Menopause counselling tool

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MenoTool

Explore systemic menopause hormone therapy options and match the conversation to patient priorities.

Therapy

Options

Hormones labelled as bioidentical

Combined bioidentical

This combines estrogen with a progesterone-type hormone. The estrogen is usually estradiol, which is the same main estrogen the ovaries make before menopause. Progesterone is added for people with a uterus to protect the uterine lining.

This is a common option for menopause symptoms when a person has a uterus. The main choices are how to take the estrogen, such as patch, gel or pill, and which progesterone-type hormone to use.

Clinician-focused

Specialist expertise recommended

Seek specialist expertise before starting or continuing MHT when any of the following are present:

  • Breast, ovarian or endometrial cancer
  • Stroke, myocardial infarction or cardiovascular disease
  • High-risk thromboembolic genetic mutation
  • Venous thromboembolism
  • Familial hypertriglyceridemia
  • Porphyria cutanea tarda

Clinician-focused

Use transdermal estradiol when possible

These comorbidities favor transdermal estradiol over oral estrogen when MHT is appropriate:

  • Type 2 diabetes
  • Dyslipidemia
  • Hypertension
  • Migraine with or without aura
  • Smoking
  • Inflammatory bowel disease
  • Malabsorption
  • Metabolic syndrome
  • Obesity (BMI > 30)

Priorities

Match the conversation

Symptoms and goals

TreatmentHot flashesNight sweatsSleep disordersLibido, desire and sexual functionSymptoms of anxietySymptoms of depressionJoint pain
Combined bioidentical✓✓✓✓==
Combined classical✓✓✓✓x✓
Estrogen-only bioidentical✓✓✓✓✓=x
Estrogen-only classical✓✓✓xx
Tibolone✓=x✓✓=x
Bazedoxifene/CEE✓✓✓x
Progesterone onlyx✓
Estradiol + Slynd/IUD
✓Positive outcome evidence=Mixed evidenceNo data availablexNo observed effect/no difference

Risks and trade-offs

Other topics

Key messages from International Menopause Society (IMS) on venous thromboembolism

  • Individuals at increased risk for VTE include those with obesity, inherited thrombophilia or a previous history of VTE.
  • Individuals requiring MHT should be risk assessed and counselled about their risk of VTE.
  • Oral estrogen therapy increases the risk of VTE and is not recommended in women at increased risk for VTE.
  • Unlike oral estrogen therapy, transdermal estrogen therapy does not increase the risk of VTE, even in the presence of additional risk factors such as obesity, inherited thrombophilia and previous history of VTE.
  • Transdermal estrogen is recommended for use in high-risk women requiring MHT, in combination with a suitable progestogen in women with an intact uterus.
  • For combination therapy, the choice of progestogen is important; the use of suitable progestogens is recommended, such as micronized progesterone, dydrogesterone, or a levonorgestrel-releasing intrauterine system.
  • There is no indication for thrombophilia testing before commencing MHT.
Source: IMS Recommendations and Key Messages full document

INESSS information

Combined bioidentical hormones

INESSS page 6
  • Transdermal current use showed no difference from absence of hormone therapy.
  • Oral current use was associated with a 70% risk increase.
  • Micronized progesterone combined with estrogen showed no difference from absence of hormone therapy in the reviewed literature.
  • No difference from absence of hormone therapy was observed.

Duavive (bazedoxifene/CEE)

INESSS page 21
  • No data available from the INESSS document for venous thromboembolic risk.