Menopause Management

Last Updated: September 15, 2025

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This tool is designed to support primary care clinicians in screening, diagnosing and implementing treatment for women and people experiencing perimenopause, menopause and post-menopause. Although a natural transition, menopause is often under-recognized in healthcare and can have a significant impact on a person’s life and long-term health. Primary care is an important setting to normalize this life stage, provide evidence-based care, and reduce the stigma surrounding it.

Important Considerations

  • Symptoms are common and can be long-lasting. The average age of menopause onset is 51, with 90% of women experiencing it between the ages of 45 and 56. Vasomotor symptoms (VMS) affect about 80% of women and can last for an average of 7-11 years. Genitourinary Syndrome of Menopause (GSM) affects 45-77% of women, with symptoms that often worsen over time and persist if untreated.
  • Menopause affects half the population, yet many are unprepared for it. 50% of people will experience menopause, but 46% of Canadian women feel unprepared for this stage.
  • The economic and personal costs of unmanaged symptoms are significant. An estimated 1 in 10 women leave the workforce due to unmanaged symptoms, resulting in an annual economic loss of $3.5 billion. The personal toll includes lost income, stalled career progression, and reduced self-esteem.
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Assessment New

The menopause journey

  • Perimenopause, also known as “the menopause transition”, begins when people experience menopause-associated symptoms and/or can be accompanied by changes in their menstrual cycle. It is an important time for preventative care, as it can be associated with increased risk of cardiovascular disease and bone loss (NICE, OH). It is not unusual for this stage to be 10 years or more.
  • Menopause is when a person has not had a period for at least 12 months and is not on hormonal contraception.
  • Premature menopause occurs when menopause happens before the age of 40.
  • Early menopause occurs between ages 40 and 45.
  • Post-menopause refers to the time of life from the day of menopause until the end of life.
  • Menopause can also be induced either surgically (e.g. bilateral oophorectomy) or medically (e.g. chemotherapy, radiation) (SOGC).

The term women and people experiencing perimenopause and menopause is inclusive of all individuals who will experience perimenopause and menopause, including women, Two-Spirit people, trans men, and nonbinary people assigned female at birth. (OHQS)

Talking tips
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The menopause journey

“Many people think of ‘menopause’ as a single event, but it’s a natural and significant transition in your life – a journey that unfolds over several years. This journey, often starting with perimenopause, can feel unique for each person, and how you’re experiencing it is completely valid. My role is to partner with you, listen to your experience, and together, we’ll find the best ways to manage your symptoms and support your long-term health through this important time.”

“You may have heard about the Women’s Health Initiative (WHI) study, which caused a lot of fear about MHT. While the study initially suggested increased risks, since then, evidence shows that hormone therapy is generally safe and effective”

This tool aims to empower and guide primary care clinicians in managing menopause within the primary care setting. For additional support consider consulting specialists across the province at OTN eConsult.

Screening

Consider screening individuals who are ≥ 40 years for menopause-associated symptoms which can begin during perimenopause or menopause. Symptoms can include: (OHQS)

  • Changes in menstrual cycle
  • Vasomotor symptoms (VMS), such as hot flashes or night sweats
  • Symptoms of genitourinary syndrome of menopause (GSM):
    • vaginal dryness
    • discomfort with sexual intercourse
    • vulvovaginal discomfort or irritation
    • discomfort, pain or urgency associated with urination
    • frequent urinary tract infections, incontinence
  • Sexual difficulties, such as low sexual desire
  • Mood changes, such as depressive symptoms or anxiety
  • Musculoskeletal symptoms, such as joint and muscle pain
  • Sleep disturbances
  • Changes in weight and/or body fat distribution
  • Difficulties with concentration or memory

Diagnosis

Identification of perimenopause or menopause is a clinical diagnosis, based on the menopause-associated symptoms that the person is experiencing. Consider using a screener such as Menopause Quick 6 (MQ6) to guide conversations. Conduct a thorough evaluation with detailed history including family, obstetrics, gynaecological, cancer, menstrual and sexual history. (Malaysian Guideline). It can be difficult to identify menopause in women and people who are taking hormonal treatments (e.g. birth control pills/IUS).

Consider assessing the individual using the MQ6 questionnaire:

  1. Any changes in your periods?
  2. Are you having any hot flashes?
  3. Any vaginal dryness or pain or sexual concerns?
  4. Any bladder issues or incontinence?
  5. How is your sleep?
  6. How is your mood?

