Menopause: what the guidelines say

Menopause is defined, clinically, as having gone 12 consecutive months without a menstrual period, marking the end of a woman’s reproductive years. The years leading up to that point, when periods become irregular and hormone levels fluctuate, are called perimenopause, and many of the symptoms people associate with menopause typically begin during this transition rather than after it. This page describes what The Menopause Society, the organization formerly known as the North American Menopause Society (NAMS), says in its current position statements about the menopause transition and the treatment options its guidance describes, primarily its 2022 Hormone Therapy Position Statement.

The two symptom categories the guideline centers

The Menopause Society’s position statement organizes menopause symptoms around two categories where the evidence for treatment is strongest.

Vasomotor symptoms (VMS), commonly known as hot flashes and night sweats, are the symptoms most people associate with menopause. They result from hormonal shifts affecting the body’s temperature regulation and can persist for years, into the postmenopausal period, for a substantial share of women.

Genitourinary syndrome of menopause (GSM) is a newer, broader term that replaced older labels like vaginal atrophy. It describes a collection of changes, vaginal dryness, irritation, and discomfort, along with urinary symptoms, that result from declining estrogen in the tissues of the vagina, vulva, and lower urinary tract. Unlike hot flashes, which often ease over time, GSM tends to be progressive without treatment and does not typically resolve on its own.

The guideline states that hormone therapy is the most effective treatment option for both of these symptom categories among the options it reviews.

The Women’s Health Initiative and why it still shapes this conversation

Any honest description of this topic has to account for the Women’s Health Initiative (WHI), the large randomized trial whose initial 2002 results are the reason hormone therapy use fell sharply and stayed lower for two decades. That first analysis, in a study population whose average age was in the early 60s, well past the average age of menopause onset, reported increased risks of breast cancer, stroke, and blood clots in the group assigned to combined estrogen-progestin therapy, results that were widely reported as applying to hormone therapy broadly.

Subsequent reanalyses of the same WHI data, published over the following years including a 2017 follow-up in JAMA reporting on long-term mortality, examined outcomes by the age of participants and how many years had passed since their menopause began. Those age-stratified analyses found a different pattern for younger, recently menopausal women than the original headline results suggested: women who started hormone therapy in their 50s or within 10 years of menopause onset did not show the same elevated cardiovascular risk seen in the older participants, and some analyses found more favorable outcomes in that younger group. This is the evidence base behind what is often called the “timing hypothesis”: that when hormone therapy is started relative to menopause onset materially changes its benefit-risk profile.

The Menopause Society’s current position statement reflects this reappraisal. It is not a claim that the original WHI findings were wrong; the increased risks the WHI identified in its older study population were real. It is a statement that those findings do not straightforwardly generalize to a woman in her early 50s with hot flashes, which is a different clinical picture than the trial’s average participant.

How the guideline frames the benefit-risk decision

The position statement states that for most healthy, symptomatic women younger than 60 or within 10 years of menopause onset, the benefits of hormone therapy generally outweigh the risks. It describes this as neither a blanket recommendation for all menopausal women nor a narrow exception; it is a framework that the guideline says should be individualized based on a woman’s symptoms, age, time since menopause, personal and family medical history, and specific risk factors such as history of blood clots, stroke, heart disease, or certain cancers. The guideline also notes that route of administration matters: it describes transdermal (through the skin) forms of estrogen as potentially carrying a lower risk of blood clots and stroke than oral forms for some women, one of several factors a clinician weighs alongside a person’s individual risk profile.

This area is actively changing at the regulatory level as well. In November 2025, the FDA announced that it would remove the boxed warning, the most prominent safety warning a drug label can carry, from menopausal hormone therapy products and move to age-specific labeling, describing the change as bringing the labels closer to the age-stratified evidence above. The Menopause Society, in its published comment on the announcement, characterized the move as consistent with the current understanding of how benefit and risk vary by age. A labeling change alters how the warning is presented, not the individualized weighing the position statement calls for: the decision still belongs to each woman and her clinician together.

Option categories the guideline describes

For systemic symptoms like hot flashes, the guideline describes systemic estrogen therapy, taken together with a progestogen for women who still have a uterus (to protect the uterine lining), as the primary hormonal option category. Estrogen alone is described as appropriate only for women who have had a hysterectomy.

For GSM specifically, the guideline describes low-dose vaginal estrogen, applied locally rather than absorbed throughout the body to the same degree as systemic therapy, as an option with a different, generally more favorable risk profile than systemic hormone therapy, since it treats local tissue rather than circulating throughout the body.

For women who cannot or choose not to use hormone therapy, The Menopause Society’s separate nonhormone therapy position statement describes several non-hormonal option categories for vasomotor symptoms: certain SSRI and SNRI antidepressants, used in this context for their effect on temperature regulation rather than for a mood disorder, and fezolinetant, an FDA-approved neurokinin-3 (NK3) receptor antagonist, a newer nonhormonal drug class specifically developed to target the hot-flash pathway, approved by the FDA in 2023.

This page names these as categories the guideline describes. It does not state a dose, a brand, or which option is right for any individual reader; that determination depends on a full medical history only a clinician has.

The honest nuances

The genuine, ongoing debate in this area is less about whether hormone therapy works for symptoms, the trial evidence on that is strong, and more about who the WHI’s risk findings actually apply to, and how confidently a clinician can extrapolate the timing-hypothesis pattern to an individual woman decades after the original trial was designed. The WHI was not built to test the timing hypothesis; the age-stratified findings come from secondary analyses of a trial designed around a different, older population, which is a real limitation the guideline itself acknowledges even as it relies on that evidence. There is also genuine variation in how different clinicians weigh a family or personal history of breast cancer, clotting disorders, or cardiovascular disease against the symptom relief hormone therapy offers, which is why the guideline calls for individualized, shared decision-making rather than a single rule.

Questions to discuss with your clinician

• Where do I fall in the age and years-since-menopause framing the guideline uses, and how does that affect my own benefit-risk picture?
• Do I have personal or family history factors, such as blood clots, stroke, heart disease, or certain cancers, that would change how this guideline applies to me?
• Am I dealing primarily with vasomotor symptoms, genitourinary symptoms, or both, and does that change which option category is worth discussing?
• If hormone therapy is on the table, would a transdermal route be relevant to my risk profile compared to an oral one?
• What would a nonhormonal option look like for my situation, and how does its evidence compare to hormone therapy for what I am experiencing?
• How often should this decision be revisited as I move further from menopause onset?

For related evidence on midlife health factors that intersect with the menopause transition, see bone density and strength training and the osteoporosis screening guideline, or read the companion profile on thyroid function, whose symptoms can overlap with perimenopause.