Menopause

Practice Standards
Produced by:
British Menopause Society (BMS)
Royal College of Obstetricians and Gynaecologists
(RCOG) Society for Endocrinology (SfE)
Faculty of Sexual and Reproductive Health (FSRH)
Faculty of Pharmaceutical Medicine (FPM)
Royal Pharmaceutical Society (RPS)

Haitham Hamoda Chairman BMS

Sara Moger CEO BMS
Edward Morris President RCOG
Stephanie Baldeweg Chair of Clinical Committee SfE
Asha Kasliwal President FSRH
Flic Gabbay President FPM
Heidi Wright Policy and Practice Lead England RPS

First published: July 2022

The aim of the standards is to provide evidence-based recommendations and guidance on

best menopause practice to support healthcare practitioners delivering menopause care in
line with current national and international guidelines and recommendations.

The BMS is the specialist authority for menopause and post reproductive health
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British Menopause Society
Menopause Practice Standards

Standard 1:
In women aged 45 years and over presenting with menopausal symptoms,
the diagnosis of perimenopause or menopause should be considered
based on their symptoms alone, without confirmatory blood tests unless
uncertainty about the diagnosis:

• The diagnosis should be based on symptoms experienced and there is no indication

for laboratory testing (FSH, oestradiol) to confirm unless uncertainty about the
diagnosis or suspicion of other pathology.

• The average age of the menopause in the UK is 51 with a normal range of 45-55.
• The menopause transition can have a significant impact on many women, with
more than 75% experiencing menopausal symptoms, a quarter describing severe
symptoms, and a third experiencing long-term symptoms.

• A significant proportion of women may experience troublesome menopausal

symptoms while still perimenopausal (the phase proceeding the menopause where
women experience menstrual cycle irregularities +/- menopausal symptoms) and
the latter should be considered when assessing women.

• A wide range of menopausal symptoms have been reported. Commonly

experienced menopausal symptoms include the following:

— Vasomotor symptoms (hot flushes/night sweats).

— Cognitive symptoms and mood disorders (low mood, labile mood,

anxiety, irritability, loss of confidence, low self-esteem, difficulties with short-term
concentration and memory (‘Brain fog’), and difficulties in multi-tasking).

Menopause and perimenopause should be considered in women with mood disorders

experienced de-novo during the menopause transition in the absence or pre-existing
depression/anxiety.

— Sleep disturbances (insomnia and disturbed sleep)

— Fatigue, tiredness and low energy levels

— Loss of sexual desire and libido

— Joint and muscle pains

— Headaches

— Genitourinary symptoms (vaginal dryness, irritation, discomfort, burning,

itching, dyspareunia. This may also include urinary symptoms such as urinary
frequency urgency, dysuria and recurrent lower urinary tract infections).

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British Menopause Society
Menopause Practice Standards

Genitourinary symptoms may present a number of years after the menopause and
should be considered in women who experience the above symptoms.

— Reduced quality of life as a result of the above symptoms as well as the

detrimental effect on relationships and women’s working life.

STRUCTURE:
1. Follow national recommendations or implement local guidance that women
aged 45 years and over presenting with menopausal symptoms are diagnosed as
being perimenopausal or menopausal based on their symptoms alone, without
confirmatory blood tests.

2. Follow national recommendations or implement local guidance that there is no

indication for laboratory testing (FSH, oestradiol) to confirm the diagnosis unless
uncertainty about the diagnosis.

OUTCOME:
Proportion of women aged 45 years and over presenting with menopausal symptoms
are diagnosed as being perimenopausal or menopausal based on their symptoms
alone, without confirmatory blood tests.

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British Menopause Society
Menopause Practice Standards

Standard 2:
Women presenting with menopausal symptoms should be made aware of
resources available for guidance and should be encouraged to seek help for
managing their menopausal symptoms.

• All women should be able to access accurate advice on how they can optimise
their menopause transition and the years beyond.

• Women should be made aware of resources available for guidance. Links for such
information are included below:

https://thebms.org.uk/ https://thebms.org.uk/publications/videos/bms-tv/
https://www.nice.org.uk/guidance/ng23/resources/menopause-
pdf-718895758021
https://www.womens-health-concern.org/ https://www.rcog.org.uk/en/
patients/menopause/ https://www.yourhormones.info/
https://pcwhf.co.uk/resources https://elearning.rcgp.org.uk/mod/book/view.
php?id=12534&chapterid=336 https://rockmymenopause.com/
https://www.rcn.org.uk/clinical-topics/womens-health/menopause https://
www.menopausematters.co.uk/ www.managemymenopause.co.uk
https://www.daisynetwork.org/
https://journals.sagepub.com/doi/pdf/10.1177/2053369120957514 https://
thebms.org.uk/find-a-menopause-specialist/

STRUCTURE:
Follow national recommendations or implement local guidance that women
presenting with menopausal symptoms are made aware of resources available for
guidance and offered access to such information.

