Menopause: identification and management

Why the committee made the recommendation

In the committee's experience, some people can be distressed by going through menopause at an earlier age than expected and earlier than their peers. If someone is experiencing emotional distress to a level that raises concerns, the committee agreed that they may need to be referred to psychology services.

How the recommendation might affect practice

It is common practice to provide psychological support to this group of people. While a potential referral will have a resource impact, support from psychology services will lead to improvements in quality of life and reduce future contacts with health services.

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Why the committee made the recommendation

Evidence is lacking on the average age of menopause in people from ethnic minority backgrounds. However, the committee was aware, from experience, that people from some ethnic minority groups, and people with some lifelong conditions (for example, Down's syndrome), experience menopause at a younger age. The committee agreed it was important to raise awareness of this so that healthcare professionals can more easily identify symptoms of menopause in ethnic minority populations or in people with lifelong conditions.

How the recommendation might affect practice

The recommendation will raise awareness that people from some ethnic minority groups, and those with some lifelong conditions, experience menopause at a younger age. It is unclear whether this will change clinical practice, but it might lead to earlier identification of menopause and earlier management of menopause symptoms.

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Why the committee made the recommendations

Based on experience, the committee agreed that these basic principles of care would allow people to make an informed choice about management options:

How the recommendations might affect practice

The recommendations reflect best practice principles for shared decision-making. The recommendations will make healthcare professionals aware of what to discuss as part of this process.

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Why the committee made the recommendation

The committee based the recommendation on both the evidence and their expert knowledge. They looked at evidence on CBT compared with no intervention or to treatment as usual.

There was no evidence available for trans men and non-binary people registered female at birth. However, the committee agreed that the use of CBT for menopause-associated symptoms would be suitable for anyone, regardless of whether they have taken gender-affirming hormone therapy in the past. (This is also covered in the rationale on managing symptoms associated with menopause in people who have taken gender-affirming hormone therapy in the past.)

Overall, the evidence showed CBT was beneficial for women with vasomotor symptoms associated with menopause. The benefits related to 3 outcomes: the frequency of symptoms, severity of symptoms and how much the symptoms bothered the person (using a questionnaire that measured 'distress or bother'). The greatest effect was seen in how much symptoms bothered the person – many women felt their symptoms affected them less after taking part in CBT.

The committee also discussed the following limitations that affected the quality of the evidence:

For this reason, the committee decided to recommend CBT in addition to HRT, or as an option for people who prefer not to take HRT or for whom HRT is contraindicated. They also agreed the chosen CBT approach should be specifically designed for menopause symptoms.

How the recommendation might affect practice

These recommendations are a change to clinical practice. While wider use of CBT as an additional option could increase costs and add pressure to already limited services, especially in the short-term, it also gives people more choices for managing symptoms, including the option to have both CBT and HRT. This may lead to better outcomes.

The committee noted that there are long waiting times for CBT. They also noted that people currently trained in providing this kind of therapy may not be familiar with menopause-specific CBT, so training on this may incur costs and increase waiting times in the short term. However, online and group CBT may be easier and less costly to adapt to be menopause specific. There are also resources available to train people in providing menopause-specific CBT (that could also inform the adaptation of online CBT), which could facilitate implementation.

Currently, the treatment recommended for vasomotor symptoms associated with menopause is HRT. Access to CBT may address some health inequalities, providing other effective options for those who cannot or do not wish to use pharmacological treatments for menopause symptoms.

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Why the committee made the recommendations

The committee discussed evidence from network meta-analyses (NMA) which looked at a number of management options for specific subtypes of genitourinary symptoms associated with menopause such as vaginal dryness, pain with sex, and vulvovaginal discomfort or irritation. They also took into account evidence from the health economic model developed for the 2024 update of this guideline.

There was no evidence available for trans men and non-binary people registered female at birth. The committee agreed that their conclusion from the available evidence could be extended to those who have never taken gender-affirming hormone therapy. But they did not think they could be extended to those who have taken this type of therapy in the past, because it is not known whether such therapy would alter the benefits and risks of any management option (especially hormonal treatments), or which management option might be best for the person.