The following laboratory and imaging tests should not be used to identify perimenopause or menopause in people aged 40 or over: 

  • Anti-Müllerian hormone 
  • Inhibin A 
  • Inhibin B 
  • Estradiol 
  • Antral follicle count
  • Ovarian volume

Note: While not necessary to do a FSH and estradiol routinely to diagnose menopause in patients over 40, these tests can be considered if there is a history of hysterectomy or IUD that makes diagnosis difficult. (EO)

Premature ovarian insufficiency (POI)
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Premature ovarian insufficiency (POI)

  • Premature ovarian insufficiency (POI) is a condition in which the ovaries stop producing eggs before the age of 40. (Sinai health).
  • While symptoms are similar to menopause (e.g. irregular periods, hot flashes, night sweats), POI requires further investigation.
  • Management of POI often requires higher doses of hormone therapy than standard menopause treatment
  • POI is characterized by:
    • Oligo/amenorrhoea
    • FSH concentration >25 IU/l represents a value greater than the physiological peak observed in premenopausal women and will encompass women with POI due to autoimmune causes.
    • Fluctuating ovarian activity may occur resulting in variable FSH concentrations, including into the normal range.
  • While guideline does not suggest a repeat FSH, this can be helpful for patients to understand the diagnosis
  • Consider referral for additional care and support

(HealthlinkBC) (Australian Family Physician)

Resources
Clinician resources
People with lived experience resources

Management New

Menopausal Hormonal Therapy for VMS (SOGC, Malaysian, NICE)

Menopausal hormone therapy (MHT) is the most effective option for managing vasomotor symptoms in women and people experiencing menopause (SOGC part A, Malaysian). MHT can be safely initiated in patients without contraindications who are younger than 60 years of age or less than 10 years post-menopause (SOGC, Malaysian). Ensure routine screening (e.g. mammograms, cholesterol, blood sugar, relevant blood work) is completed prior to initiating therapy. 

Primary care clinicians initiating MHT should ensure it is individualized and consider the following when determining dose and duration:

  • Ongoing symptoms and impact on quality of life
  • Medical conditions
  • Health benefits and risks
  • Family history
  • Patient preferences and treatment goals, cost of treatment
  • Timing of last menstrual period

Compounded bioidentical hormone therapy is not approved by Health Canada, is not considered standard of care, and should not be offered in place of Health Canada approved, pharmaceutical-grade menopausal hormone therapy. (OH)

Note: Clonidine and pregabalin are no longer used for treatment as there are more effective treatment options available.

Perimenopause (SOGC part A, Malaysian, OH)

For women and people experiencing perimenopause, contraceptive needs and bleeding patterns must be discussed when considering options including:

  • Low dose combined hormonal contraceptives
  • Estrogen in combination with a levonorgestrel-releasing intrauterine system
  • MHT with a cyclical progestogen for 12 – 14 days/month
  • Progestogen only
GSM (SOGC Part B, OHQS)
  • For women and people experiencing moderate to severe genitourinary syndrome of menopause, local vaginal estrogen is first line treatment, administered either as a cream, tablet, or sustained-release ring.
  • This may be added to systemic hormonal therapy and in combination with non-hormonal treatments such as:
    • Vaginal lubrication – reduce friction during intercourse and can be used as needed for mild symptoms
    • Vaginal moisturizers – regular application required, provides more continuous relief than lubricants for mild symptoms
    • Vaginal dehydroepiandrosterone (DHEA) ovules – if non-hormonal options or vaginal estrogen have been ineffective or not tolerated
    • Oral selective estrogen receptor modulator (Ospemifene) – to support treatment of dyspareunia if the use of locally applied treatments is impractical or not desired

Contraindications to systemic menopausal hormone therapy include the following:

Contraindications to estrogen:

  • Undiagnosed abnormal vaginal bleeding
  • Active breast cancer, suspected breast cancer, or a personal history of breast cancer
  • Active estrogen-dependent cancers or suspected estrogen-dependent cancers (i.e., endometrial, ovarian)
  • Coronary heart disease
  • Active venous thromboembolism or history of venous thromboembolism
  • Active stroke or history of stroke
  • Known thrombophilia
  • Active liver disease
  • Known or suspected pregnancy

Contraindications to progestogen:

  • Undiagnosed abnormal vaginal bleeding
  • Active breast cancer or personal history of breast cancer

Practice point

Abnormal Uterine Bleeding (SOGC)

Breakthrough bleeding is a common side effect of MHT. It is common to see bleeding up to 6 months after starting continuous MHT. Heavy bleeding or continued breakthrough bleeding after 6 months requires further investigation.