OUTCOME:
Proportion of women presenting with menopausal symptoms made aware of
resources available for guidance and offered access to such information.

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British Menopause Society
Menopause Practice Standards

Standard 3:
Women aged 45 years and over who seek help for managing their menopausal
symptoms should be offered treatment after information and support to make
an informed decision about their management options.

• There should be a holistic and individualised approach in assessing and advising

women, with particular reference to lifestyle advice and dietary modification
including optimising weight, stopping smoking, exercising, healthy diet, and
reducing alcohol consumption. It should also include advice on risk factors for
cardiovascular disease (including raised blood pressure, raised cholesterol and
obesity), advice on bone health and osteoporosis as well as cancer risk reduction,
in addition to management options including HRT or non-hormonal and
alternative therapies.

• Women who wish to have HRT should be offered treatment (if not
contraindicated) after counselling about the benefits and risks of HRT. Women
should be provided information and given sufficient time to make an informed
decision.

• Women should be informed that HRT compared with placebo, has been
consistently shown to improve menopausal symptoms and overall quality of life
and remains the most effective treatment for menopausal symptoms for most
women.

• The decision whether to take HRT, the dose of HRT used, regimen and the
duration of its use should be made on an individualised basis after discussing the
benefits and risks with each patient and supplying the patient information leaflet
for the product selected. This should be considered in the context of the overall
benefits obtained from using HRT including symptom control and improving
quality of life as well as considering the bone and potential cardiovascular benefits
associated with HRT use.

• Transdermal administration of estradiol is unlikely to increase the risk of venous

thrombosis or stroke above the risk in non-users and is associated with a lower
risk compared with oral administration of estradiol. The transdermal route should
therefore be considered as the first-choice route of estradiol administration in
women with related risk factors.

• Alternative treatments and non-hormonal options should be discussed with

women who are unable to take or do not wish to take HRT.

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British Menopause Society
Menopause Practice Standards

STRUCTURE:
1. Follow national recommendations or implement local guidance that women aged
45 years and over who seek help for managing their menopausal symptoms are
offered treatment after information and support to make an informed decision
about their management options.

2. Follow national recommendations or implement local guidance that women who

seek help for managing their menopausal symptoms should be offered advice
regarding lifestyle and dietary modification, advice on risk factors for cardiovascular
disease, advice on bone health and osteoporosis, advice on reducing cancer risk, in
addition to management options including HRT or non-hormonal and alternative
therapies.

3. Follow national recommendations or implement local guidance that women

aged 45 years and over who seek help for managing their menopausal symptoms
and who wish to have HRT should be offered treatment (if not contraindicated)
after counselling about the benefits and risks of HRT. Women should be provided
information and given sufficient time to make an informed decision. Alternative
treatments and non-hormonal options should be discussed with women who are
unable to take or do not wish to take HRT.

4. Follow national recommendations or implement local guidance to indicate that

the transdermal route of oestradiol administration should be considered as the
first-choice route of oestradiol administration in women with increased risk of
thrombosis including women with raised BMI who wish to take HRT.

OUTCOME:
1. Proportion of women aged 45 years and over who seek help for managing their
menopausal symptoms offered treatment after information and support to make an
informed decision about their management options.

2. Proportion of women who seek help for managing their menopausal symptoms
offered advice regarding lifestyle, dietary modification, advice on risk factors for
cardiovascular disease, bone health and osteoporosis, cancer risk reduction, in
addition to management options including HRT or non-hormonal and alternative
therapies.

3. Proportion of women aged 45 years and over who seek help for managing their
menopausal symptoms who wish to have HRT, are being offered HRT (if not
contraindicated).

4. Proportion of women with increased risk of thrombosis who wish to take HRT are
being offered transdermal oestradiol.

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British Menopause Society
Menopause Practice Standards

Standard 4:
Women with genitourinary symptoms of the menopause should be offered
vaginal oestrogen treatment and this can be continued long term as required to
relieve symptoms.