Evidence showed that vaginal oestrogen (particularly estriol but also oestradiol) was effective in reducing vaginal dryness and pain with sex. Estriol also showed effectiveness in reducing vulvovaginal discomfort or irritation. The economic model conducted for this review showed that vaginal oestrogen was cost-effective.

There was limited evidence on long-term use of vaginal oestrogen preparations. However, the committee acknowledged that efficacy and tolerability would be assessed regularly, as per the recommendations on reviewing treatment.

To gain a better understanding of it, the committee made a recommendation for research on the safety of vaginal oestrogen when used for more than 12 months.

Based on their expertise, the committee agreed that what is known about the safety of long-term use should be taken into account and discussed with the person before offering vaginal oestrogen. They agreed that the following points should also be brought up:

Preparations were not all shown to be equally effective. However, there were also uncertainties around the differences observed. So, the committee agreed that, overall, it was unlikely that 1 type of vaginal oestrogen preparation would be more effective than another. They concluded that people with genitourinary symptoms associated with menopause should be given different options for vaginal oestrogen preparations so they could choose the 1 they prefer.

The committee thought that people did not always realise that moisturisers or lubricants can be used alone or in addition to vaginal oestrogen and, therefore, thought that this information should be included in discussions about management options.

The NMA suggested that non-hormonal vaginal moisturisers and lubricants were less effective than vaginal oestrogen, but a smaller proportion of people stopped using their treatment when using non-hormonal vaginal moisturisers or lubricants than when using other types of treatments. This may suggest that, when non-hormonal vaginal moisturisers and lubricants worked for a person, the person felt comfortable to keep using them (for example, because these are readily available over the counter options). While the evidence highlighted uncertainty around the effectiveness of non-hormonal moisturisers and lubricants, based on their experience, the committee decided that moisturisers and lubricants could be tried when vaginal oestrogen is contraindicated or not preferred.

The committee discussed the role of vaginal prasterone and oral ospemifene in the management of genitourinary symptoms associated with menopause. They noted that both these medicines are more expensive than vaginal oestrogen, moisturisers or lubricants. However, the NMA showed them to be effective in reducing vaginal dryness and pain with sex but not vulvovaginal discomfort or irritation. They were also seldom discontinued because of adverse events.

The economic model showed vaginal prasterone was not cost-effective as a first-line option. However, given its clinical effectiveness, the committee agreed that it could be offered as a second-line management option when other options (vaginal oestrogen, or non-hormonal moisturisers or lubricants) are ineffective for persisting genitourinary symptoms or are not tolerated.

Evidence showed that ospemifene was not cost-effective and could therefore not be recommended as a first-line treatment option for all people with genitourinary symptoms associated with menopause. However, the committee noted that, for some people, local application of vaginal oestrogen may be impractical. For example, people with physical or intellectual disabilities may find it difficult to use local vaginal oestrogen. Ospemifene is an oral tablet and should therefore be considered as an option in such specific circumstances.

The committee was aware that the symptoms of overactive bladder can occur alongside genitourinary symptoms associated with menopause and that vaginal oestrogen can be given in these circumstances. They decided not to include people with a personal history of breast cancer in the recommendation on this because vaginal oestrogen is not the first-line treatment for genitourinary symptoms associated with menopause in this population.

How the recommendations might affect practice

The evidence showed that the most cost-effective option for the treatment of genitourinary symptoms associated with menopause is vaginal oestrogen, which is routinely offered in current practice. The recommendations will standardise practice rather than change it.

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Why the committee made the recommendations

The committee acknowledged that evidence was sparse, with only 4 studies providing information on breast cancer recurrence in people with a personal history of breast cancer taking vaginal hormone treatment for genitourinary symptoms associated with menopause. The committee also had methodological concerns about some of the studies, particularly about:

There was no evidence available for trans men and non-binary people registered female at birth. The committee agreed that their conclusion from the available evidence could be extended to those who have never taken gender-affirming hormone therapy. But they did not think they could be extended to those who have taken this type of therapy in the past, because it is not known whether such therapy would alter the benefits and risks of any management option (especially hormonal treatments), or which management option might be best for the person.

The committee discussed the evidence comparing vaginal oestrogen to no treatment in women with a personal history of breast cancer. Most of the evidence included all women together and so did not distinguish between those who used adjuvant treatment for breast cancer and those who did not. Based on this evidence, it is not possible to say with certainty whether vaginal oestrogen, when used for genitourinary symptoms associated with menopause, leads to any change in breast cancer recurrence or not.

