Guide for General Practitioners Menopause

Introduction

This guide is a practical tool for general practitioners in the assessment and treatment of peri- and menopausal women. It is based on the Norwegian Gynecological Guidelines 2024, NICE NG23 (2024), British Menopause Society (BMS) guidelines, European Society of Endocrinology (ESE) clinical guidelines 2025, as well as relevant research concerning special patient groups.

Important clarification: This document represents a proposed clinical approach. Clinicians must always apply professional judgment and remember that guidelines change continuously. Individual assessment and follow-up are essential.

Assessment

Holistic approach: The four pillars

When evaluating peri- and menopausal symptoms, a comprehensive approach based on four pillars is recommended:

1. Hormones – Estrogen, progesterone, and testosterone status
2. Psychological status – Family relationships, work conflicts, anxiety, depression, sleep quality
3. Nutrition – Diet, weight, metabolic health
4. Physical activity – Exercise habits and daily movement

Differential diagnoses

• Hyperthyroidism and hypothyroidism (pheochromocytoma, carcinoid syndrome, leukemia, arrhythmias)
• Sleep disorders of other causes
• Medication side effects
• Anxiety disorders and depression

Age-based management

Under 40 years: Premature ovarian insufficiency (POI)

All women with POI should be referred to a gynecologist for evaluation and follow-up. POI is diagnosed by oligo-/amenorrhea for at least 4 months combined with FSH levels in the postmenopausal range measured twice at least 4 weeks apart. These women have an increased risk of cardiovascular disease, osteoporosis, cognitive impairment, and premature death, and therefore require specialist follow-up.

40–45 years: Early menopause

Referral to a gynecologist is recommended where possible.

Women with early menopause have increased long-term health risks, and specialist assessment may ensure optimal hormone replacement at least until the expected age of menopause (approximately 52–53 years).

45 years and older: Natural menopause

Can generally be managed by general practitioners.

Important exception: All bleeding disorders (menorrhagia/metrorrhagia) should be referred to a gynecologist for further evaluation. This particularly applies to irregular or heavy bleeding, as underlying pathology (polyps, fibroids, adenomyosis, endometrial hyperplasia, or malignancy) must be excluded.

Treatment

Overall principle

“It is the woman’s subjective menopausal symptoms, and her experience of how the symptoms affect her quality of life, that determine whether treatment should be offered.”
– Norwegian Gynecological Guidelines 2024

Treatment steps

1. Lifestyle optimization

Before initiating pharmacological treatment, advice should always include:

• Smoking cessation
• Regular physical activity (including strength training)
• Healthy diet and weight control
• Sleep hygiene
• Stress management / cognitive strategies

2. Menopausal Hormone Therapy (MHT)

MHT is the most effective treatment for vasomotor symptoms, sleep disturbances, mood fluctuations, and reduced quality of life related to estrogen and progesterone deficiency.

General principles for MHT

Estrogen therapy

Transdermal estrogen is recommended over oral administration to reduce the risk of thromboembolic events.

• Patches (Estradot) provide more stable hormone delivery and fewer fluctuations compared with spray (Lenzetto) and gel (Estrogel).
• In natural menopause, treatment should start with the lowest effective dose.
• Dosage is adjusted according to symptoms and response — individual titration is key.

Endometrial protection with progestogen

All women with a uterus must receive progestogen for endometrial protection.

First choice: Micronized progesterone (Utrogestan)

• Lower breast cancer risk compared with synthetic progestogens.
• Should be taken in the evening due to its sedative effect.
• Many women experience improved sleep quality and reduced anxiety/restlessness.

Mirena IUS as an alternative

• Provides local endometrial protection with minimal systemic progesterone exposure.
• Reduces bleeding by up to 90%; particularly suitable when contraception or bleeding disorders coexist.
• Important: Mirena does not always relieve typical progesterone-deficiency symptoms such as early waking, inner restlessness, or nervous tension.
• In such cases, Utrogestan may be added to Mirena plus transdermal estrogen.

Treatment regimens

Sequential therapy

Indication: Perimenopause and up to 6–12 months after the last menstrual period.

• Utrogestan is given for 12–14 days per month, estrogen continuously.
• This regimen mimics the natural menstrual cycle and produces predictable withdrawal bleeding.