Genitourinary symptoms of the menopause have been reported to be experienced by

approximately 50% of postmenopausal women. Topical vaginal estrogen treatment
has been shown to be effective in improving symptoms related to vaginal atrophy,
such as vaginal dryness and superficial dyspareunia.

Low-dose vaginal oestrogen preparations can be used by symptomatic women and

continued for as long as required. All topical estrogen preparations have been shown
to be effective in this context.

There is no requirement to combine vaginal oestrogens with systemic progestogen

treatment for endometrial protection, as low-dose vaginal oestrogen preparations do
not result in significant systemic absorption or endometrial hyperplasia.

Women with genitourinary symptoms of the menopause can use moisturisers and
lubricants alone or in addition to vaginal oestrogen.

STRUCTURE:
Follow national recommendations or implement local guidance that women with
genitourinary symptoms of the menopause should be offered vaginal oestrogen
treatment and this can be continued long term as required to relieve symptoms.

OUTCOME:
Proportion of women with genitourinary symptoms of the menopause offered vaginal
oestrogen treatment.

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British Menopause Society
Menopause Practice Standards

Standard 5:
Women having treatment for menopausal symptoms should ideally have a
review 3 months after starting treatment and should continue to be reviewed at
least annually after that.

• The objective of the review would include assessment of the following:

— Symptom management.
— Side effects (such as nausea, breast discomfort and bloating).
— Basic health checks including measuring weight and blood pressure.
— Changes to dosage or preparation can be considered if required.
— Discussion of routine cervical and breast screening in accordance with NHS
Screening Programmes guidance.

• Once optimal replacement is achieved, further interval reviews should be

considered at least once a year.

• More frequent reviews may be needed depending on the woman’s response to

treatment and her medical background and the option of patient initiated follow
up appointments should be offered where feasible.

STRUCTURE:
Follow national recommendations or implement local guidance that women having
treatment for menopausal symptoms should ideally have a review 3 months after
starting treatment and should continue to be reviewed at least annually after that.

OUTCOME:
1. Proportion of women having treatment for menopausal symptoms reviewed 3
months after starting treatment.

2. Proportion of women having ongoing treatment for menopausal symptoms being

reviewed at least annually.

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British Menopause Society
Menopause Practice Standards

Standard 6:
Duration of treatment should be individualised. No arbitrary limits should
be placed on the dose of HRT, duration of usage or age of women taking
treatment.

Cochrane analysis suggests that HRT (oestrogen with or without progestogen)

started before the age of 60 or within 10 years of the menopause is associated with
a reduction in atherosclerosis progression, coronary heart disease and death from
cardiovascular causes as well as all-cause mortality.

Evidence from the Cochrane data-analysis as well as the long-term follow-up data
from the WHI showed no increase in cardiovascular events, cardiovascular mortality
or all-cause mortality in women who initiated HRT more than 10 years after the
menopause.

This decision should be made on an individualised basis after discussing the benefits
and risks with each patient and should be considered in the context of the overall
benefits obtained from using HRT.

The median duration of menopausal symptoms is over 7 years and it estimated that
approximately 20% of women experience symptoms up to 15 years. This decision
regarding the duration of HRT intake should be made on an individualised basis taking
into consideration the benefits and risks for the individual woman.

Advise women who continue HRT intake over the age of 60 to have estradiol
administered transdermally.

Women should continue routine cervical and breast screening in accordance with NHS
Screening Programme guidance.

Women taking HRT should continue basic health checks including measuring weight
and blood pressure on an annual basis.

STRUCTURE:
Follow national recommendations or implement local guidance that duration of
treatment should be individualised. No arbitrary limits should be placed on the dose of
HRT, duration of usage or age of women taking treatment.

OUTCOME:
1. Reasons for discontinuation of HRT.

2. Assessment of average durations of HRT intake.

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British Menopause Society
Menopause Practice Standards

Standard 7:
If HRT with adequate oestrogen intake has not been effective, testosterone
supplementation can be considered in menopausal women with low sexual desire.

• There are no testosterone products for female use licensed in the UK. The
previous license for female testosterone patches and implants were both
withdrawn for commercial (not medical) reasons and there is good evidence to
support the efficacy and safety of testosterone replacement.

