Evaluation
R 1.1 We recommend that menopause is considered as a spectrum and includes the perimenopause and postmenopause. (Good Clinical Practice)
R 1.2 We recommend that perimenopause is considered when menstrual irregularity and/or vasomotor symptoms (VMS) are present, even in younger women (40-45 years). (Good Clinical Practice)
R 1.3 We recommend that premature ovarian insufficiency (POI) is considered in women under 40 years of age in the presence of menstrual irregularity and/or subfertility and/or vasomotor symptoms. (Good Clinical Practice)
R 1.4 We recommend biochemical testing for diagnosis or management of (peri)menopause in women older than 45 years is not necessary. (Good Clinical Practice)
R 1.5 We recommend biochemical testing for the presence of POI in women under 40 years of age in the presence of menstrual irregularity and/or subfertility and/or vasomotor symptoms; biochemical testing for the presence of perimenopause or menopause can also be considered in women aged 40-45 years. (Good Clinical Practice)
R 1.6 If biochemical testing for perimenopause is considered, we suggest measuring FSH at day 2 to 5 of the menstrual cycle or after an interval greater than 40 days without menstruation. (Good Clinical Practice)
R 1.7 We recommend that, when the medical history and clinical presentation of a woman of reproductive age include interference with the menstrual cycle and/or lead to menopause-like symptoms, other diagnoses should be considered. These may require additional testing. (Good Clinical Practice)
R 1.8 We recommend that all women with POI are referred to a menopause expert and where possible, a multidisciplinary team. (Good Clinical Practice)
R 1.9 We suggest that where possible, women in perimenopause, who are under the age of 40 and have apparent contraindications for hormone replacement therapy, are referred to a unit with particular expertise in managing such women. These include, for example, women with a history or high risk of a hormone dependent cancer, thrombotic or cardiovascular high risk, women who have an inadequate response to hormone therapy or those who have significant adverse effects.
Management
R 2.1 We recommend that a holistic approach is taken for women during perimenopause and menopause, not having a sole focus on hormone replacement therapy (HRT)/ menopausal hormone therapy (MHT). (Good Clinical Practice)
R 2.2 We recommend that women in peri- and post-menopause who are appropriate candidates for MHT can be managed in primary care according to recognized guidelines.
R 2.3 We recommend that before starting HRT/MHT women are well-informed about the benefits and risks of treatment and other options in order to facilitate shared decision making. (Good Clinical Practice)
R 2.4 We recommend, if indicated, in women with a uterus, to start MHT with a preparation combining oestrogen and progestogen. (⊕⊕⊕⊕)
R 2.5 We recommend, if indicated, in women without a uterus, to start MHT with a preparation with oestrogen alone. (⊕⊕⊕○)
R 2.6 We recommend that in women treated with MHT for symptoms, treatment effects should be re-evaluated after 3 months. In case of an inadequate response, adverse effects or intolerability, dose and formulation should be re-evaluated. (Good Clinical Practice)
R 2.7 We recommend taking into account individual characteristics and comorbidities when prescribing MHT and also, preference, availability and costs when choosing between transdermal and oral preparations. (Good Clinical Practice)
R 2.8 We recommend HRT in POI irrespective of the presence of vasomotor—or other climacteric symptoms as the multimodal benefits clearly exceed the risk. HRT should be continued until the anticipated age of natural menopause and then the ongoing prescription reevaluated periodically. (Good Clinical Practice)
R 2.9 We recommend initiating MHT in women within 10 years of natural menopause onset or under 60 years for bothersome menopausal symptoms such as vasomotor or other climacteric symptoms. (⊕⊕⊕⊕○) Women should also be informed that MHT prevents bone loss and reduces fracture risk and may have positive effects on the cardiovascular system. (Good Clinical Practice)
R 2.10 We suggest that for women with symptoms of vulvovaginal atrophy local or systemic MHT can be considered depending on the presence of other symptoms. Local oestrogen is usually started alone but can be administered with systemic MHT if needed. (⊕⊕○○)
R 2.11 We suggest that in women without symptoms of perimenopause/menopause who are under 60 years of age, MHT initiation might be considered for bone protection. (⊕⊕○○)
Specific conditions
Age
R 3.1 We suggest a targeted approach to MHT continuation in women over 60 yrs. We suggest taking into account the effect on VMS and/or other climacteric symptoms, the changing benefit-risk profile with age and effect on bone and personal preferences. (Good Clinical Practice)
Venous thromboembolism (VTE)
R 3.2 We recommend that, if in a woman with a previous VTE, HRT/MHT is indicated after individual risk—benefit assessment, transdermal low dose oestrogen should be used. (⊕⊕⊕○)
Cardiovascular disease
R 3.3 MHT should not be used primarily for primary or secondary prevention of cardiovascular disease (CVD). (⊕⊕⊕○)
Diabetes
R 3.4 We recommend that well-controlled diabetes is not considered a contraindication for MHT use; transdermal oestrogen is the preferred choice. (⊕⊕⊕○)
Hypertension
R 3.5 In women with well-controlled hypertension there is no contra-indication for MHT; transdermal oestrogen is the preferred choice. (⊕⊕○○) We recommend MHT not be initiated in the presence of uncontrolled hypertension. (Good Clinical Practice)
Stroke
R 3.6 We recommend that MHT is not used to prevent stroke. (⊕○○○)
Migraine
R 3.7 We suggest that in women with an indication for MHT and a history of migraine with aura, transdermal oestrogen is recommended. (⊕○○○)
Breast cancer
R 3.8 We recommend that all women initiating MHT are informed about the increased risk for breast cancer. (Good Clinical Practice)
R 3.9 We recommend that systemic MHT is not used in women with a history of breast cancer. Considerations include factors such as age and individual characteristics of the tumour. (⊕⊕○○)
R 3.10 We suggest that low dose vaginal oestrogen, dosed to treat vaginal issues, can be considered in women with a history of breast cancer and genitourinary symptoms if other non-hormonal therapies are ineffective. (⊕○○○)
Endometrial cancer
R 3.11 We suggest that initiation of MHT can be considered in women with a history of early stage endometrial cancer who are considered disease free. (⊕○○○)
Ovarian cancer
R 3.12 We suggest that the risk for ovarian cancer is not a major determinant for the decision to initiate MHT or not. (⊕○○○)
R 3.13 We suggest that initiation of MHT can be considered in women with (a history of) certain subtypes of ovarian cancer. (⊕○○○)
Mood and cognition
R 3.14 We recommend not to routinely use MHT to treat clinical depression in perimenopause/menopause. (⊕○○○)
Dementia
R 3.15 We recommend that MHT is not used to prevent or treat dementia (⊕○○○)
