Choice of systemic MHT for premature ovarian insufficiency and early menopause

Untreated POI and early menopause are risk factors for cardiovascular disease and osteoporosis (although they reduce risk of breast cancer). Estrogen therapy is indicated in individuals with POI or early menopause for prevention of cardiovascular disease and osteoporosis, regardless of menopausal symptoms or bone mineral density (see also Osteoporosis and minimal-trauma fracture and Identifying people suitable for atherosclerotic cardiovascular disease risk estimation).

Addition of a progestogen is required for individuals with endometrial tissue. This may include individuals who have had a total hysterectomy, but who have significant endometriosis, to prevent stimulation of endometrial deposits and malignant transformation; seek specialist advice. See also Systemic MHT in individuals with endometriosis.

The optimum regimen of hormone therapy for individuals with POI or early menopause is unknown; however, higher estrogen doses may be required for symptom relief and bone mineral density accrual.

Continue treatment at least until the median age of natural menopause (51 years) to minimise risks of osteoporosis and cardiovascular disease.

Note: Treat premature ovarian insufficiency or early menopause until at least age 51 years to minimise cardiovascular and bone health risks.

Individuals with spontaneous POI or early menopause may require contraception. MHT is not contraceptive, so these individuals should be counselled regarding the potential (but very low chance) of pregnancy. Options of hormone therapy that also provide contraception are:

continuous use of combined hormonal contraception (a combined oral contraceptive or the contraceptive vaginal ring)—hormone-free intervals must be avoided to ensure adequate estrogen for bone health and symptom control; individuals with POI have minimal endogenous estrogen production. See Tailored regimens of combined hormonal contraceptives for continuous use regimens
continuous estrogen-only systemic menopausal hormone therapy (MHT) plus the 52 mg levonorgestrel-releasing intrauterine contraceptive device ¹.

Note: If an individual with POI is using combined hormonal contraception, use should be continuous to ensure adequate bone protection and to avoid symptoms of estrogen deficiency.

Specialist referral is needed for individuals with POI or early menopause who do not tolerate hormone therapy.

¹ The 19.5 mg levonorgestrel-releasing intrauterine contraceptive device is not recommended because it does not provide endometrial protection in menopause.Return