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gyn.menopause-management.core.v1PRODUCTION
gyn.menopause-management.core.v1

Menopause & vasomotor-symptom management (MHT & non-hormonal)

obstetricschronicadultgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Menopause management is a person-centred BENEFIT/RISK ELIGIBILITY decision over symptom domains (vasomotor, GSM, sleep, mood, long-term bone/CV), staged by STRAW+10 and gated by the MHT timing hypothesis × route × progestogen rule — not a single disease (NAMS HT 2022 PMID 35797481; Harlow 2012 PMID 22344196). BAYESIAN CONDITIONAL #1 (VMS-cause prior | age + menstrual pattern): the pre-test probability that midlife VMS = the menopausal transition is NOT fixed — it is conditioned on age band and STRAW+10 menstrual pattern. Prior ≈0.85–0.90 when age ≥45 y AND ≥60-day amenorrhoea/late-transition pattern AND typical hot flushes (VMS ~80% prevalence, persist median >7 y — Wang 2025 PMID 40049806); prior falls to ≈0.30–0.40 when age <40 y (POI competes — route OUT) or when menstrual cycles remain regular with isolated sweats (thyroid / drug-induced / anxiety mimics rise). The clinical-diagnosis LR is therefore evaluated AGAINST this conditioned prior, not a flat prior

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STRAW+10 stage assigned and the symptom-domain inventory framed against the timing-hypothesis structure

Patient inputs (15)

Age <60 vs ≥60 is half of the MHT timing hypothesis; age <40 raises the POI prior; ≥45 with typical symptoms makes the diagnosis clinical (NAMS HT 2022; NICE NG23)

<10 y vs >10 y since FMP is the other half of the timing hypothesis — drives systemic-MHT benefit/risk (NAMS HT 2022 PMID 35797481; ELITE Karim 2022)

STRAW+10 menstrual criteria stage the transition and anchor the clinical diagnosis without biochemistry (Harlow 2012 PMID 22344196)

Uterus present → progestogen MANDATORY with systemic estrogen for endometrial protection; hysterectomy → estrogen-alone (WHI PMID 12117397; NAMS HT 2022)

Bothersome moderate–severe VMS is the principal T_treat driver for systemic MHT or the non-hormonal ladder (NAMS HT 2022; NAMS Nonhormone 2023)

Current/prior breast or other estrogen-sensitive cancer is an absolute/relative contraindication to systemic estrogen → non-hormonal ladder; vaginal estrogen only with oncology input (NAMS HT 2022; NAMS GSM 2020)

Prior VTE, stroke, or CHD makes systemic estrogen (esp. oral) a contraindication; if MHT still pursued, transdermal is preferred (lower VTE/stroke signal) (NAMS HT 2022; WHI PMID 12117397)

Combined hormonal contraception confounds FSH interpretation and overlaps the perimenopausal transition; enzyme inducers/SSRIs interact — drives cross-ref to contraception engine (NICE NG23; Harlow 2012)

Unexplained / postmenopausal bleeding must be investigated (endometrial cancer) BEFORE starting MHT — a hard red flag (NAMS HT 2022; ACOG)

FSH/AMH ONLY when clinical dx insufficient — POI <40, post-hysterectomy, or contraceptive overlap; low incremental value when ≥45 y with typical symptoms (NICE NG23; Harlow 2012)

GSM (dryness/dyspareunia/urinary) is treated with local therapy INDEPENDENT of systemic MHT eligibility (NAMS GSM 2020 PMID 32852449)

Active liver disease contraindicates oral estrogen (first-pass); transdermal may be considered with hepatology input (NAMS HT 2022)

Obesity, thrombophilia, smoking, migraine, hypertriglyceridaemia shift estrogen route to transdermal (the route conditional) (NAMS HT 2022; ELITE serum-E2 PMID 32925623)

Thyroid dysfunction mimics VMS/mood/sleep — exclude as a reversible MECE alternative (NICE NG23; cross-ref endo.hypothyroidism.core.v1)