The uncertainties around the evidence also led the committee to agree that:

The committee made these recommendations because:

The committee advised that the mechanism of action of aromatase inhibitors makes genitourinary symptoms likely. However, the mechanism of action of tamoxifen is less likely to cause genitourinary symptoms and may even alleviate some of them. Vaginal oestrogen may also lessen the efficacy of aromatase inhibitors.

The committee agreed it could not be confident about the evidence on the safety of local vaginal oestrogens in those taking either tamoxifen or aromatase inhibitors. This was because of:

For this reason, the committee agreed that, if vaginal oestrogen is considered for people on aromatase inhibitors as an adjuvant treatment, treatment options should be discussed with a breast cancer specialist (for example, this may include switching to tamoxifen).

The committee noted that treatment decisions would need to be tailored to each person because:

In someone with an oestrogen receptor negative breast cancer, oestrogen does not affect the growth of cancer cells, but in someone with an oestrogen receptor positive breast cancer, it increases the risk of recurrence.

In someone with an oestrogen receptor positive breast cancer taking adjuvant treatment:

There was relatively little evidence for the use of vaginal oestrogen to manage genitourinary symptoms associated with menopause after breast cancer, particularly related to long-term use and use in conjunction with adjuvant therapy. Therefore, the committee made a recommendation for research on the safety of vaginal oestrogen in terms of breast cancer recurrence.

How the recommendations might affect practice

The recommendation about the use of non-hormonal treatment options as first-line treatment for people with a personal history of breast cancer and genitourinary symptoms associated with menopause is in line with current practice. There is variation in:

The recommendations will standardise practice.

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Why the committee made the recommendation

The committee made a recommendation on vaginal laser treatment that applies to people with genitourinary symptoms associated with menopause, regardless of whether they have a personal history of breast cancer.

The evidence showed that laser treatment was effective for all outcomes. However, the committee agreed that, despite some promising results, the evidence base was too small. In addition, laser treatment has a potential for harm (for example, scarring) and evidence showed it was not cost-effective. As a result, it should only be offered in the context of research. The committee also made a recommendation for research on vaginal laser treatment to address this.

There was no evidence available for trans men and non-binary people registered female at birth. The committee agreed that their conclusion from the available evidence could be extended to those who have never taken gender-affirming hormone therapy. But they did not think they could be extended to those who have taken this type of therapy in the past, because it is not known whether such therapy would alter the benefits and risks of any treatment (especially hormonal treatments), or which treatment option might be best for the person.

How the recommendation might affect practice

Laser treatment was not included in the previous version of this guideline, but the recommendation to only consider it in the context of research will not affect practice.

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Why the committee made the recommendations

The committee made recommendations based on the evidence which looked at CBT compared with no treatment or to treatment as usual, in the context of menopause. The common criteria used in all studies to show that women had experienced or were approaching menopause was the presence of vasomotor symptoms.

There was no evidence available for trans men and non-binary people registered female at birth. However, the committee agreed that the use of CBT for menopause symptoms would be suitable for anyone, regardless of whether they have taken gender-affirming hormone therapy in the past. (For more details, see the rationale on managing symptoms associated with menopause in people who have taken gender-affirming hormone therapy in the past.)

There were many different scales and measurements for mental health-related symptoms, and, in the context of menopause:

There were some concerns about the evidence. These related to study design and to biases in the way studies were carried out. There were also uncertainties around:

However, the committee acknowledged that the overall effectiveness of CBT for depressive symptoms is established (see NICE's guideline on depression in adults). For this reason, they agreed that CBT should be a management option for depressive symptoms associated with vasomotor symptoms.

If depression is suspected or diagnosed, the committee noted that the optimal treatment plan can only be achieved by following both this menopause guideline and NICE's guideline on depression in adults.

How the recommendations might affect practice

These recommendations could lead to a change to clinical practice. Wider use of CBT could increase costs and add pressure onto already limited services, especially in the short term. However, it also gives people more management choices, including the option to have both CBT and HRT. Having more options may result in better outcomes.