Exception: In cases of severe sleep disturbance or pronounced progesterone-deficiency symptoms, continuous Utrogestan may be tried, but sequential use should be resumed if no effect is seen within 3 months.

Continuous combined therapy

Indication: Postmenopause (>12 months since last menstruation).

• Both estrogen and progestogen are given daily.
• The goal is bleeding cessation after 3–4 months.

Vaginal estrogen

Indications: Vaginal atrophy, recurrent urinary tract infections, urinary leakage, prolapse.

• May be given in addition to systemic MHT.
• Minimal systemic absorption — generally considered safe even in women with contraindications to systemic MHT?
• Preparations: Vagifem (vaginal tablets), Ovesterin (gel/tablets), Gynoflor (estriol + lactobacilli).

Testosterone for women

Indication

• Reduced sexual desire in women not adequately responding to estrogen and progesterone alone.
• Some studies suggest improved focus, concentration, and energy (insufficient evidence according to Norwegian Gynecological Guidelines 2024).

Dosage and follow-up

• Preparation: Tostran gel
• Dose: Pea-sized amount applied behind the knee every other morning.
• Target level: Should not exceed 2.2 nmol/L (testosterone measured after 3 weeks).
• Follow-up:
  • Effect on sexual function and side effects (hair growth, acne) assessed after 6 weeks.
  • Thereafter review every 6 months.

Note: Testosterone is not approved for women in Norway but may be prescribed off-label following individual assessment.

Contraindications to MHT

MHT is discouraged in:

• Active or previous breast cancer
• Known or suspected estrogen-sensitive malignancy
• Vaginal bleeding of unknown cause
• Current venous thromboembolism (VTE)
• Previous or ongoing coronary heart disease
• Active liver disease
• Porphyria cutanea tarda

Special patient groups

Migraine with aura

Transdermal estrogen may be used, but oral estrogen is contraindicated due to increased risk of arterial events. Severe symptoms or multiple risk factors should be discussed with a neurologist.

Recommendations:

• Patches (Estradot) provide more stable hormone levels and fewer fluctuations than spray/gel, potentially reducing migraine triggers.
• Cyclical progesterone may worsen migraine; micronized progesterone provokes fewer attacks.
• Alternative: Mirena IUS + transdermal estrogen for maximal hormonal stability.

Absolute contraindication if combined with:

• Smoking
• Two or more stroke risk factors (diabetes, hyperlipidemia, hypertension)

Endometriosis

MHT should be offered to menopausal women with endometriosis — research indicates benefits outweigh risks.

Special considerations:

• Continuous combined MHT is first choice, even after hysterectomy.
• Estrogen monotherapy may reactivate endometriotic lesions.
• Recommended regimen: Mirena and/or Utrogestan (depending on progesterone deficiency symptoms) + transdermal estrogen.
• Women with repeated surgical treatment for endometriosis are at higher risk of early menopause and require particular attention.

ADHD

Estrogen increases dopamine production in the brain; declining estrogen may worsen ADHD symptoms.

Progesterone has a more complex and often negative effect, potentially reducing dopamine release in the prefrontal cortex and worsening inattention, emotional dysregulation, and irritability.

Recommendations:

• Cyclical regimen with evening Utrogestan, though Mirena IUS is often preferred due to minimal systemic progesterone effects.
• Transdermal estrogen (patch, gel, or spray).
• Evidence base limited — only 11 studies included in the systematic review by Osianlis et al. (2025).

Hypothyroidism

Hypothyroidism is 10 times more common in women than men, and 12–20% of women over 60 have underactive thyroid function.

Important interaction:

• Oral estrogen increases thyroxine-binding globulin (TBG), reducing free (bioactive) T4.
• This may require increased levothyroxine dosage.

Recommendations:

• TSH should be rechecked after starting oral combined MHT.
• Transdermal MHT has less effect on thyroid function.
• Many women experience improved thyroid function with MHT.
• Approximately 5% of menopausal women use both MHT and levothyroxine.

Type 2 diabetes

Menopause significantly increases the risk of insulin resistance due to declining estrogen.

MHT may be beneficial:

• Reduces HbA1c and fasting glucose
• 35.8% reduction in insulin resistance (HOMA-IR) compared with placebo
• 21–30% lower risk of developing diabetes (WHI study)
• Improves lipid profile, reduces central fat accumulation, and may lower blood pressure

Important clarification: MHT should not be prescribed solely for diabetes prevention — symptom relief remains the main indication.