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“If we decide that Menopausal Hormone Therapy (MHT) is a good option, you should start to feel the effects on some symptom relief within a few weeks, but can take up to 12 weeks to fully work, depending on the dosage we start with. We may need to adjust your dosage along the way to find what works best for you.”

“When it comes to managing your menopausal symptoms, there are many good options, and what’s right for one person isn’t always right for another. My role is to help you understand all of the options available, both hormonal and non-hormonal and what they involve and their benefits. Let’s explore these together and decide on the best path forward that aligns with your symptoms, your health, and your preferences.”

Pharmacotherapy Options

Systemic and local MHT

*insert meds table*

Non-Hormonal Therapy

For patients who have contraindications or prefer alternatives to hormone therapy, non-hormonal prescription therapies can be considered. (SOGC part A, Malaysian). While these have shown efficacy in VMS relief, results vary with each option having their own adverse effects. It is important to flag that estrogen is still the most effective therapy for vasomotor symptom relief.

Non-hormonal therapies include:

  • Neurokinin B antagonist (Fezolinetant)
  • Gabapentin
  • Oxybutynin
  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs)

Non- Pharmacological Therapy

  • Non-vasomotor symptoms experienced during perimenopause or menopause can affect quality of life.
  • Prioritizing lifestyle modifications can help improve quality of life:
    • Weight management
    • Blood pressure management
    • Smoking cessation
    • Minimizing alcohol
    • Physical activity and strength training
    • Healthy diet (limiting caffeine, diet high in fibre, protein, unsaturated fats)
    • Sleep
  • A shared decision-making approach is a vital ongoing process that involves the patient, their care team, family and caregivers.

Referrals

Consider referral to clinicians with expertise in menopause when there are: (OH)

  • No improvement in symptoms with treatment, or continued side effects
  • Contraindications to menopausal hormone therapy
  • Menopause-associated symptoms in a person who has taken gender-affirming hormone therapy in the past

Considerations for specific populations and symptoms New

Considerations for specific populations

  • Systemic MHT is contraindicated in women and people with a history of breast cancer. Instead, non-hormonal and non-pharmacologic options can be used.
  • Encourage individuals to talk to their oncologist about their treatment options.
  • Genitourinary symptom management
    • Non-hormonal options – vaginal moisturizers, lubricants, pelvic floor physiotherapy, dilators or vibrators
    • Local vaginal estrogen can be considered for individuals with breast cancer in consultation with an oncologist. (NAMS, SOGC)
  • Vasomotor symptom management:
    • Non-hormonal options – CBT
    • First line non-hormonal option –Neurokinin B receptor antagonists (Fezolinetant), venlafaxine
    • Second line non-hormonal option – Paroxetine, gabapentin, oxybutynin
  • MHT, while primarily used for vasomotor symptom relief, can prevent bone loss and reduce fracture risk in post-menopausal individuals, if the following criteria is met: (NAMS)
    • < 60 years
    • no history of breast cancer or thromboembolic disease
    • low risk of cerebrovascular disease or CVD
  • Pharmacologic therapy should be initiated once a fragility fracture occurs.
  • Consider using the FRAX tool and/or bone mineral density testing (BMD) to determine fracture risk.
  • Encourage all postmenopausal women to employ lifestyle practices that reduce the risk of bone loss and osteoporotic fractures:
    • Maintaining a healthy weight
    • Eating a balanced diet
    • Obtaining adequate protein, calcium and vitamin D. Routine supplementation with protein, vitamin K, or magnesium is not recommended for fracture prevention. Supplements should only be used when daily targets are not achieved from dietary sources.
    • Participating in regular physical activity
    • Avoiding excessive alcohol consumption
    • No smoking
    • Fall prevention

 

Mood

  • Women and people experiencing perimenopause can develop depressive symptoms, even without a previous history. This can be due to factors caused by menopause (e.g. vasomotor symptoms, poor sleep) and lifestyle factors.
  • It is also common for depression to resurface for individuals who have had it in the past. (Expert Review)
  • Assess for severity and impact on daily living and rule out other possible conditions contributing to change in mood.
  • Choice of antidepressants should be based on:
    • patients’ response and tolerability
    • potential adverse effects that may influence other concerns (i.e. weight, sexual dysfunction)
    • drug to drug interactions
  • Non-pharmacologic treatment – CBT, counselling, lifestyle modifications
  • As vasomotor symptoms are one of the main reasons for disruption in sleep and mood, hormone therapy may improve mood when used as treatment for vasomotor symptoms.

