Menopause
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Menopause | 12 months of amenorrhea with no other cause, a clinical diagnosis. |
| Stage | Early perimenopause: cycle interval under 60 days. Late perimenopause: 60 days or more. Postmenopause: 12 months of amenorrhea. |
| Contraception | Pregnancy is still possible in both perimenopause stages.Discuss contraception. |
| Timing of a start | Starting before 60 would not raise stroke or Alzheimer disease risk.
Starting at 60 or later would raise breast cancer, ovarian cancer, stroke and Alzheimer disease risk. INESSS tool opens in a new tabINESSS benefits and risks tool opens in a new tab Can start safely under 60 or under 10 years past menopause, with no contraindication. |
| Before 45 | Higher risk of fracture and cardiovascular disease Continue at least until the usual age of menopause, then reassess. |
| Before 40 | Consider a specialist referralOutside the INESSS tool. Contraception may still be needed. |
Investigate
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Age 45 and older | No labs to confirm menopause |
| Mainly under 45 | FSH and estradiol may be considered if:amenorrhea over 3 months, off hormonal contraception; estrogen-deficiency symptoms after hysterectomy. |
| Do not | Salivary or urinary hormone tests are not recommended |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Genitourinary symptoms only | Local vaginal estrogen, no progestogen.Active or past breast cancer: consider a specialist (INESSS). |
| Systemic symptoms | |
| Defer | Abnormal vaginal bleeding or an acute medical condition:Wait for work-up or stabilization. |
| Specialist first | Hormone therapy only if non-hormonal options failPersonal history of: breast, ovarian or endometrial cancer; stroke, myocardial infarction or cardiovascular disease; venous thromboembolism; high-risk thrombophilia; familial hypertriglyceridemia; porphyria cutanea tarda. |
| Not a barrier alone | Family history of breast cancer; BRCA 1 or 2 with preventive salpingo-oophorectomy; benign breast tumour. |
| Route | Oral or transdermal estradiol.Prefer transdermal with: type 2 diabetes; dyslipidemia; hypertension; migraine; smoking; inflammatory bowel disease; malabsorption; metabolic syndrome; BMI over 30. |
| Uterus present | Add micronized progesterone, or an LNG-IUD under 5 years old.Cyclic if cycles are under 3 months apart. Continuous if cycles are 3 months or more apart. |
| Every start | |
| Do not | Compounded creams or hormone implants not approved by Health Canada |
| Duration | No maximum definedLocal therapy continues as long as symptoms bother. They usually return on stopping. |
Adjustment, high doses and other products: INESSS tool opens in a new tab.
| Drug | Start | Next step | Note |
|---|---|---|---|
| Systemic estrogen | |||
| 17β-estradiol oral | 0.5 mg DIE titration: see INESSS tool opens in a new tab | 1 mg DIE (standard) | Standard start if menopause before 45 |
| 17β-estradiol patch | 25 mcg/day titration: see INESSS tool opens in a new tab | 50 mcg/day (standard) | Change once or twice weekly, per product |
| Progestogen, uterus present | |||
| Micronized progesterone, continuous | 100 mg DIE, at bedtime | Cycles 3 months or more apart | |
| Micronized progesterone, cyclic | 200 mg DIE, at bedtime, 14 days of 28 | Cycles under 3 months apart | |
| LNG-IUD | 52 mg device | Replace every 5 years for endometrial protection. Not Health Canada-labelled for this use. | |
| Vaginal estrogen | |||
| Estradiol vaginal ring | 2 mg, replace every 90 days | About 7.5 mcg/day | |
| Estradiol vaginal tablet | 4 or 10 mcg at bedtime for 14 days titration: see INESSS tool opens in a new tab | Then twice weekly | Space maintenance doses 3–4 days apart |
| Estrone cream 1 mg/g, or conjugated estrogen cream 0.625 mg/g | 0.5 g at bedtime twice weekly | Estrone dose differs from the monograph (stakeholder experience) | |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Visits | About 3 months after a start or change Then about yearly. |
| Expected effect | Vasomotor: 1–4 weeks, up to 6–8 weeks at low dose. Genitourinary, local therapy: 1–3 months. |
| Unexpected bleeding | |
| Investigate | Assess the endometrium if:heavy, persistent or post-coital bleeding, even in the first 6 months; postmenopause: bleeding still present 6 months after starting, or new months or years later. |
| Wait | Light to moderate bleeding in the first 6 months needs no work-up. |
| No extra tests | None required because of hormone therapy itself |
| 65 or older, or 10 or more years of use | Consider: a lower estrogen dose; continuing if bothersome symptoms persist; trial stops of 2–3 months about every 5 years. |
| Stopping | Stop at once or taperA restart after a brief stop counts as continuing, not a new start. |
| Suspend | During work-up of a breast mass or an acute medical event |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.