There are currently long waiting times for CBT. However, the use of online and group CBT may make it easier and less costly to introduce CBT for depressive symptoms associated with menopause, where this option is not already in place.

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Why the committee made the recommendation

The committee based the recommendation on the evidence on CBT compared with no treatment or compared with treatment as usual.

There was no evidence available for trans men and non-binary people registered female at birth. However, the committee agreed that the use of CBT for menopause symptoms would be suitable for anyone, regardless of whether they have taken gender-affirming hormone therapy in the past. (For more details, see the rationale on managing symptoms associated with menopause in people who have taken gender-affirming hormone therapy in the past.)

Evidence showed CBT improved sleep quality, but this varied depending on the scale used to measure sleep disturbances. The committee agreed it was difficult to define difficulties with sleep, but the evidence showed that CBT was beneficial for various aspects of sleep, as defined by each scale (for example, the measures contributing to scales included the number of hours of sleep per night, how long it takes to fall asleep and the number and duration of night-time awakenings; there were also some specific scales for insomnia). The committee acknowledged there may be other options to manage difficulties with sleep associated with menopause. NICE will monitor evidence on these for a future update. While not all the CBT approaches used in the evidence were specifically developed for menopause-associated symptoms, the committee agreed that this kind of CBT would be more effective given that the evidence showed that:

The committee agreed that the evidence had some limitations, including uncertainties around:

The committee also had concerns around study design and biases around how studies were carried out.

As a result, they recommended CBT as an option rather than as routine management for sleep problems associated with menopause.

How the recommendation might affect practice

These recommendations could lead to a change to clinical practice. Although increased use of CBT could have a resource impact and add pressure to already limited services, especially in the short term, it also provides more management choices, including the option to have both CBT and other treatments (including HRT). This may lead to better outcomes.

There are currently long waiting lists for CBT and people who are already trained in this type of therapy may need further training before they can provide menopause-specific CBT. However, the use of online or group CBT may make it easier and less costly to adapt as menopause-specific CBT. The committee was aware of existing resources that can be used to train people in providing menopause-specific CBT (including adapting online CBT). They agreed that this would facilitate implementation.

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Why the committee made the recommendation

For people with a history of coronary heart disease or stroke, the committee agreed that different risk factors mean that people have different baseline levels of risk. They concluded that decisions on HRT use for menopause-associated symptoms would need to be tailored to the person and their particular risk factors and risk levels and that, therefore, these decisions should be made with a healthcare professional with expertise in menopause.

How the recommendation might affect practice

It is current practice that people with pre-existing conditions get expert advice on HRT as a treatment option for menopause-associated symptoms. However, there is variation in which expert would be consulted on this. This recommendation will standardise practice.

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Why the committee made the recommendations

The committee noted a lack of evidence on HRT use in trans men and non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past. This uncertainty means that, for example, it is not known whether past hormone treatment could influence the choice of HRT, or whether giving HRT to someone who previously had hormone therapy would alter their health risks. For this reason, the committee agreed that trans men and non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past should be able to discuss their menopause-associated symptoms with a healthcare professional with expertise in menopause. They can then make a shared decision about any potential treatment the person may wish to have. Because of the lack of evidence, the committee also made a recommendation for research on the impact of HRT on health outcomes for trans men and non-binary people registered female at birth, which covers people who have never taken gender-affirming hormone therapy, or who have taken it in the past but are not currently taking it.

The committee discussed the evidence related to CBT. This did not include evidence related to trans men or non-binary people registered female at birth. However, the committee agreed that the use of CBT for menopause symptoms would be suitable for any person, regardless of whether they have taken gender-affirming hormone therapy in the past.

The committee decided to make a specific recommendation for trans men and non-binary people registered female at birth who have taken gender-affirming hormone therapy in the past to promote equality in access to CBT services for managing menopause-associated symptoms within these groups, acknowledging their unique experiences and needs. Because, without further evidence, other recommendations in this guideline cannot be extended to these groups, the committee agreed that a separate recommendation would highlight CBT as a management option for these groups.

How the recommendations might affect practice

In the committee's experience, there is no clear current practice related to the treatment of menopause-associated symptoms in people who have taken gender-affirming hormone therapy in the past. The committee agreed that access to both advice from a healthcare professional with expertise in menopause and to CBT were a matter of equality and inclusivity.

