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Menopause & Hormone Replacement Therapy

Permanent cessation of menses from ovarian follicle depletion, with vasomotor and genitourinary symptoms managed by individualized hormonal or nonhormonal therapy

Review date
reviewed 2026-05-04
Reading time
8 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Obstetrics & Gynecologycommonlong-term-condition
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Condition details
Obstetrics & Gynecology
common
8 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Menopause = 12 months of amenorrhea without another pathologic cause, usually around age 51
  • Diagnosis is clinical in typical age range; FSH testing usually unnecessary
  • Systemic menopausal hormone therapy is most effective for vasomotor symptoms
  • Patients with a uterus need estrogen plus progestin to prevent endometrial hyperplasia/cancer
  • Do not use systemic hormone therapy solely for chronic disease prevention

Overview

Menopause results from ovarian follicle depletion and reduced estrogen. Symptoms include irregular cycles, vasomotor symptoms, sleep disturbance, mood symptoms, and genitourinary syndrome. Hormone therapy is effective but must be individualized.

Epidemiology

Natural menopause occurs at a median age of about 51 years. Vasomotor symptoms can persist for years. Early menopause occurs before 45; primary ovarian insufficiency before 40 requires separate evaluation.

Clinical Features

Symptoms
Irregular menses during perimenopause then amenorrhea
Hot flashes and night sweats
Sleep disturbance, mood changes, brain fog, fatigue
Vaginal dryness, dyspareunia, urinary urgency/recurrent symptoms
Postmenopausal bleeding is abnormal
Signs
Vulvovaginal atrophy: pale thin mucosa, loss of rugae
Normal exam common with vasomotor symptoms
BP/VTE risk factors influence hormone therapy
Breast mass, unexplained bleeding, active liver disease affect candidacy
Hypoestrogenic signs before age 40 suggest POI

Investigations

First-line
Clinical diagnosisTypical age with 12 months amenorrhea generally needs no labs
Pregnancy testNeeded in perimenopausal amenorrhea if pregnancy possible
Evaluation of abnormal bleedingPostmenopausal bleeding requires endometrial biopsy or TVUS evaluation
Second-line
FSH/estradiolNot routine; useful for suspected POI/uncertain diagnosis
TSH and prolactinConsider if symptoms or menstrual changes suggest mimics
Bone density testingDXA based on age/fracture risk
Specialist
Primary ovarian insufficiency workupRepeat FSH/estradiol, pregnancy test, autoimmune/genetic evaluation as indicated
Menopause specialist/gynecology referralComplex contraindications, premature menopause, refractory symptoms, cancer history

Management

ACOG Menopausal Symptom Guidance and USPSTF Hormone Therapy for Primary Prevention Recommendation
1
Systemic hormone therapy
  • Most effective for moderate-severe vasomotor symptoms
  • Estrogen-only therapy only after hysterectomy
  • If uterus present, add progestin to protect endometrium
  • Best risk-benefit profile generally age <60 or within 10 years of menopause without contraindications
  • Use lowest effective dose with periodic reassessment
2
Contraindications/cautions
  • Avoid systemic HT with breast cancer, estrogen-dependent cancer, unexplained bleeding, active/prior VTE or stroke in many cases, active liver disease, high-risk thrombophilia
  • Transdermal estrogen may have lower VTE risk in selected patients
  • Do not use systemic hormone therapy solely to prevent cardiovascular disease, dementia, or chronic disease
3
Nonhormonal options
  • SSRIs/SNRIs, gabapentin, clonidine, or NK3 receptor antagonists reduce vasomotor symptoms
  • Cooling, trigger avoidance, weight management, sleep optimization
  • CBT/behavioral approaches can help coping and sleep
4
Genitourinary syndrome
  • First-line vaginal moisturizers/lubricants
  • Low-dose vaginal estrogen, vaginal DHEA, or ospemifene for persistent symptoms
  • Local vaginal estrogen has minimal systemic absorption and is often preferred for isolated vaginal/urinary symptoms

Complications

  • Endometrial hyperplasia/cancer: Unopposed systemic estrogen with uterus intact
  • VTE and stroke: Systemic estrogen increases thrombotic risk in susceptible patients
  • Breast cancer: Combined estrogen-progestin may increase risk with longer use
  • Osteoporosis: Estrogen loss accelerates bone loss
  • Genitourinary syndrome: Vaginal dryness, dyspareunia, urinary symptoms can worsen
USMLE Step 2 CK Exam Tips
  • 1Menopause diagnosis = 12 months amenorrhea; no FSH needed in typical 51-year-old
  • 2Postmenopausal bleeding is never normal
  • 3Systemic estrogen with uterus intact requires progestin
  • 4Hysterectomy patient can use estrogen-only therapy if appropriate
  • 5Do not use HT solely for chronic disease prevention
  • 6Vaginal dryness without hot flashes = local therapy, not necessarily systemic HT
  • 7Hot flashes with hormone contraindication = SSRI/SNRI, gabapentin, or nonhormonal option
  • 8POI before age 40 requires evaluation

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Verified Sources & References

ACOG FAQ — Hormone Therapy for Menopause
USPSTF Hormone Therapy for Primary Prevention of Chronic Conditions
ACOG Clinical Guidance
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