• Given the lack of availability of licensed preparations, it is now common practice to

use testosterone preparations licensed for use in men out with their product license
to provide testosterone in female replacement doses. This is backed by national
guidance and meets the criteria proposed by the GMC and MHRA on prescribing an
unlicensed medicine or using a medicine off-label (i.e. No suitably licensed products
available / Be satisfied there is sufficient evidence or experience of using the medicine
to demonstrate its safety and efficacy / Make a clear record of reasons for prescribing
an unlicensed medicine / give patients, or those authorising treatment on their
behalf, sufficient information about the proposed treatment).

• Assessment of serum androgen levels is unlikely to be beneficial in making the

diagnosis of hormone dependent low sexual desire, as there is poor correlation
between circulating androgen levels and clinical symptoms.

• However, best practice as recommended by the Global Consensus Position

Statement on the Use of Testosterone Therapy for Women is that testosterone
levels should be checked to exclude high baseline levels and to prevent
subsequent supraphysiological replacement.

• Assessment of total testosterone level should be kept within the female

physiological threshold.

STRUCTURE:
1. Follow national recommendations or implement local guidance that if HRT with
adequate oestrogen intake has not been effective, testosterone supplementation
can be considered in menopausal women with low sexual desire.

2. Follow national recommendations or implement local guidance that serum

testosterone levels are assessed to exclude high baseline levels.

3. Follow national recommendations or implement local guidance that serum

testosterone levels are assessed ideally within 3-4 months of starting treatment to
ensure levels are kept within the female physiological threshold.

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British Menopause Society
Menopause Practice Standards

OUTCOME:
1. Proportion of women on HRT with adequate oestrogen intake with low sexual
desire receiving testosterone supplementation.

2. Proportion of women having their baseline serum testosterone levels assessed prior
to starting testosterone supplementation.

3. Proportion of women receiving testosterone supplementation having their serum

testosterone levels assessed within 3-4 months of starting treatment.

Standard 8:
Women under the age of 40 presenting with a picture suggestive of premature
ovarian insufficiency (POI) should have their levels of follicle stimulating
hormone (FSH) measured.

Diagnosis of POI should be based on a combination of oligomenorrhoea/

amenorrhoea of more than 3 months’ duration associated with elevated
gonadotropins (FSH >30IU/l) on at least two occasions measured four to six weeks
apart in women under the age of 40.

If the diagnosis of POI is inconclusive, consider referral to (or seek advice from) a
specialist menopause service. Consider assessment for other causes if there is suspicion
of other pathology.

STRUCTURE:
1. Follow national recommendations or implement local guidance that women under
the age of 40 presenting with a picture suggestive of POI should have assessment of
their FSH serum levels on at least two occasions measured four to six weeks apart.

2. Follow national recommendations or implement local guidance that if the diagnosis

of POI is inconclusive referral to (or seeking advice from) a specialist menopause
service should be considered.

OUTCOME:
1. Proportion of women under the age of 40 presenting with a picture suggestive of
POI having their FSH serum levels assessed.

2. Proportion of women with suspected POI being referred to a specialist menopause

service and indications for referral.

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British Menopause Society
Menopause Practice Standards

Standard 9:
Women with POI should be advised to take hormone replacement and
continue to do so at least until the natural age of the menopause (unless
contraindicated).

POI can result in a number of short-term and long-term sequelae related to the hypo-
oestrogenic status associated with the condition.

Women with POI are at increased risk of cardiovascular disease, osteoporosis and
cognitive impairment.

Women with POI should be advised to take hormone replacement and continue
to do so at least until the natural age of the menopause in the absence of a contra-
indication. Hormone replacement is likely to lower the long-term risk of cardiovascular
disease in women with POI, prevent osteoporosis and have a beneficial effect on
cognitive function.

The aim of hormone replacement in women with POI should be to achieve

physiological levels of oestradiol.

Women with POI who do not experience menopausal symptoms would still be
advised to consider hormone replacement for the prevention of the long-term
sequelae of the condition.

HRT and the combined contraceptive pill containing ethinyl oestradiol are both
suitable options for hormone replacement. However, HRT may be more beneficial
in improving bone health and blood pressure and may be associated with lower
cardiovascular risk when compared to the combined oral contraceptive pill.

STRUCTURE:
Follow national recommendations or implement local guidance that women
diagnosed with POI should be advised to take hormone replacement and
continue to do so at least until the natural age of the menopause (unless there is a
contraindication).

OUTCOME:
Proportion of women diagnosed with POI advised to take hormone replacement and
to continue to do so at least until the natural age of the menopause.