Baseline BP before systemic MHT; uncontrolled HTN modifies route/eligibility and overlaps US-MEC if perimenopausal contraception is in play (NAMS HT 2022; US-MEC overlap)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningacute_vte_or_arterial_event_on_mht
    New VTE, stroke, TIA, or acute coronary event in a woman on systemic estrogen (NAMS HT 2022; WHI PMID 12117397)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunexplained_postmenopausal_bleeding
    Unexplained / postmenopausal vaginal bleeding (on or off MHT) — endometrial cancer must be excluded before/continuing estrogen (NAMS HT 2022; ACOG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereestrogen_sensitive_cancer_or_strong_contraindication
    Current/prior breast (or other estrogen-sensitive) cancer, or prior VTE/stroke/CHD, or active liver disease — systemic estrogen contraindicated (NAMS HT 2022; NAMS GSM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogestogen_omitted_with_uterus_on_systemic_estrogen
    Systemic estrogen prescribed/continued WITHOUT a progestogen in a woman with an intact uterus (endometrial hyperplasia/cancer risk) (WHI PMID 12117397; NAMS HT 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemht_timing_window_unfavourable
    Request for systemic MHT in a woman >60 y or >10 y since FMP (timing hypothesis unfavourable) (NAMS HT 2022 PMID 35797481; Manson 2017 PMID 28898378)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepremature_ovarian_insufficiency_under_40
    Amenorrhoea + vasomotor symptoms before age 40 — premature ovarian insufficiency, NOT standard menopause (Harlow 2012 PMID 22344196)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_mht_deprescribing_review
    Woman ≥65 y (or ≥10 y of continuous MHT) on systemic estrogen ± high anticholinergic burden (e.g. oxybutynin) — geriatric STOPP/START deprescribing review of MHT and the non-hormonal stack (NAMS HT 2022; Heiss 2008 PMID 18319414)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildperimenopausal_still_fertile_contraception_transition
    Symptomatic perimenopausal woman still requiring contraception (not yet 12-mo amenorrhoeic / age <55) — needs a deliberate CHC→MHT transition plan and US-MEC eligibility check (NICE NG23; CDC US-MEC)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Systemic menopausal hormone therapy — timing-hypothesis × route × mandatory-progestogen gated (NAMS HT 2022 PMID 35797481)
axis: systemic_mht_timing_route_progestogen_gated
Selected axis "Systemic menopausal hormone therapy — timing-hypothesis × route × mandatory-progestogen gated (NAMS HT 2022 PMID 35797481)" by default fallback (first axis)
  • estradiol (transdermal patch / gel / spray)
    first line
    systemic_estrogen_transdermal
    lowest effective transdermal dose (e.g. 25–50 mcg/24h patch), titrate to symptom control • transdermal • patch twice weekly / gel daily
    triggers: within_timing_window, vte_or_stroke_risk_factors, migraine, hypertriglyceridemia, obesity, no_estrogen_sensitive_cancer
    NAMS HT 2022 — transdermal estrogen carries LOWER VTE/stroke signal than oral (no first-pass thrombotic activation); preferred route when any thrombotic/migraine/metabolic modifier present. rxcui 4096 = estradiol (in-repo validated, uro vaginal-estrogen dossiers); transdermal MHT-specific product code OMITTED (no in-repo precedent)
    rxcui 24395
  • estradiol / conjugated equine estrogens (oral)
    second line
    systemic_estrogen_oral
    lowest effective oral dose (e.g. estradiol 1 mg or CEE 0.3–0.625 mg daily) • PO • once daily
    triggers: within_timing_window, no_thrombotic_or_metabolic_route_modifier, patient_preference_oral, no_estrogen_sensitive_cancer
    NAMS HT 2022 — effective for VMS; WHI used CEE 0.625 mg (PMID 12117397: CHD HR 1.29 [1.02–1.63], stroke 1.41 [1.07–1.85], PE 2.13 [1.39–3.25] at mean age 63 — drove the timing reinterpretation). Reserve oral when no thrombotic/metabolic modifier. rxcui OMITTED — no in-repo precedent for oral estradiol/CEE MHT products
  • micronized progesterone
    comorbidity specific
    progestogen_endometrial_protection
    100 mg nightly (continuous-combined) or 200 mg ×12–14 d/mo (sequential) • PO • nightly or cyclical
    triggers: uterus_present, on_systemic_estrogen, preferred_progestogen_for_breast_metabolic_profile
    NAMS HT 2022 — endometrial protection is MANDATORY with systemic estrogen when a uterus is present; micronized progesterone preferred for the breast/metabolic profile vs MPA. ELITE used vaginal micronized progesterone with oral E2 if uterus (PMID 35474254). rxcui OMITTED — no in-repo precedent
    rxcui 8727
  • medroxyprogesterone acetate / LNG-IUS (alternative progestogens)
    comorbidity specific
    progestogen_endometrial_protection
    MPA 2.5 mg daily (continuous) or LNG-IUS 52 mg in situ • PO or intrauterine • daily or in situ (LNG-IUS up to 5 y)
    triggers: uterus_present, on_systemic_estrogen, micronized_progesterone_intolerant, wants_intrauterine_progestogen
    NAMS HT 2022 — alternative endometrial-protection progestogens; WHI CEE+MPA arm (PMID 12117397) is the canonical absolute-risk dataset; LNG-IUS gives local endometrial protection with the lowest systemic progestogen exposure. rxcui OMITTED — no in-repo precedent for medroxyprogesterone (consistent with gyn.abnormal-uterine-bleeding.core.v1)
  • tibolone (where available — synthetic STEAR)
    add on
    selective_tissue_estrogenic_activity_regulator
    2.5 mg daily • PO • once daily
    triggers: within_timing_window, wants_combined_estrogenic_progestogenic_androgenic_single_agent, uterus_present_no_separate_progestogen_needed
    NAMS HT 2022 / IMS — single-agent option (not available in the US); not for women with prior breast cancer (increased recurrence). rxcui OMITTED — no in-repo precedent
    rxcui 38260

