Menopausal Hormone Therapy (MHT) · Indications and Regimen

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Complaint + age/years since menopause + contraindications + uterus
   Complaint (VMS / GSM / bone)? Age and years since menopause? Contraindications? Uterus present? (Contraindications: breast cancer or estrogen-sensitive tumor, coronary disease, prior VTE/stroke/MI, active liver disease, unexplained vaginal bleeding (investigate first).)
   • VMS/prevent bone loss, <60 years or <10 years since menopause, no contraindication, uterus present → Uterus present, in window → estrogen + progestogen
   • VMS/prevent bone loss, <60 years or <10 years since menopause, no contraindication, post-hysterectomy → Post-hysterectomy, in window → estrogen alone
   • Genitourinary syndrome only (GSM: dryness/dyspareunia/recurrent UTIs) → GSM only → vaginal estrogen
   • Contraindication or starting >60 years/>10 years since menopause → Contraindicated/outside window → non-hormonal
2. [End] Uterus present, in window → estrogen + progestogen
   Uterus present, within the window (<60 years or <10 years since menopause), no contraindication → systemic estrogen + progestogen (progestogen protects the endometrium), relieves VMS and prevents bone loss; transdermal estrogen + low dose lowers VTE/stroke risk; reassess periodically.
3. [End] Post-hysterectomy, in window → estrogen alone
   Post-hysterectomy, within the window, no contraindication → estrogen alone (no progestogen needed); transdermal/low-dose preferred; relieves VMS, prevents bone loss.
4. [End] GSM only → vaginal estrogen
   GSM only → vaginal low-dose estrogen (or vaginal DHEA / oral ospemifene), minimal systemic absorption, no added progestogen needed; some breast/endometrial cancer survivors may individually consider low-dose vaginal therapy after non-hormonal options fail.
5. [End] Contraindicated/outside window → non-hormonal
   Contraindication or outside the window (starting >60 years/>10 years since menopause, raised absolute risk) → prefer non-hormonal: SSRI/SNRI, gabapentin, oxybutynin, or an NK3 receptor antagonist (fezolinetant) for VMS; investigate unexplained bleeding first; premature menopause/ovarian insufficiency is an exception, hormones can be used until the average age of menopause.

Source guidelines & references

• Menopausal hormone therapy (NAMS 2022 hormone therapy position statement)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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