The recommendations may increase the number of referrals both to healthcare professionals with expertise in menopause, and for CBT. The committee noted that there is pressure on services providing CBT. However, the recommendations should also lead to more appropriate care and improved outcomes for people who have had gender-affirming hormone therapy in the past.

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Why the committee made the recommendation

The committee discussed the evidence on the impact of HRT on all-cause mortality (life expectancy). The multitude of confounding factors that may affect life expectancy meant that evidence had to be restricted to randomised controlled trials (RCTs). This is because, in RCTs, participants are randomly assigned to different treatment groups, which helps control known and unknown confounders.

The committee noted that high-quality evidence showed no difference in mortality with either oestrogen-only or combined HRT compared with not taking HRT. They agreed that this was an important finding and therefore emphasised the need to tell people thinking about either treatment option that taking combined or oestrogen-only HRT is unlikely to affect life expectancy.

The committee looked at the analysis for groups of women starting HRT at different ages. They noted that, for most age groups, there was no difference in mortality between those who are taking or have taken HRT compared with placebo. There was also no significant variation in this difference depending on the age of starting HRT.

A decrease in all-cause mortality was reported for 1 isolated subgroup (women starting oestrogen-only HRT aged between 50 and 59). In isolation, this was a statistically significant figure. But in a wider context, it cannot be interpreted as good evidence of a different effect in this group. This is because:

As a result, the committee did not refer to this decrease in all-cause mortality in the recommendation.

How the recommendation might affect practice

It is current practice to discuss benefits and risks with people when treatment options are being considered. The effect of treatment on life expectancy is an important part of these discussions and was not covered in the previous version of this guideline. The recommendations will standardise the information that will be given. But it is unclear how this will change the treatment choices made and how this will impact on practice.

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What this rationale covers

The committee highlighted the importance of presenting people with a complete picture of benefits and risks associated with HRT to enable shared and informed decision making.

This rationale briefly describes the available evidence on combined HRT and how it affects risks related to:

It also covers other considerations related to cardiovascular disease, and the need for further research in this area.

There was no evidence available for trans men and non-binary people registered female at birth. The committee agreed that their conclusion from the available evidence could be extended to those who have never taken gender-affirming hormone therapy. But they did not think it could be extended to those who have taken this type of therapy in the past, because it is not known whether such therapy would alter the benefits and risks of any treatment (especially hormonal treatments), or which treatment option might be best for the person. So, they made a recommendation for research on the impact of HRT on health outcomes for these groups. Combined and oestrogen-only HRT are prescribed to different groups of people, and so the committee looked separately at the benefits and risks associated with the 2 types of HRT.

Why the committee made this recommendation

How the recommendation might affect practice

It is current practice to discuss benefits and risks with people when thinking about treatment options. The recommendation will standardise and update the information that will be shared. While the 2024 version of this guideline includes some new or updated information to share, it is unclear how this will affect treatment choices and impact on practice.

It is possible that the recommendation may increase the use of transdermal HRT, given that it was not associated with an increased risk of stroke (and, according to 2015 recommendations that were not reviewed in 2024, it is also associated with a lower risk of venous thromboembolism than oral preparations).

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What this rationale covers

The committee agreed that people should be presented with a complete picture of benefits and risks associated with HRT to enable shared, and informed, decision making.

This rationale briefly describes the available evidence on oestrogen-only HRT and how it affects risks related to:

It also covers other considerations related to cardiovascular disease, and the need for further research in this area.

There was no evidence available for trans men and non-binary people registered female at birth. The committee agreed that their conclusion from the available evidence could be extended to those who have never taken gender-affirming hormone therapy. But they did not think it could be extended to those who have taken this type of therapy in the past, because it is not known whether such therapy would alter the benefits and risks of any management option (especially hormonal treatments), or which management option might be best for the person. So, they made a recommendation for research on the impact of HRT on health outcomes for these groups.

Combined and oestrogen-only HRT are prescribed to different groups of people, as per recommendation 1.8.1, and so the committee looked separately at the benefits and risks associated with the 2 types of HRT.