outpatient playbook — drug actions (5)

  1. 1. transdermal estradiol (+ progestogen if uterus)
    lowest effective transdermal dose; micronized progesterone 100 mg nightly if uterus • transdermal + PO • patch twice weekly + progesterone nightly
    trigger: Bothersome VMS within timing window, no contraindication, any thrombotic/metabolic route modifier
    First-line systemic MHT, route-optimised, with mandatory endometrial protection (NAMS HT 2022)
  2. 2. oral estradiol/CEE (+ progestogen if uterus)
    estradiol 1 mg or CEE 0.3–0.625 mg daily + progestogen if uterus • PO • once daily
    trigger: Within window, no thrombotic/metabolic modifier, oral preference
    Effective alternative when no route modifier (WHI PMID 12117397)
  3. 3. fezolinetant
    45 mg once daily • PO • once daily
    trigger: MHT contraindicated/declined and bothersome VMS
    Targeted non-hormonal first-line (NAMS Nonhormone 2023; Santoro 2025 PMID 40044127)
  4. 4. paroxetine 7.5 mg / venlafaxine / escitalopram
    paroxetine 7.5 mg qHS; venlafaxine XR 37.5–75 mg; escitalopram 10–20 mg • PO • once daily
    trigger: Fezolinetant unsuitable, or coexisting mood disorder
    Paroxetine 7.5 mg only FDA-approved non-hormonal; ~50 % vs ~30 % placebo VMS reduction (MsFLASH PMID 31977667)
  5. 5. low-dose vaginal estrogen (GSM)
    estradiol 10 mcg tablet twice weekly after induction • topical_vaginal • twice weekly
    trigger: Moderate–severe GSM (independent of systemic eligibility)
    GSM track is independent of systemic-MHT eligibility; no added progestogen needed (NAMS GSM 2020)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Hot flushes / night sweats (vasomotor symptoms) in a midlife woman (NAMS HT 2022); Vaginal dryness / dyspareunia / urinary symptoms — genitourinary syndrome of menopause (NAMS GSM 2020); Cycle-length variability / skipped periods (menopausal transition) (STRAW+10 Harlow 2012).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Menopause & vasomotor-symptom management (MHT & non-hormonal)** (gyn.menopause-management.core.v1).
Phenotype framing: MECE: perimenopause/menopause vs thyroid dysfunction (TSH) vs premature ovarian insufficiency (age <40 — route to POI) vs anxiety/depression (mood-predominant, VMS-poor) vs medication-induced flushing/sweats (SSRI, opioids, niacin, tamoxifen, GnRH agonist). VMS + cycle change + age ≥45 with normal TSH = menopause; isolated GSM is treated locally regardless of the systemic differential (NICE NG23; NAMS GSM 2020)
Scope: Menopause management is a person-centred BENEFIT/RISK ELIGIBILITY decision over symptom domains (vasomotor, GSM, sleep, mood, long-term bone/CV), staged by STRAW+10 and gated by the MHT timing hypothesis × route × progestogen rule — not a single disease (NAMS HT 2022 PMID 35797481; Harlow 2012 PMID 22344196). BAYESIAN CONDITIONAL #1 (VMS-cause prior | age + menstrual pattern): the pre-test probability that midlife VMS = the menopausal transition is NOT fixed — it is conditioned on age band and STRAW+10 menstrual pattern. Prior ≈0.85–0.90 when age ≥45 y AND ≥60-day amenorrhoea/late-transition pattern AND typical hot flushes (VMS ~80% prevalence, persist median >7 y — Wang 2025 PMID 40049806); prior falls to ≈0.30–0.40 when age <40 y (POI competes — route OUT) or when menstrual cycles remain regular with isolated sweats (thyroid / drug-induced / anxiety mimics rise). The clinical-diagnosis LR is therefore evaluated AGAINST this conditioned prior, not a flat prior

