1. In any woman of menopausal age, screen for symptoms of menopause and (e.g., hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes).
  2. In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.)
  3. In a patient with atypical symptoms of menopause (e.g., weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause.
  4. In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results.
  5. When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices
  6. In menopausal or perimenopausal women:
    1. Specifically inquire about the use of natural or herbal products.
    2. Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions.
  7. In a menopausal or perimenopausal women, provide counselling about preventive health measures (e.g., osteoporosis testing, mammography).
  8. Establish by history a patient’s hormone-replacement therapy risk/benefit status.

General Overview

    • Diagnosis
      • Perimenopause
        • Irregular periods and VMS until menopause
      • Menopause
        • >45yo and no period for 12 consecutive months and not using contraception
          • If no uterus, diagnose based on symptoms
          • Consider FSH <40-45yo
            • If elevated FSH on 2 blood samples 4-6w apart and <40yo, diagnose premature ovarian insufficiency

Symptoms of menopause

      • Vasomotor symptoms (VMS)
        • Hot flashes, sweats
      • Genitourinary syndrome of menopause (GSM) - previously vulvovaginal atrophy
        • Urinary frequency/urgency/incontinence, dysuria
        • Vaginal dryness/burning/pruritus, post-coital bleeding, sexual dysfunction, dyspareunia
      • Mood, irritability
      • Sleep changes
      • Joint and muscle pain


    • Changes in periods
    • Symptoms of menopause
      • Hot flashes, sweats
      • Vaginal dryness/burning
      • Sexual concerns (desire, arousal, pain, or orgasm)
      • Bladder issues / incontinence
      • Sleep
      • Mood


    • Lifestyle
      • Healthy weight
      • Diet (low sodium, low sugars - increase vegetables/fibers)
        • Avoid VMS triggers (hot drinks, alcohol, caffeine)
      • Exercise >150mins moderate-vigorous per week
      • Routine Vitamin D +/- calcium
      • STOP Smoking, alcohol
      • Optimize sleep, relationship, mood
      • Assess for HTN/DM/DLP
    • VMS
      • Hormone replacement therapy first-line if <60yo or <10y past menopause (can be continued beyond 65yo in cases where risk>benefit)
        • Contraindicated in unexplained vaginal bleeding, pregnancy, history of breast cancer, coronary heart disease, a previous venous thromboembolic event or stroke, or active liver disease
          • Risks per 1000 women with five years of hormone use
            • Coronary heart disease (CHD) – 2.5 additional cases
            • Invasive breast cancer – 3 additional cases
            • Stroke – 2.5 additional cases
            • Pulmonary embolism – 3 additional cases
            • Colorectal cancer – 0.5 fewer cases
            • Endometrial cancer – no difference
            • Hip fracture – 1.5 fewer cases
            • All-cause mortality – 5 fewer events
          • Review at three months then annually (use up to 5y or longer)
            • Unscheduled vaginal bleeding may happen in first 3 months
              • Vaginal bleeding should be investigated to r/o endometrial cancer
              • May consider waiting for 6 months before endometrial biopsy
      • Offer choice of preparations
        • Estrogen-progesterone (EP) or tissue-selective estrogen complex (eg. Duavive)
          • Transdermal
            • Climara Pro (matrix patch) 45mcg Estradiol + 15mcg LNG once weekly
            • Estalis 50mcg Estradiol + 140mcg NETA (or 250mcg NETA) twice weekly
          • Oral
            • FemHRT 2.5mcg EE + 0.5mg NETA once daily
            • Premplus continuous 0.625mg CE + 2.5mg MPA (or 5mg MPA) once daily
            • Premplus cycle 0.625mg CE + 10mg MPA 2 tabs once daily
        • If post-hysterectomy (no need for endometrial protection), estrogen only
        • If comorbidities (Diabetes mellitus, HTN, smoking, obesity, DLP/CVD risk, gallstones), Transdermal preparation recommended
      • Consider off-label transdermal testosterone therapy for menopausal women with low sexual desire if HRT alone is not effective
      • Consider tissue-selective estrogen complexes (eg. Duavive) for breast/endometrial safety
      • Non-hormonal (Clonidine, Pregabalin, SSRI, SNRI) are second-line, if failed HRT or contraindicated
    • GSM
      • Water-based lubricants/moisturizer (equivalent to vaginal estrogen in a recent RCT)
      • Vaginal estrogen (even if on systemic HRT)
        • Estradiol 10mcg intravaginal tablet (Vagifem) daily x 2 weeks, then twice per week
        • Estradiol 2mg intravaginal ring (Estring) in place for 90 days
        • Estradiol 0.1mg/g cream (Estrace) 2-4g daily x 1-2w, then half dose 1-2 weeks, then maintenance dose of 1g 1-3x/week
        • Conjugated estrogens 0.625mg/g cream (Premarin), dose 0.5-2g cream twice weekly (or cyclic 21 days on, 7 days off)
    • CBT for mood and anxiety
    • Limited evidence (efficacy and safety) for complementary and alternative medicine