Why the committee made this recommendation

How the recommendation might affect practice

It is current practice to discuss benefits and risks with people when considering treatment options. The recommendation will standardise the information that will be shared. While the 2024 version of this guideline includes some new or updated information to share, it is unclear how this will change the treatment choices made and how this will impact on practice.

It is possible that the recommendation may increase the use of transdermal HRT since it was not associated with an increased risk of stroke (and, according to 2015 recommendations that were not reviewed in 2024, it is also associated with a lower risk of venous thromboembolism than oral preparations).

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Why the committee made the recommendation

Given the findings about the effect of HRT on coronary heart disease and stroke (as covered in the rationales on the effect of combined and of oestrogen-only HRT) the committee agreed that the evidence did not support the use of combined or oestrogen-only HRT for primary or secondary prevention of cardiovascular disease.

How the recommendation might affect practice

It is unclear whether it is current practice to use HRT for the specific purpose of primary or secondary coronary heart disease prevention. So, the recommendation is likely to standardise practice.

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Why the committee made the recommendation

The committee noted the scope of this guideline and agreed that the indication for HRT prescriptions in the UK was menopause symptoms. Therefore, the aim of the included studies was not dementia prevention. They agreed it was important to highlight that the evidence did not support this indication.

How the recommendation might affect practice

It is unclear whether it is current practice to use HRT for the specific purpose of dementia prevention. So, the recommendation is likely to standardise practice.

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Why the committee made the recommendation

No evidence was identified on the benefits and risks of either taking or not taking HRT relating to osteoporosis, risk of fractures or cardiovascular outcomes, or endometrial or ovarian cancer in people experiencing early menopause (people aged 40 to 44). Some evidence was identified on the effect of taking or not taking HRT on breast cancer risk in this age group.

The committee did not look at evidence on whether early menopause itself may have an impact on health outcomes, and how to manage any impact it might have. Therefore, they could not make any recommendations on the benefits and risks of HRT to manage any differences in risk that may result from early menopause.

The committee agreed it was important to take a person's age at the onset of menopause-associated symptoms into account during discussions about HRT (in line with the section on discussing management options). They agreed that the age cut-offs defining premature ovarian insufficiency (POI), early menopause and typical menopause were a little arbitrary. They also agreed it is clinically plausible that the benefits and risks evolve gradually from what they are for people with premature ovarian insufficiency to what they are for people aged 45 or over. As a result, it is likely that, for people with early menopause, the benefits and risks of either taking or not taking HRT lie somewhere between those for people with premature ovarian insufficiency and those for people aged 45 or over, for whom there is more evidence about these benefits and risks.

The committee discussed the similarities between early menopause and POI. Although there is little evidence of the impact of HRT on health outcomes in people with POI, it is current practice for this group to take HRT routinely. HRT is offered to them to lower the risk of some health outcomes, for example, osteoporosis. The situation may be similar for early menopause, for which routine HRT is also current practice.

Evidence showed that, as for people aged 45 or over, the risk of breast cancer in early menopause is increased when taking HRT compared with not taking HRT. However, the committee agreed that taking HRT in early menopause may affect the risk of different health outcome in different ways (that is, it may decrease some risks and increase others), as it does for people with POI and for people experiencing menopause at 45 or over.

As a result, the lack of evidence on outcomes other than breast cancer meant that it was not possible to make recommendations about the overall balance of benefits and risks of taking or not taking HRT in early menopause.

The committee agreed that it was important to highlight this lack of evidence and made a key recommendation for research on the impact of HRT in early menopause on specific health outcomes to address it.

How the recommendation might affect practice

While the recommendation may help people make decisions about treatment, it is unclear how it will change these decisions and how that will impact overall resource use. It would however be unethical to prevent such information being discussed with people experiencing early menopause even if it did lead to an increase in resource use.

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Why the committee made the recommendations

How the recommendations might affect practice

The recommendations reflect current practice in choice of HRT prescribing for people with a uterus or for people who have had a total hysterectomy.

It is common practice to seek advice from a healthcare professional with expertise in a condition when the clinical situation is complex, such as identifying the most suitable type of HRT for someone whose condition may be affected by it. This would usually be an informal process, so it is unlikely to have a significant impact on practice.

Stopping HRT if a person is diagnosed with breast cancer is also current practice.

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