No severity triggers fired against current inputs.

Plan

Regimen axis: **Systemic menopausal hormone therapy — timing-hypothesis × route × mandatory-progestogen gated (NAMS HT 2022 PMID 35797481)**.
1. estradiol (transdermal patch / gel / spray) lowest effective transdermal dose (e.g. 25–50 mcg/24h patch), titrate to symptom control transdermal patch twice weekly / gel daily (systemic_estrogen_transdermal, first line) — NAMS HT 2022 — transdermal estrogen carries LOWER VTE/stroke signal than oral (no first-pass thrombotic activation); preferred route when any thrombotic/migraine/metabolic modifier present. rxcui 4096 = estradiol (in-repo validated, uro vaginal-estrogen dossiers); transdermal MHT-specific product code OMITTED (no in-repo precedent)
2. estradiol / conjugated equine estrogens (oral) lowest effective oral dose (e.g. estradiol 1 mg or CEE 0.3–0.625 mg daily) PO once daily (systemic_estrogen_oral, second line) — NAMS HT 2022 — effective for VMS; WHI used CEE 0.625 mg (PMID 12117397: CHD HR 1.29 [1.02–1.63], stroke 1.41 [1.07–1.85], PE 2.13 [1.39–3.25] at mean age 63 — drove the timing reinterpretation). Reserve oral when no thrombotic/metabolic modifier. rxcui OMITTED — no in-repo precedent for oral estradiol/CEE MHT products
3. micronized progesterone 100 mg nightly (continuous-combined) or 200 mg ×12–14 d/mo (sequential) PO nightly or cyclical (progestogen_endometrial_protection, comorbidity specific) — NAMS HT 2022 — endometrial protection is MANDATORY with systemic estrogen when a uterus is present; micronized progesterone preferred for the breast/metabolic profile vs MPA. ELITE used vaginal micronized progesterone with oral E2 if uterus (PMID 35474254). rxcui OMITTED — no in-repo precedent
4. medroxyprogesterone acetate / LNG-IUS (alternative progestogens) MPA 2.5 mg daily (continuous) or LNG-IUS 52 mg in situ PO or intrauterine daily or in situ (LNG-IUS up to 5 y) (progestogen_endometrial_protection, comorbidity specific) — NAMS HT 2022 — alternative endometrial-protection progestogens; WHI CEE+MPA arm (PMID 12117397) is the canonical absolute-risk dataset; LNG-IUS gives local endometrial protection with the lowest systemic progestogen exposure. rxcui OMITTED — no in-repo precedent for medroxyprogesterone (consistent with gyn.abnormal-uterine-bleeding.core.v1)
5. tibolone (where available — synthetic STEAR) 2.5 mg daily PO once daily (selective_tissue_estrogenic_activity_regulator, add on) — NAMS HT 2022 / IMS — single-agent option (not available in the US); not for women with prior breast cancer (increased recurrence). rxcui OMITTED — no in-repo precedent

