Menopause toolkit updated – with major implications for clinical practice

Fiona Clark


Fiona Clark


Fiona Clark

The Practitioner’s Toolkit for Managing the Menopause has been revised. Here’s what’s new and what you need to know

It’s been almost a decade since the Practitioner’s Toolkit for Managing the Menopause was revised and much has changed, not just in the way we talk about it, but in the understanding of its effects on the body and the options available to treat symptoms.

The 2023 Toolkit is the work of an independent panel of experts led by Monash University’s Professor Susan Davis, and endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean Hailes for Women’s Health.

It reviewed guidelines, position and consensus statements published since 2014. Although there are differences across the globe in terms of recommended investigations, access to medications and costs, the panel said the “focus has been to recommend the minimum best care for all women.”

The reviews found many interesting things that have implications for the way we think about and treat various symptoms and conditions associated with the menopause.

A question of age

We tend to think 51.5 is the average age that menopause occurs in high income countries, with a range of 45-55 years. The 2014 Toolkit’s diagnostic algorithm classified women as postmenopausal if they were aged >56 years. However, the updated Toolkit has changed this.

“There is evidence that the age of menopause is increasing. Therefore, to be conservative, the updated algorithm now classifies women as postmenopausal if they are aged >58 years irrespective of symptoms,” the new version says.

At the other end of the spectrum, the Toolkit also points out that different ethnic groups may go through menopause much earlier, for example the average in India is 46.

This has flow on effects on the generally applied age definitions of early menopause and primary ovarian insufficiency (POI), which is something practitioners treating people from diverse backgrounds need to bear in mind.

Vasomotor symptoms just keep keeping on

The Toolkit also turned on its head the commonly touted mantra that only a few women will experience vasomotor symptoms more than a decade after menopause. The reviews found that 42% and 33% of women aged 60–64 years and 65–79 years, respectively, still have vasomotor symptoms which severely impact on their wellbeing.

Women with moderate to severe vasomotor symptoms are up to three times more likely to have moderate–severe depressive symptoms than other women, it stated, along with other common menopause-associated symptoms including anxiety, disturbed sleep, joint pain and vaginal dryness.

The Toolkit also dispelled another commonly held belief that vasomotor symptoms are purely a phenomena of western countries. The researchers found similar prevalences across the world including Japan, Bangladesh and Iran.

But there were differences with other symptoms in some countries. For example, people in Bangladesh and Nepal reported musculoskeletal pain as more problematic than vasomotor symptoms.

Depression vs low mood

When it came to menopause, mood and depression, the Toolkit caused controversy in the UK press, which ran headlines saying hormone replacement therapy should not be given to women who present with depressive symptoms, despite various guidelines recommending it.

The Toolkit stated: “Regarding mood, although menopause-associated anxiety and depressive symptoms (but not clinical depression) are generally considered indications for menopausal hormone therapy (MHT), systematic reviews and meta-analyses of randomised controlled trials found no benefit of estrogen therapy on depressive symptoms, alone or with a progestogen, over placebo in postmenopausal women. While benefits for perimenopausal women have been suggested, the data to support this are too scant to draw conclusions.”

The references cited showed that hormone replacement could be useful for mood issues that occur in perimenopause as they stabilised the fluctuating hormones, but there was no recommended dose. Post-menopause, it was not so effective. There are also questions about differentiating clinical depression from hormonal related mood issues, the upshot being that more research is needed.

Brain fog and cognitive impairment

Many women claim they experience brain fog and that MHT, particularly testosterone therapy helps, but the Toolkit states that impaired memory and concentration and cognitive complaints alone are not considered an indication because clinical trials to date have not demonstrated objective improvement in cognitive performance with MHT over placebo post menopause.

“Research regarding cognitive effects of MHT during the perimenopause is lacking and urgently required. Women frequently experience an array of other symptoms not listed that may or may not improve with MHT,” it adds.

Bone health

The current approach to fragility fractures was another area that the Toolkit suggested was doing a disservice to postmenopausal women.

“Guidance as to when postmenopausal women not requiring MHT for symptoms, but who have osteopenia, merit MHT to protect against fragility fracture is starkly absent in osteoporosis guidelines,” it stated.

It also said that relying on the Fracture Risk Assessment tool (FRAX) ‘lacked validity” and could mean women missing out on fracture preventing treatments.

Bone loss accelerates from the onset of a natural menopause transition, peaking at about 2 years after the final menstrual period with around 7.4% of bone loss for the lumbar spine and 5.8% for the femoral neck, they said.

The authors went on to suggest that the bone mineral density (BMD) T-score ≤ −2.5 may be off the mark and that “studies support a peripheral or hip T-score of −1.8 to be a useful indicator of increased fracture risk in postmenopausal women aged <65 years.”

“For postmenopausal women not identified as at high fracture risk by FRAX, no study to date has provided a clear T-score cut-off for the initiation of MHT solely for fracture prevention,” they explained.

They proposed a peripheral or femoral neck T-score of −1.8 as “a pragmatic, conservative, cut-off point after which fracture risk increases in postmenopausal women aged <65 years.”

While the individual’s BMI and time since menopause need to be taken into consideration when applying this cut off, they concluded that “MHT has been shown to prevent bone loss and fragility fractures in all postmenopausal women irrespective of BMD and other risk factors. In asymptomatic postmenopausal women aged <65 years with a T-score of −1.8 or less, MHT use is therefore likely to reduce future fractures, and for many the benefit will outweigh any potential risk.”

High doses of estrogen

The Toolkit also tackled the topic of high doses of MHT. Those who still report symptoms on high doses of oral MHT should try transdermal options. And if they don’t respond to high transdermal doses, other causes for their symptoms should be investigated, the authors wrote.

They warn against compounded products as they are not regulated or tested for safety or efficacy.

The Toolkit also reminds practitioners that:

  • No tests are required for people over the age of 45 as symptoms should suffice
  • There are metabolic effects associated with menopause as well as effects on the heart, brain, insulin and lipids
  • To review all women at menopause for CVD risk, diabetes, genitourinary symptoms and cancer screening
  • Lifestyle factors including exercise, weight reduction, stopping smoking and stress reduction are important
  • Endometrial protection is essential in non-hysterectomised women and for those who have recent severe endometriosis or a subtotal hysterectomy with possible endometrial tissue in the retained cervix
  • POI diagnosis requires FSH to be elevated and estradiol to be low on at least two occasions at least 4–6 weeks apart
  • Breast cancer is a contraindication for MHT

Check out the full resource here: The Practitioner’s Toolkit for the Management of the Menopause – Australasian Menopause Society

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Fiona Clark


Fiona Clark


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