Menopause and menopausal hormone therapy: NICE NG23 and the IMS framework

A 51-year-old sits in your clinic drenched in night sweats, sleeping two hours, snapping at her children, and terrified of HRT because her mother "read about it causing breast cancer in 2002". Your job is not to reassure her generically or to hand her a script — it is to diagnose clinically, characterise the symptom burden, lay out the real risk-benefit numbers from the WHI and what came after, and individualise the HRT choice to her uterus, her VTE risk and her age. The 2002 WHI headline damaged a generation of women's care; understanding what it actually showed is the whole fellowship answer.^[2][8]

Overview and definition

Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, confirmed after 12 months of amenorrhoea in a woman over 45 with no other cause. NICE NG23 makes the diagnosis clinically in this group — you do not need a blood test, and ordering one is a common error.^[8][14]

The clinically useful distinctions are:^[1][8]

• Perimenopause (the menopausal transition) — the years around menopause: cycle irregularity and vasomotor symptoms. A woman still having periods can be perimenopausal and symptomatic.
• Natural menopause — typically between 45 and 56 years, median around 51.
• Early menopause — between 40 and 44.
• Premature ovarian insufficiency (POI) — under 40. This is a different condition with a different risk-benefit calculation; cross-link the POI topic.

^{[1] [9]}

References14ShowHide

1. [1]Crandall CJ, Mehta JM, Manson JE Management of Menopausal Symptoms: A Review. JAMA, 2023.PMID 36749328
2. [2]Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA, 2002.PMID 12117397
3. [3]Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA, 2004.PMID 15082697
4. [4]Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA, 2017.PMID 28898378
5. [5]Hodis HN, Mack WJ, Henderson VW, et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N Engl J Med, 2016.PMID 27028912
6. [6]Canonico M, Oger E, Plu-Bureau G, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation, 2007.PMID 17309934
7. [7]Chlebowski RT, Rohan TE, Manson JE, et al. Breast Cancer After Use of Estrogen Plus Progestin and Estrogen Alone: Analyses of Data From 2 Women's Health Initiative Randomized Clinical Trials. JAMA Oncol, 2015.PMID 26181174
8. [8]Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner's Toolkit for Managing Menopause. Climacteric, 2023.PMID 37902335
9. [9]Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med, 2015.PMID 25686030
10. [10]Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Maturitas, 2014.PMID 25179577
11. [11]The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022.PMID 35797481
12. [12]Handley AP, Williams M The efficacy and tolerability of SSRI/SNRIs in the treatment of vasomotor symptoms in menopausal women: a systematic review. J Am Assoc Nurse Pract, 2015.PMID 24944075
13. [13]Ayers B, Smith M, Hellier J, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause, 2012.PMID 22336748
14. [14]Panay N, Anderson RA, Nappi RE, et al. Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric, 2020.PMID 32896176