Setting playbook (outpatient) — Stage with STRAW+10, diagnose clinically, inventory symptom domains, apply the MHT timing/route/progestogen conditional, and deliver the eligible regimen (systemic MHT / non-hormonal / GSM local) with shared decision-making and a duration plan (NAMS HT 2022; NAMS Nonhormone 2023; NAMS GSM 2020)
6. transdermal estradiol (+ progestogen if uterus) lowest effective transdermal dose; micronized progesterone 100 mg nightly if uterus transdermal + PO patch twice weekly + progesterone nightly — Bothersome VMS within timing window, no contraindication, any thrombotic/metabolic route modifier (First-line systemic MHT, route-optimised, with mandatory endometrial protection (NAMS HT 2022))
7. oral estradiol/CEE (+ progestogen if uterus) estradiol 1 mg or CEE 0.3–0.625 mg daily + progestogen if uterus PO once daily — Within window, no thrombotic/metabolic modifier, oral preference (Effective alternative when no route modifier (WHI PMID 12117397))
8. fezolinetant 45 mg once daily PO once daily — MHT contraindicated/declined and bothersome VMS (Targeted non-hormonal first-line (NAMS Nonhormone 2023; Santoro 2025 PMID 40044127))
9. paroxetine 7.5 mg / venlafaxine / escitalopram paroxetine 7.5 mg qHS; venlafaxine XR 37.5–75 mg; escitalopram 10–20 mg PO once daily — Fezolinetant unsuitable, or coexisting mood disorder (Paroxetine 7.5 mg only FDA-approved non-hormonal; ~50 % vs ~30 % placebo VMS reduction (MsFLASH PMID 31977667))
10. low-dose vaginal estrogen (GSM) estradiol 10 mcg tablet twice weekly after induction topical_vaginal twice weekly — Moderate–severe GSM (independent of systemic eligibility) (GSM track is independent of systemic-MHT eligibility; no added progestogen needed (NAMS GSM 2020))

Non-pharmacologic actions:
- CBT / clinical hypnosis for VMS interference and CBT-I for menopausal insomnia (NAMS Nonhormone 2023; MsFLASH PMID 31977667)
- Weight loss counselling if overweight (NAMS Nonhormone 2023 Level II–III)
- Non-hormonal vaginal moisturiser + lubricant for mild GSM (NAMS GSM 2020)
- Counsel AGAINST paced respiration / supplements / clonidine / pregabalin for VMS (ineffective) (NAMS Nonhormone 2023)
- Bone-health and CV-risk modification; age-appropriate breast screening (NAMS HT 2022; cross-ref endo.osteoporosis.core.v1)

AVOID / contraindication checks:
- Absolute contraindication systemic estrogen if current estrogen sensitive cancer or prior VTE stroke CHD or active liver disease or unexplained bleeding (NAMS HT 2022)
- Progestogen MANDATORY with systemic estrogen if uterus present endometrial protection (WHI PMID 12117397; NAMS HT 2022)
- Prefer transdermal over oral estrogen if VTE stroke migraine hypertriglyceridemia or obesity (NAMS HT 2022)
- Timing hypothesis unfavourable if age over 60 or over 10y since FMP prefer non hormonal (NAMS HT 2022 PMID 35797481; Manson 2017 PMID 28898378)
- Investigate postmenopausal bleeding for endometrial cancer before initiating MHT (NAMS HT 2022; ACOG)
- Avoid tibolone and systemic estrogen in breast cancer survivors use non hormonal and oncology input (NAMS HT 2022; NAMS GSM 2020)
- Compounded bioidentical hormones not recommended unmonitored purity dose endometrial risk (NAMS HT 2022)