Metformin

Metformin may be particularly effective during menopause due to its effect on insulin resistance. Research suggests potential benefit in women with type 2 diabetes and obesity who have or are at risk of breast cancer.

Metabolic syndrome and obesity

Menopause induces metabolic disturbances including increased visceral fat, insulin resistance, dyslipidemia, and hypertension. Approximately 50% of cardiovascular events in women are related to metabolic disturbances.

MHT effects:

• Reduces BMI, waist circumference, and abdominal fat
• Lowers LDL cholesterol and triglycerides, increases HDL
• Reduces insulin resistance and may lower blood pressure

Tirzepatide (GLP-1/GIP agonist) + MHT

A recent study showed that combining tirzepatide with MHT produced significantly greater weight loss in postmenopausal women with overweight or obesity compared with tirzepatide alone.

Results:

• MHT users: ~20% total body weight loss after 18 months
• Non-users: ~15% total body weight loss
• 45% of MHT users achieved ≥20% weight loss vs. 18% of non-users

Explanation: Preclinical data suggest synergistic interaction between estrogen and GLP-1 signaling, where estrogen enhances appetite-suppressing effects.

Rheumatoid arthritis (RA)

Early menopause increases the risk of RA and may worsen existing disease.

MHT may be protective:

• Reduces inflammatory markers (TNF-α, IL-6)
• Improves disease activity score (DAS28)
• Improves bone mineral density (BMD) and may protect against joint destruction
• Women with RA using MHT have higher remission rates

Important: The American College of Rheumatology recommends MHT for most postmenopausal women with rheumatic conditions, except those with lupus and antiphospholipid antibodies due to increased thrombosis risk.

PCOS (Polycystic Ovary Syndrome)

Women with PCOS are accustomed to higher testosterone levels and may experience more pronounced symptoms when levels decline rapidly in peri- and menopause.

Recommendations:

• Transdermal estrogen (patch, spray, or gel) + micronized progesterone (Utrogestan) or Mirena IUS
• Testosterone may be beneficial as part of MHT due to abrupt decline
• Lifestyle interventions remain important (weight loss, diet, physical activity)

Significant bleeding disorders

Significant perimenopausal bleeding disorders are best treated with Mirena IUS or surgical intervention (TCRE — transcervical resection of the endometrium — or hysterectomy).

Referral to a gynecologist is recommended for:

• Heavy or irregular bleeding not responding to conservative treatment
• Postmenopausal bleeding
• Bleeding of unknown cause

Summary and practical advice

Start with the basics:

1. Lifestyle optimization always comes first.
2. Individual assessment of symptoms, risk factors, and patient preferences.
3. Start with the lowest effective dose; no strict time limit for treatment. For economic reasons, consider discontinuation after 3–5 years around the usual age of menopause.

Choose the right MHT

• Estrogen: Transdermal (patch, gel, spray) preferred over oral.
• Progestogen: Micronized progesterone (Utrogestan) preferred over synthetic progestogens (lower breast cancer and thromboembolic risk).
• Regimen: Generally sequential in perimenopause, continuous postmenopause.

Do not forget special needs:

• Vaginal atrophy: add local estrogen.
• Reduced libido: consider testosterone.
• Comorbidities: adapt treatment to hypothyroidism, diabetes, ADHD, migraine, endometriosis, etc.

Refer to a gynecologist when:

• POI (<40 years) — always
• Early menopause (40–45 years) — recommended
• Bleeding disorders — menorrhagia/metrorrhagia
• Complex cases or lack of treatment response

Sources

1. Norwegian Gynecological Guidelines, menopause chapter, 2024
2. NICE NG23 Menopause Guideline 2024 — menopause, POI, genitourinary symptoms
3. British Menopause Society guidelines 2022–2025 — endometriosis, migraine, ADHD, autoimmune diseases, diabetes, metabolic syndrome, PCOS
4. European Society of Endocrinology Guidelines 2025
5. Osianlis E, et al. ADHD and Sex Hormones in Females: A Systematic Review. Journal of Attention Disorders 2025; 29(9):706–723

Final note: This guide represents a suggested clinical practice approach and does not replace individual clinical judgment or updated national guidelines. Professional judgment and a patient-centered approach remain essential at all times.