Menopause and Premature Ovarian Insufficiency
NICE guideline [NG23] Menopause: identification and management. Last updated: Nov 2024.
NICE CKS Menopause. Last revised: Apr 2025.
Background Information
Definition
| Term | Definition |
|---|---|
| Menopause | Biological stage where menstruation stops permanently due to loss of ovarian follicular activity
Usually happens between 45-55 y/o, mean age of menopause is 51 y/o |
| Early menopause | Menopause that happens between 40-45 y/o |
| Peri-menopause | The period before menopause, where there are irregular cycles of ovulation and menstruation |
| Post-menopause | The period after menstruation has not occurred for 12 consecutive months |
| Premature ovarian insufficiency (premature ovarian failure) | Transient or permanent loss of ovarian function before 40 y/o |
Menopause Guidelines
Investigation and Diagnosis
Clinical diagnosis (with no blood tests) of menopause if:
- ≥45 y/o, AND
- ≥12 months of amenorrhoea
For those with menopause associated symptoms <45 y/o → take 2 samples of serum FSH level to confirm the diagnosis:
- 40-44 y/o + menopause + ↑ FSH: early menopause
- <40 y/o + menopause + ↑ FSH: premature ovarian failure
Do not use FSH blood test to identify menopause in those using COCP or high-dose progestogen.
FSH levels can be unreliable in the presence of tamoxifen.
Management
Do not offer all the below routinely to patients, treat accordingly to what the patient presents with.
Vasomotor Symptoms
- 1st line: hormone replacement therapy (HRT)
- 2nd line: menopause-specific CBT (in addition to HRT or alone with HRT not appropriate)
- 3rd line: SSRIs / SNRIs / clonidine
Genitourinary Symptoms
- 1st line: vaginal oestrogen +/- non-hormonal vaginal moisturisers / lubricants
- Options of vaginal oestrogen: tablets, creams, pessaries, gels
- Vaginal tablets and creams should be used nightly for 2 weeks (3 weeks for pessary and gel) and then twice weekly (maintenance dose)
- Maintenance dosing is important as symptoms frequently recur on cessation
- 2nd line: non-hormonal vaginal moisturisers / lubricants alone
- 3rd line: vaginal prasterone
- 4th line: oral ospemifene
Vaginal oestrogen should be avoided in those with a personal history of breast cancer → offer non-hormonal vaginal moisturisers / lubricants as 1st line
However, NICE do state that vaginal oestrogen is likely to be safe in those with a personal history of oestrogen receptor -ve breast cancer.
Depressive Symptoms
Consider:
- HRT
- CBT
Sleep Problems
Consider menopause-specific CBT
Sexual Dysfunction
Consider testosterone supplementation if HRT alone is not effective.
Premature Ovarian Insufficiency
Investigation and Diagnosis
Diagnose premature ovarian insufficiency if:
- <40 y/o with menopause-associated symptoms, and
- ↑ FSH levels on 2 blood samples taken 4-6 weeks apart
Management
Offer sex steroid replacement in the form of HRT or COCP until 51 y/o (age of natural menopause)
References