal hormone therapy has evolved considerably over time. Here are some of the key points international medical societies take into consideration (as of 2017):


The benefits of hormone therapy often outweigh risks for symptomatic women 50-59 years old.1,4,5

  Time since menopause onset  
The benefits of hormone therapy often outweigh risks for symptomatic women < 10 years from menopause onset.1,4

  Treatment duration  
The duration of hormone therapy should be individualised for each patient based on her treatment goals and risk profile.3,4

  Patient medical history  
The presence of certain risks factors (eg, metabolic syndrome, family history of breast cancer) may increase certain risks.1,6

  Route of administration  
Local low-dose oestrogen therapy is preferred for women whose menopausal symptoms are limited to vaginal dryness or dyspareunia so as to avoid any potential risks associated with systemic therapy.1,3,4

Transdermal oestrogens avoid first-pass metabolism and may be more appropriate for women at high risk of venous thromboembolism.1,4

Individualising a patient’s treatment regimen can help maximise benefits and minimise risks.1
When discussing benefit-risk data for menopausal hormone therapy with women, putting the evidence in the context of other known benefits or risks may aid patient understanding.

Based on established research:
Among 1000 women, not on HRT, 23 will develop breast cancer over a 5-year period.
Among 1000 women given HRT that contains oestrogen and progesterone, 27 will develop breast cancer: an additional 4 women in a 1000 on HRT.
Among 1000 women given oestrogen-only HRT (because they do not have a womb, having had a hysterectomy), there is no increase in the number that develop breast cancer; indeed, most research shows the number to be lower.

Taken from Menopause Clinic London7

“Bioidentical” Hormone Therapy

International medical societies do not recommend prescribing custom-compounded “bioidentical” hormone therapy due to the lack of quality control and regulatory oversight of these products, together with a lack of evidence regarding safety and efficacy.1,3

These formulations are usually prepared by compounding pharmacies but do not go through the same rigorous manufacturing standards, quality control, and regulatory oversight as pharmaceutical-grade registered products.1  

Women who request compounded bioidentical hormone therapy should be encouraged to consider regulated prescription HRT products, which are available in a wide range of doses and delivery methods.1


Estring (estradiol hemihydrate) prescribing information can be found here
Premarin (oestrogens, conjugated) prescribing information can be found here
Premique (medroxyprogesterone acetate oestrogens, conjugated) prescribing information can be found here

1.Baber RJ, Panay N, Fenton A; IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric. 2016;19(2):109-150.
2. GOV.UK, DHSC Guidance- Alcohol. Available at: [Accessed June 2022].
3. de Villiers TJ, Hall JE, Pinkerton JV, et al. Revised global consensus statement on menopausal hormone therapy. Climacteric. 2016;19(4):313-315.
4. NICE NG23, 2015, updated December 2019. Available at: [Accessed June 2022].
5. Manson JE, Kaunitz AM. Menopause management--getting clinical care back on track. N Engl J Med. 2016;374(9):803-806. 
6. Bassuk SS, Manson JE. Menopausal hormone therapy and cardiovascular disease risk: utility of biomarkers and clinical factors for risk stratification. Clin Chem. 2014;60(1):68-77.
7. Menopause Clinic, London. 2017. Available at:
PP-UNP-GBR-0581. June 2022

Treatment Options

Discover a wide range of treatment options for menopause including both systemic and local therapies

Learn more

Diagnosing Menopause

Learn the fundamental strategies for diagnosing menopausal symptoms principles before you make a treatment decision

Learn more

Common Symptoms

Discover common symptoms of menopause to help understand the condition and reassure patients

Learn more

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PP-PFE-GBR-3863. November 2021



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