Monitoring

Regimen monitoring:
- benefit risk re evaluation at <=3 months then at least annually (NAMS HT 2022)
- BP weight breast awareness age appropriate mammography (NAMS HT 2022)
- any new or breakthrough bleeding investigated (NAMS HT 2022; ACOG)
- VTE CV symptom screen each visit (WHI PMID 12117397)
- achieved estrogen exposure varies with BMI alcohol smoking individualise (ELITE serum-E2 PMID 32925623)
- deliberate duration and deprescribing conversation each review (NAMS HT 2022; Heiss 2008 PMID 18319414)

Setting (outpatient) monitoring:
- Benefit/risk re-evaluation at ≤3 months then ≥annually (NAMS HT 2022)
- VMS/GSM response at 4–12 weeks; any new bleeding investigated (NAMS HT 2022; NAMS GSM 2020)
- BP, weight, breast awareness, VTE/CV symptom screen (WHI PMID 12117397)
- Deliberate duration / de-prescribing conversation each review (Heiss 2008 PMID 18319414)

Follow-up plan: Long-term: there is no fixed mandatory stop date — continue for documented persistent VMS with shared decision-making and periodic re-evaluation; attempt taper/withdrawal trials and reassess. Bone health → cross-ref endo.osteoporosis.core.v1 (MHT is bone-protective but not first-line solely for bone if >60 y). Perimenopausal contraception transition (still fertile until 12 mo amenorrhoea / age ~55) → gyn.contraception-management.core.v1. CV risk modification; breast-cancer surveillance; return precautions (new bleeding, breast change, focal neurology, calf swelling) (NAMS HT 2022; Heiss 2008 PMID 18319414)
- Close-out criterion: Long-term duration/de-prescribing plan, bone + CV + breast surveillance, and cross-engine transitions booked

Monitoring phase: Re-evaluate benefit/risk at ≤3 months after starting then at least annually: VMS response, GSM response, BP, weight, breast awareness/age-appropriate mammography, any new bleeding (investigate), VTE/CV symptom screen, and a deliberate duration/de-prescribing conversation. Achieved estrogen exposure varies with BMI/alcohol/smoking — individualise (ELITE serum-E2 PMID 32925623; NAMS HT 2022). Non-hormonal: efficacy + tolerability (SSRI/SNRI ~50 % vs ~30 % placebo VMS reduction — MsFLASH PMID 31977667)

Disposition

Current setting: outpatient — Stage with STRAW+10, diagnose clinically, inventory symptom domains, apply the MHT timing/route/progestogen conditional, and deliver the eligible regimen (systemic MHT / non-hormonal / GSM local) with shared decision-making and a duration plan (NAMS HT 2022; NAMS Nonhormone 2023; NAMS GSM 2020)

Disposition criteria:
- Continue outpatient with individualised regimen and duration plan (NAMS HT 2022)
- Refer gynaecology/menopause specialist for complex contraindications or refractory VMS; oncology for vaginal-estrogen decisions in cancer survivors (NAMS GSM 2020)
- Route POI<40 and perimenopausal-contraception questions to the dedicated engines

Escalation triggers (move to higher acuity):
- Unexplained / postmenopausal bleeding → urgent endometrial evaluation, withhold MHT (NAMS HT 2022; ACOG)
- New VTE / stroke / CHD event on MHT → stop estrogen, acute evaluation (WHI PMID 12117397)
- Treatment-resistant severe VMS despite optimised therapy → menopause-specialist referral (NAMS HT 2022)
- Amenorrhoea + VMS before age 40 → POI pathway, not standard menopause (Harlow 2012)

Patient Action Plan

**Menopause symptom & MHT self-management plan**
Personalised values: regimen_type_and_route, has_uterus_progestogen_status, mht_timing_eligibility, gsm_local_therapy, deprescribing_target_date.

