Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Society of Endocrinology.

Evaluation and Management of Menopause and the Perimenopause

European Society of Endocrinology

Publication Date: Oct 13, 2025

Page Last Updated: May 6, 2026

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 (⊕○○○)

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Grading System

GRADE Classification of Guideline Recommendations

Certainty of Evidence	Interpretation
High ⊕⊕⊕⊕	There is high confidence that the true value of the estimate of interest is on one side of a threshold of interest or within a specific range.
Moderate ⊕⊕⊕o	There is moderately confidence that the true value of the estimate of interest is on one side of a threshold of interest or within a certain range. The true value of the estimate may deviate slightly from the target of the certainty rating (i.e. may possibly fall in a different range).
Low ⊕⊕oo	There is low confidence that the true value of the estimate of interest is on one side of a threshold of interest or within a certain range. The true value of the estimate may deviate from the target of the certainty rating (i.e. likely fall in a different range).
Very Low ⊕ooo	There is very-low confidence that the true value of the estimate of interest is on one side of a threshold of interest or within a certain range. The true value of the estimate may deviate significantly from target of the certainty rating (i.e. probably fall in a different range).

Adapted with permission from Neumann I, Schünemann H (Editors). The GRADE Book version 1.0 (updated September 2024). The GRADE Working Group.

GRADE Strength of Recommendation Classifications and Interpretation

Strength of recommendation	Criteria	Interpretation by individuals	Interpretation by health care providers	Interpretation by policy makers
1 – Strong recommendation for or against	Desirable consequences CLEARLY OUTWEIGH the undesirable consequences in most settings (or vice versa).	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	Most individuals should follow the recommended course of action. Formal decision aids are not likely to be needed to help individual individuals make decisions consistent with their values and preferences.	The recommendation can be adopted as policy in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.
2 – Conditional recommendation for or against	Desirable consequences PROBABLY OUTWEIGH undesirable consequences in most settings (or vice versa).	The majority of individuals in this situation would want the suggested course of action, but many would not. Decision aids may be useful in helping individuals make decisions consistent with their individual risks, values and preferences.	Clinicians should recognize that different choices will be appropriate for each individual and that clinicians must help each individual arrive at a management decision consistent with the individual’s values and preferences.	Policy-making will require substantial debate and involvement of various stakeholders. Performance measures should assess whether decision making is appropriate.

Source: Reprinted from Schünemann HJ, et al. Blood Adv, 2018; 2(22):3198–3225
© The American Society of Hematology, published by Elsevier.

Document Overview

Document Title: Evaluation and Management of Menopause and the Perimenopause

Authoring Society: European Society of Endocrinology

Endorsing Societies

Endocrine Society

European Menopause and Andropause Society

Document Publication Date: Oct 13, 2025

Page Last Reviewed/Updated: May 6, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: academic.oup.com/ejendo/article/193/4/G49/8281862

Source Citation: Mary Ann Lumsden, Olaf M Dekkers, Stephanie S Faubion, Angelica Lindén Hirschberg, Channa N Jayasena, Irene Lambrinoudaki, Yvonne Louwers, JoAnn V Pinkerton, Antoan Stefan Sojat, Leonie van Hulsteijn, European Society of Endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause, European Journal of Endocrinology, Volume 193, Issue 4, October 2025, Pages G49–G81, https://doi.org/10.1093/ejendo/lvaf206

Document Scope, Criteria, and Use Cases

Document Objectives: The overall purpose of this guideline is to provide clinicians with practical guidance on the evaluation and management of women in menopause and beyond, including hormonal, non-hormonal, lifestyle, and psychosocial interventions, with an emphasis on patient-centred care. Gender-affirming hormonal therapy is not included within this guideline because the therapeutic goals and risks of therapy in transwomen are distinct to those of MHT for menopause. Women make up 51% of the world's population, and the global population of postmenopausal women is growing. About 25% of these women experience debilitating menopausal symptoms. Since it is important that all health care professionals have a fundamental knowledge of managing women presenting with symptoms related to the menopause, this European Society of Endocrinology Clinical Practice Guideline was developed. It provides guidance on evaluation and optimal clinical management of women who go through the menopause in middle age, those with Premature Ovarian Insufficiency (POI), Early Menopause and those for whom hormones are not appropriate, including women with, or at high risk of, breast cancer. This guideline discusses the benefits and risks of hormone therapy administration as well as summarizing other treatments for menopausal symptoms. Further, the contentious issue of the impact of menopausal hormone therapy in the prevention of chronic disease is considered.

Scope: Assessment and Screening, Management

Keywords: Perimenopause, menopause, postmenopause

Target Patient Population: Women in perimenopause and beyond

Target Provider Population: Health care professionals who see women in (peri)menopause and beyond and who seek guidance for evaluation and management of these women

Inclusion Criteria: Female, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

PICO Questions

What is the efficacy of locally absorbed low dose oestrogen on sexual function, compared to systemically absorbed oestrogen or placebo?
What is the impact of different oestrogen dosages on fracture risk in peri/postmenopausal women?
What is the impact of progestogen monotherapy on menopausal symptoms?

Evaluation and Management of Menopause and the Perimenopause

Summary of Recommendations

Evaluation

Management

Specific Conditions

Figure 5. Evaluation and treatment algorithm

Table 2. Impact of progestogen monotherapy on menopausal symptoms

Table 4. Clinical assessments prior to introduction of HRT/MHT

Table 5. MHT/ HRT preparations and regimens

Table 6. Differential diagnosis for POI and early menopause

Table 3. Alternative non-pharmacological treatments

Grading System

GRADE Classification of Guideline Recommendations

GRADE Strength of Recommendation Classifications and Interpretation

Document Overview

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology