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  • Review Article
  • Published:

Treating menopause — MHT and beyond

Nature Reviews Endocrinology volume 18, pages 490–502 (2022)Cite this article

Subjects

Abstract

Every woman who lives past midlife will experience menopause, which, by definition, is complete cessation of ovarian function. This process might occur spontaneously (natural menopause) or be iatrogenic (secondary menopause), and can be further classified as ‘early’ if it occurs before the age of 45 years and ‘premature’ if it occurs before the age of 40 years. Globally, the mean age of natural menopause is 48.8 years, with remarkably little geographic variation. A woman’s age at menopause influences health outcomes in later life. Early menopause is associated with a reduced risk of breast cancer, but increased risks of premature osteoporosis, cardiovascular disease and premature death. The cardinal symptoms of menopause, and adverse health sequelae, are due to loss of ovarian oestrogen production. Consequently, menopausal hormone therapy (MHT) that includes oestrogen or an oestrogenic compound ameliorates menopausal symptoms, while preventing menopause-associated bone loss and cardiometabolic changes. Importantly, comprehensive care of postmenopausal women involves lifestyle optimization (attention to nutrition and physical activity, reducing alcohol consumption and not smoking) and treating other established chronic disease risk factors. This Review offers a commentary specifically on the contemporary use of MHT and novel pharmaceutical alternatives to manage menopausal symptoms.

Key points

  • Most women experience menopause between the ages of 45 and 55 years, and 75% will experience oestrogen deficiency symptoms.

  • Menopausal hormone therapy (MHT), including tibolone, remains the most effective treatment for menopausal symptoms.

  • MHT considerably lowers the risk of hip, vertebral and other osteoporosis-related fracture in women with normal bone density, osteopenia and osteoporosis; fracture prevention is a primary indication for its use.

  • Urogenital atrophy symptoms are common and should be treated, with several effective hormonal and non-hormonal treatments available.

  • Several novel therapies for the treatment of menopausal symptoms are in development; however, the new non-hormonal therapies are specific for vasomotor symptoms and, unlike oestrogen therapy, will not prevent bone loss or cardiometabolic disease risk.

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Fig. 1: Issues to be considered to deliver menopause-related holistic care.
Fig. 2: Pathways by which oestrogen depletion at menopause adversely affects cardiometabolic health.
Fig. 3: Postulated role of KNDy neurons in generation of vasomotor symptoms.

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Acknowledgements

S.R.D. is an NHMRC senior principal research fellow (grant no. 1135843).

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Authors and Affiliations

  1. Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia

    Susan R. Davis

  2. Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, VIC, Australia

    Susan R. Davis

  3. Department of Obstetrics and Gynaecology, University of Sydney, Sydney, NSW, Australia

    Rodney J. Baber

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Correspondence to Susan R. Davis.

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S.R.D. has been paid for developing and delivering educational presentations for Besins Healthcare, Abbott, Mayne Pharma and BioFemme, has been on advisory boards for Theramex, Abbott Laboratories, Mayne Pharma and Roche and a consultant to Lawley Pharmaceuticals, Southern Star Research and Que Oncology, and has received institutional grant funding from Que Oncology and Ovova Bio. R.J.B. has been paid for delivering educational presentations for Besins Healthcare, Abbott, Viatris and Pfizer Australia, and has served on medical advisory boards for Theramex, Mayne Pharma and Besins Healthcare.

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Davis, S.R., Baber, R.J. Treating menopause — MHT and beyond. Nat Rev Endocrinol 18, 490–502 (2022). https://doi.org/10.1038/s41574-022-00685-4

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