Millions of European women navigating menopause may soon see a shift in their treatment plans. The European Society of Endocrinology (ESE) has released a major new clinical practice guideline, urging doctors across the continent to adopt a “holistic approach” to midlife health and, critically, to reconsider the way they prescribe hormone therapy to reduce the risk of stroke and breast cancer associated with menopausal hormone therapy (MHT), while recommending safer alternatives for high-risk patients.
The comprehensive guideline, “European Society of Endocrinology clinical practice guideline for evaluation and management of menopause and the perimenopause,” published recently in the European Journal of Endocrinology, emphasizes that while Menopausal Hormone Therapy (MHT) is highly effective for severe symptoms like hot flashes and night sweats, the method of delivery is key to patient safety.
The guidance is particularly pointed for high-risk patients: Women with a history of migraine aura are already at a higher baseline risk for stroke. For this group, the ESE strongly suggests transdermal estrogen due to its proven superior cardiovascular safety profile compared to oral forms.
The ESE analysis found that standard oral hormone treatments — the traditional pills — carry an increased risk of ischemic stroke. The guideline now clearly advises that for women who are appropriate candidates for MHT, low-to-standard dose transdermal oestradiol (delivered via a patch or gel on the skin) is the preferred method, as it demonstrated a neutral effect on stroke risk.
“This is a crucial distinction,” says Mary Ann Lumsden, an endocrinology specialist at the University of Glasgow and one of the guideline authors. “We know MHT works, but now the consensus is moving away from oral pills toward transdermal patches to safeguard the cardiovascular health of patients, especially as they age.”
The guidance is particularly pointed for high-risk patients: Women with a history of migraine aura are already at a higher baseline risk for stroke. For this group, the ESE strongly suggests transdermal estrogen due to its proven superior cardiovascular safety profile compared to oral forms.
The guidelines stress that treatment is not just about hormones. The ESE called for a fundamental shift toward a holistic approach, recommending that clinicians address diet, exercise, and mental health rather than focusing solely on hormone replacement therapy (HRT).
The new ESE document also clarifies the diagnostic pathway for women who experience menopause prematurely. The guidelines recommend that Premature Ovarian Insufficiency (POI) should be considered for any woman under the age of 40 experiencing irregular periods, subfertility, or classic menopausal symptoms. Biochemical testing is recommended for this younger group. Furthermore, the experts urge immediate referral of women with POI to a specialized menopause expert or multidisciplinary team. This is particularly important for those who have complex medical histories, such as a high risk of hormone-dependent cancers.
Finally, the guideline mandates clear communication on cancer risk. Doctors are instructed to ensure that all women initiating MHT are informed about the increased risk for breast cancer. With the lifetime risk of breast cancer in Western women exceeding 10%, according to the ESE, American Cancer Society, and the U.S. National Cancer Institute, the ESE emphasized that transparency and informed consent are non-negotiable parts of the prescribing process. The comprehensive document ultimately serves as a call to action for healthcare professionals, ensuring they possess the fundamental knowledge to evaluate, counsel, and optimally manage women through the perimenopausal and postmenopausal phases of life, navigating the balance between symptom relief and long-term health risks.
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