Hormone therapy for first-line management of menopausal symptoms: Practical recommendations Original paper

What was reviewed?

This review sets out menopausal hormone therapy as first-line management and gives clear, practical steps for safe symptom control in midlife. The authors explain how to match route, dose, and regimen to a woman’s risks and goals and describe oral, transdermal, and vaginal options and explain when to use each. They outline when to choose sequential or continuous combined regimens and how to time a switch to aim for amenorrhea. The review summarizes updated guidance after the early Women’s Health Initiative results and place strong weight on age and time since menopause. They describe how local vaginal therapy eases genitourinary syndrome of menopause and lowers urinary symptoms.

Who was reviewed?

The paper focuses on symptomatic peri- and postmenopausal women, especially those younger than 60 years or within 10 years of menopause. It covers women with obesity, insulin resistance, dyslipidemia, hypertension, smoking, and a personal or family history of venous thromboembolism. It guides care for women with prior hysterectomy who can use estrogen alone and for women who need a progestogen for endometrial protection. In addition, the review addresses women over 60 who continue therapy after careful review or who may start with local routes. It includes women with premature ovarian insufficiency who need earlier and longer replacement. The review provides steps to assess risk, choose a safe route, and adjust dose over time.

Most important findings

The authors support early initiation near menopause for the best balance of benefit and risk and oppose late initiation for primary prevention alone and favor transdermal estradiol when thrombotic or cerebrovascular risk exists because it avoids first-pass hepatic effects that can raise clot risk. They state that breast cancer risk with hormone therapy remains low in absolute terms and rises most with some combined regimens and longer use, while micronized progesterone or dydrogesterone may show a more favorable profile than medroxyprogesterone acetate. They explain that women with a uterus must receive adequate progestogen and may use a levonorgestrel intrauterine system to protect the lining and steady bleeding, which can help in obesity.

The review suggests sequential regimens in the transition and early postmenopause and a later move to continuous combined regimens to achieve amenorrhea. They advise that women over 60 who start therapy should often begin with transdermal or local routes and that vaginal estrogen or DHEA suits genitourinary syndrome of menopause. These local options improve vaginal dryness, dyspareunia, urgency, and post-coital cystitis and likely support a lactobacillus-dominant state and lower vaginal pH, which links to fewer urinary infections, although the review does not report taxa. They highlight the need for shared decisions, regular review, and lifestyle change alongside therapy.

Key implications

Clinicians should start with the woman’s goals and risks, aim to begin near menopause, and prefer transdermal estradiol when thrombotic, metabolic, or cerebrovascular risks exist and pair estrogen with an appropriate progestogen when the uterus is intact and consider a levonorgestrel intrauterine system for endometrial protection and bleeding control. Clinicians should address genitourinary syndrome of menopause with low-dose vaginal estrogen or DHEA to restore comfort and urinary health and record vaginal symptom relief and urinary tract infection events as proxy microbiome outcomes. These steps align symptom relief, safety, and vaginal ecosystem support in daily practice.