Sleep

  • Change in sleep quality is common among women and people in the perimenopausal and postmenopausal period.
  • Primary sleep disorders (e.g. night terrors, obstructive sleep apnea) should be ruled out prior to recommending non-pharmacological treatment (e.g. CBT, education on sleep hygiene).
  • As vasomotor symptoms are one of the main reasons for disruption in sleep and mood, hormone therapy may improve sleep when used as treatment for vasomotor symptoms.

Cognition

  • During the menopause transition, women and people experiencing menopause can experience cognitive changes. These often include:
    • Worsening memory
    • Slower cognitive speed (i.e. brain fog)
  • It is important to rule out concerns surrounding thyroid, vitamin B12 deficiency and iron deficiency. (Expert opinion).
  • By modifying lifestyle factors such as optimizing sleep, managing mood and vasomotor symptoms can help improve cognitive function.

See Non-Pharmacological section for more details on treatment options

  • During perimenopause and the menopause transition, cardiovascular risk factors often worsen. It’s crucial to prioritize cardiovascular risk assessment during menopause, which includes screening for blood pressure, A1C, lipids, and lipoprotein(a).
  • Clinicians should be proactive in the identification and modification of risk factors as the most effective means of reducing cardiovascular risk.
  • At this time, MHT is not a indicated as a method for prevention for CVD.  However, to support risk reduction alongside other treatment options, consider prescribing women with premature menopause, menopausal hormone therapy until the average age of menopause. Consider prescribing women with premature menopause (ADD <40), MHT until the avg age (ADD 51). 
  • Encourage individuals to talk to their cardiologist about menopause hormone therapy when discussing their treatment options.

Cardiac event risk

  • Low risk – women and people who initiate MHT early into their menopause
  • Increased risk – women and people who initiate MHT 10 or more years after menopause

Stroke risk

  • There is increased risk of stroke when on MHT, regardless of age, however the risk in younger women is lower.
  • Risk prevention – The lowest effective dose of systemic estrogen (oral or transdermal) should be prescribed.

Venous Thrombotic Events (VTE)

  • MHT increases the risk of venous thrombotic events (e.g., deep vein thrombosis, pulmonary embolism).
  • There is a higher risk of VTE with oral and combined hormone therapy preparations than transdermal preparations or estrogen alone .
  • Risk reduction – the lowest effective dose of systemic estrogen, and estrogen-only therapy should be prescribed.

Practice Point

Beyond vasomotor symptoms, estrogen therapy may improve sleep, mood, and depressive symptoms in perimenopausal women. Evidence suggests a possible “window of opportunity” during perimenopause. (NAMS, 2022)

Gender-diverse individuals experience inequities in accessing appropriate menopause care which negatively affect their health outcomes. All individuals who experience perimenopause and menopause deserve quality care. (OHQS)

Follow up and monitoring New

  • Effective management of menopause involves follow-up and ongoing monitoring to ensure treatment plans are optimized and symptoms are well-controlled.
  • For primary care clinicians inheriting patients who have already initiated menopausal hormone therapy (MHT) or bioidentical hormone regimens, the focus shifts from initiating therapy to continuing and monitoring it effectively. This includes:
    • maintaining the therapeutic conversation
    • reassessing treatment goals
    • ensuring ongoing safety
  • Follow-up should include:
    • regular evaluation of symptom control and severity
    • discussion of side effects
    • regular check in for CVD and bone health to ensure safety/efficacy of MHT need and dosing
    • risk assessment
    • assessment of patient goals
  • There is no recommended duration or stop time for MHT. The duration should be individualized, treatment should continue as long as benefits outweigh risks and symptoms persist. Vaginal estrogen can be continued life-long.
  • For patients who are stopping MHT, offer the choice of gradually reducing (to limit recurrence of symptoms) or immediately stopping treatment. Gradually reducing or immediately stopping MHT makes no difference in symptoms in the long term.

References