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British Menopause Society
Menopause Practice Standards

Standard 10:
Women with early menopause (women aged 40-45 years) should be offered
information and support in a similar way to women with POI and advised to
take hormone replacement at least until the natural age of the menopause.

Diagnosis of early menopause should be based on a combination of menopausal

symptoms and or oligomenorrhoea/ amenorrhoea of more than 3 months’ duration
associated with elevated gonadotropins (FSH >30IU/l) on at least two occasions
measured four to six weeks apart in women aged 40-45.

If the diagnosis is inconclusive, consider referral to (or seek advice from) a specialist
menopause service.

Early menopause between the age 40 and 45 affects 5% of women and can result in
a number of short-term and long-term sequelae related to the hypo-estrogenic status
associated with the condition.

Women with early menopause are at increased risk of cardiovascular disease,

osteoporosis and cognitive impairment.

Women with early menopause should be offered information and support in a similar
way to women with POI and advised to take hormone replacement and continue
to do so at least until the natural age of the menopause in the absence of a contra-
indication.

Hormone replacement is likely to lower the long-term risk of cardiovascular disease in

women with early menopause, prevent osteoporosis and have a beneficial effect on
cognitive function.

STRUCTURE:
1. Follow national recommendations or implement local guidance that
women with early menopause (women aged 40-45 years) should be offered
information and support in a similar way to women with POI and advised to take
hormone replacement at least until the natural age of the menopause (unless
contraindicated).

2. Follow national recommendations or implement local guidance that diagnosis of

early menopause should be based on a combination of menopausal symptoms
and/or oligomenorrhoea/ amenorrhoea of more than 3 months’ duration associated
with elevated gonadotropins (FSH >30IU/l) on at least two occasions measured four
to six weeks apart in women aged 40-45.

3. Follow national recommendations or implement local guidance that if the diagnosis

is inconclusive, referral to (or seeking advice from) a specialist menopause service
should be considered.

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British Menopause Society
Menopause Practice Standards

OUTCOME:
1. Proportion of women with early menopause (women aged 40-45 years) having their
FSH serum levels assessed.

2. Proportion of women with early menopause (women aged 40-45 years) receiving
HRT.

3. Proportion of women with early menopause (women aged 40-45 years) referred
to a specialist menopause service where the diagnosis is inconclusive, or specialist
advice is needed.

Standard 11:
Referral to (or seeking advice from) a specialist menopause service should be
considered where menopause specialist input is required.

Healthcare professionals (HCP) in primary care should manage women and offer
menopause advice and care within their clinical expertise and seek further specialist
menopause advice (by phone, email or direct referral) as appropriate. Criteria for
referral (or seeking further advice) may include the following:

• Women who may experience difficulty obtaining satisfactory symptom control

despite adjustments of their HRT intake.

• Women experiencing ongoing unscheduled bleeding more than 4-6 months

after starting HRT despite adjustments to their progestogen intake.

• Women where the diagnosis of POI or early menopause is inconclusive.

• Women with complex medical backgrounds (such as women with breast cancer,
personal history of venous thrombosis or personal history of stroke).

• Women with genitourinary symptoms of the menopause who do not obtain

satisfactory symptom relief despite use of topical vaginal oestrogens.

• Or other related issues where it is felt that specialist input is required.

STRUCTURE:
1. Follow national recommendations or implement local guidance that referral to (or
seeking advice from) a specialist menopause service should be considered where
menopause specialist input is required. This may include the following:

• Women who may experience difficulty obtaining satisfactory symptom control

despite adjustments of their HRT intake.

• Women experiencing ongoing unscheduled bleeding more than 4-6 months

after starting HRT despite adjustments to their progestogen intake.

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British Menopause Society
Menopause Practice Standards

• Women where the diagnosis of POI or early menopause is inconclusive.

• Women with complex medical backgrounds (such as women with breast cancer,
personal history of venous thrombosis or personal history of stroke).

• Women with genitourinary symptoms of the menopause who do not obtain

satisfactory symptom relief despite intake of topical vaginal oestrogens.

OUTCOME:
Proportion of women being referred to a specialist menopause service and indications
for referral.

PUBLICATION DATE: JULY 2022

REVIEW DATE: JULY 2025

© BRITISH MENOPAUSE SOCIETY 2022

Endorsements
The British Menopause Society Menopause Practice Standards is endorsed by:

Q4P/2122

For further details – please visit

www.thebms.org.uk or telephone 01628 890 199

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