The European Society of Endocrinology (ESE) has issued a new clinical practice guideline intended to bring consistency and balance to menopause care across Europe, where access and approaches remain highly variable. Published last month in the European Journal of Endocrinology, the document lays out clear, evidence-based steps for diagnosis and management, emphasizing a “middle way” for menopausal hormone therapy (MHT) alongside lifestyle and nonhormonal options.

Why it matters: Up to 1 in 4 postmenopausal women experience symptoms severe enough to disrupt work and daily life, yet care remains uneven. Europe is ageing and demand is rising: About 11% of women in Europe are 45-60 years old, which translates to roughly 25.2 million people navigating perimenopause or postmenopause. The new guidance targets primary care, gynecology, and endocrinology to standardize practice, reduce unnecessary testing, and support appropriate, individualized MHT use.

“One in four postmenopausal women experience debilitating symptoms,” said Mary Ann Lumsden, MD, professor of medical education and gynecology at the University of Glasgow in Glasgow, Scotland, and chair of the ESE guideline committee. “They don’t function fully in their workplace or in their social lives, and all doctors should be able to help them in the best way they can.”

A Persistent Gap in Awareness and Training

Although women make up 51% of Europe’s population, awareness of menopause and its management remains low among both patients and clinicians. “Women know very little about the problems of menopause,” Costantino Di Carlo, MD, PhD, gynecologist at the University of Naples Federico II in Naples, Italy, told Medscape News Europe. “Most gynecologists do not have enough training to deal with menopausal problems,” he added.

A recent report from Portugal, Spain, and Italy found poor awareness among women and clinicians and a low uptake of MHT. Di Carlo links this to enduring fear of hormones after high-profile studies in the early 2000s, notably the Million Women Study and the Women’s Health Initiative (WHI), which spotlighted potential risks with hormonal therapies, including contraceptives and hormone replacement therapy (HRT) for menopause.

“Even if a following reanalysis of the data showed that hormone therapy is not so dangerous,” Di Carlo said, many practitioners remain reluctant to prescribe it and many patients are unwilling to take it. “Women are afraid and doctors are afraid.” In Italy, he noted, MHT use is among the lowest in Europe, at about 7%, whereas sales of food supplements for menopause (€33 million in 2023) are now more than double the market for pharmaceutical MHT (€15 million).

Care is also constrained by access. “In Naples [province], which has about three million inhabitants, there are only three centers specialized in the care of menopause,” Di Carlo said. 

Beyond infrastructure, socioeconomic, cultural, and language barriers can block engagement. In more ethnically diverse countries, “The information is mainly available in the national language or in English,” said Eleni Armeni, MD, PhD, endocrinologist at the Royal Free Hospital, London, and assistant professor at the University of Birmingham, Birmingham, both in England. Some women also hold a “strong belief that this health change is a process they have to go through and bear rather than trying to do something about it.”

The Guideline’s ‘Middle Way’

The history of MHT has been a “pendulum swinging,” Lumsden said. In the 1990s, “MHT was the answer to absolutely everything.” After the WHI papers, use “went through a nosedive.” Now the committee worries the pendulum may be swinging too far in some settings, with indiscriminate prescribing in some clinics and avoidance in others. “The purpose of the guideline is to find a way down the middle and provide a very sensible, evidence-based approach,” Lumsden said.

Key recommendations from the ESE guideline include:

• Take a holistic approach: Look beyond MHT alone to lifestyle measures, psychosocial support, and nonhormonal options as appropriate.
• Diagnosis in women aged ≥ 45 years: Do not rely on biochemical testing (eg, follicle-stimulating hormone [FSH] testing). Make a clinical diagnosis based on menstrual changes and symptoms such as hot flashes and night sweats; hormone levels fluctuate and are not diagnostically useful at this age.
• Diagnosis in women aged 40-45 years: Consider perimenopause in the presence of vasomotor symptoms or menstrual irregularity; biochemical testing can aid diagnosis.
• Women aged < 40 years: Consider premature ovarian insufficiency (POI); confirm with FSH testing. Refer all women with POI to a specialist or multidisciplinary team.
• HRT for POI: Recommend HT irrespective of vasomotor symptoms to mitigate long-term health risks; continue until the expected age of natural menopause.
• When to start MHT: Initiate for bothersome menopausal symptoms in women younger than 60 years or within 10 years of menopause onset.
• Bone health: MHT prevents bone loss and reduces fracture risk; consider initiation for bone protection in asymptomatic women younger than 60 after individual risk-benefit assessment.
• Contraindications and cautions:
  • Do not use MHT solely for primary or secondary prevention of cardiovascular disease or to prevent dementia.
  • Systemic MHT is generally not recommended in women with a history of breast cancer except in exceptional circumstances after oncology consultation.
  • For survivors of breast cancer with genitourinary symptoms, consider low-dose vaginal estrogen if nonhormonal measures fail.
• Route of administration: After individual risk-benefit assessment, prefer transdermal estrogen for women with certain comorbidities (eg, well-controlled hypertension or diabetes, history of migraine with aura, or history of venous thromboembolism).

Making Guidance Stick

Armeni and Di Carlo, who were not involved in the ESE guideline formation, believe the document can help bring menopause care onto the agendas of endocrinologists and general practitioners. But both say education is the primary challenge. “There is a lack of training and potentially a downplay of the importance of the issue among general practitioners and internists,” said Armeni. Di Carlo added that gynecologists are often more focused on surgery or obstetrics than on menopausal medicine.

This is starting to shift. Di Carlo reported that the Italian Society for Menopause is working to integrate menopausal medicine into specialist training, and he sees growing political interest in addressing the health needs of this large demographic because “it can be politically advantageous.”

Ultimately, experts argue for a two-pronged educational effort: Equip general practitioners and internists with practical, evidence-based pathways, and empower the public with clear information. “Apart from the doctors knowing what to do, it’s important for the women to know what is available for their health,” Armeni said. 

Lumsden and Armeni reported having no relevant financial relationships. Di Carlo reported being a lecturer and member of the advisory boards of Theramex, Gedeon-Richter, Exeltis, Bayer, Italfarmaco, and Shionogi. 

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, New Scientist, The Guardian, MIT Technology Review, and others.