**Stable — symptoms controlled, on plan** (green):
Triggers:
- Vasomotor symptoms well controlled on current regimen
- No abnormal vaginal bleeding
- Taking estrogen + progestogen (if uterus) / non-hormonal therapy as prescribed
Actions:
- Take MHT (and the progestogen if you have a uterus) exactly as prescribed — do not skip the progestogen (NAMS HT 2022)
- Keep your annual benefit-risk review and age-appropriate mammogram (NAMS HT 2022)
- Continue vaginal moisturiser/estrogen for dryness — it works locally and is separate from MHT (NAMS GSM 2020)
- Discuss any new medication with your prescriber

**Caution — symptoms returning or side-effects** (yellow):
Triggers:
- Hot flushes / night sweats returning or worsening
- Breast tenderness, bloating, mood change, or irregular spotting in the first months
- Missed doses
Actions:
- Do not stop abruptly — book a review to adjust dose/route or switch therapy (NAMS HT 2022)
- For night-predominant symptoms, ask about timing or a non-hormonal option (NAMS Nonhormone 2023)
- Track symptoms and bring the record to your appointment
Contact provider when:
- Symptoms not controlled after a reasonable trial
- Persistent or new irregular bleeding beyond the first few months
- Bothersome side-effects

**Medical alert — stop and seek care** (red):
Triggers:
- Any vaginal bleeding after menopause (or unexpected heavy/persistent bleeding) (NAMS HT 2022; ACOG)
- Calf pain/swelling, sudden breathlessness or chest pain (possible clot) (WHI PMID 12117397)
- Sudden severe headache, weakness, slurred speech, or vision loss (possible stroke)
- New breast lump
Actions:
- Stop the estrogen and seek urgent medical care now
- For suspected clot or stroke, go to the emergency department immediately
- Tell the clinician you are on menopausal hormone therapy and bring your medication list
Contact provider when:
- Always seek emergency care for clot/stroke symptoms; urgent review for any postmenopausal bleeding or new breast lump (NAMS HT 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New VTE, stroke, TIA, or acute coronary event in a woman on systemic estrogen (NAMS HT 2022; WHI PMID 12117397)
- [SEVERE] Unexplained / postmenopausal vaginal bleeding (on or off MHT) — endometrial cancer must be excluded before/continuing estrogen (NAMS HT 2022; ACOG)
- [SEVERE] Current/prior breast (or other estrogen-sensitive) cancer, or prior VTE/stroke/CHD, or active liver disease — systemic estrogen contraindicated (NAMS HT 2022; NAMS GSM 2020)

Citations

- 2022 NAMS Hormone Therapy Position Statement + 2023 NAMS Nonhormone Therapy Position Statement + 2020 NAMS Genitourinary Syndrome of Menopause Position Statement; STRAW+10 (Harlow 2012); NICE NG23; ACOG / Endocrine Society / IMS aligned [PMID:35797481](https://pubmed.ncbi.nlm.nih.gov/35797481/)
- Cited evidence (PMID 36270315) [PMID:36270315](https://pubmed.ncbi.nlm.nih.gov/36270315/)
- Cited evidence (PMID 37252752) [PMID:37252752](https://pubmed.ncbi.nlm.nih.gov/37252752/)
- Cited evidence (PMID 32852449) [PMID:32852449](https://pubmed.ncbi.nlm.nih.gov/32852449/)
- Cited evidence (PMID 22344196) [PMID:22344196](https://pubmed.ncbi.nlm.nih.gov/22344196/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 2022 NAMS Hormone Therapy Position Statement + 2023 NAMS Nonhormone Therapy Position Statement + 2020 NAMS Genitourinary Syndrome of Menopause Position Statement; STRAW+10 (Harlow 2012); NICE NG23; ACOG / Endocrine Society / IMS aligned — PMID:35797481
  • Cited evidence (PMID 36270315) — PMID:36270315
  • Cited evidence (PMID 37252752) — PMID:37252752
  • Cited evidence (PMID 32852449) — PMID:32852449
  • Cited evidence (PMID 22344196) — PMID:22344196