Women with POI have unique needs. They may not only suffer from symptoms associated with estrogen deficiency, but can also experience other issues, with a significant impact on their quality of life and later health outcomes. POI can have significant effects on fertility, bone health, cardiovascular health, sexual function, psychological health and neurological function.

The impact of POI on these different domains and the treatment options for each along with monitoring needs where relevant are all discussed in the guideline.

In addition to hormone therapy the guideline also covers non-hormonal and complementary treatments, lifestyle interventions and puberty induction.

This guideline is an updated version and replaces the ESHRE Guideline on the management of women with POI (2016) (see )

Guideline 

ESHRE Guideline on premature ovarian insufficiency - full version15.76 MB

Acknowledgements (from the Guideline)

We gratefully acknowledge the contribution of our engaged, funding, partner and collaborating organisations:

•  ESHRE

• Our partner organisations which co-funded the guideline: American Society for Reproductive Medicine (ASRM), International Menopause Society (IMS), and The Australian National Health and Medical Research Council (NHMRC) through the funded Centre for Research Excellence in Women’s Health in Reproductive Life (CRE WHiRL)

• Our collaborating and engaged consumer groups.

  • American College of Obstetricians and Gynecologists (ACOG)

  • ��ݮ��Ƶ (AMS)

  • British Menopause Society (BMS)

  • European Menopause and Andropause Society (EMAS)

  • Endocrine Society (ES)

  • International Society of Gynecological Endocrinology (ISGE)

  • North American Menopause Society (NAMS)

  • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

  • Royal College of Obstetricians and Gynaecologists (RCOG)

Health Professional resources

POI GUIDELINE_HCP Toolkit PDF6.05 MB

Patient resources

POI GUIDELINE Patient version2.28 MB

Reference

Guideline on premature ovarian insufficiency 

Content created February 2025

• Hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture.

• Personalization with shared decision-making remains key, with periodic reevaluation to determine an individual woman’s benefit-risk profile, with recommendations for the use of the appropriate dose, duration, regimen, and route of administration required to manage a woman’s symptoms and to meet treatment goals.

• Risk stratification by age and time since menopause is recommended.

• The benefits of hormone therapy outweigh the risks for most healthy symptomatic women who are aged younger than 60 years and within 10 years of menopause onset.

• Transdermal routes of administration and lower doses of hormone therapy may decrease risk of venous thromboembolism and stroke.

• Women with primary ovarian insufficiency and premature or early menopause have higher risks of bone loss, heart disease, and cognitive or affective disorders associated with estrogen deficiency. It is recommended that hormone therapy can be used until at least the mean age of menopause unless there is a contraindication to its use.

• There is a paucity of randomized, controlled trial data about the risks of extended duration of hormone therapy in women aged older than 60 or 65 years, although observational studies suggest a potential rare risk of breast cancer with increased duration of hormone therapy.

• For select survivors of breast and endometrial cancer, observational data show that use of low-dose vaginal estrogen therapy for those who fail nonhormone therapy for treatment of GSM appears safe and greatly improves quality of life for many.

• Breast cancer risk does not increase appreciably with short-term use of estrogen-progestogen therapy and may be decreased with estrogen alone.

• Compounded bioidentical HT presents safety concerns, such as minimal government regulation and monitoring, overdosing or underdosing, presence of impurities or lack of sterility, lack of scientific efficacy and safety data, and lack of a label outlining risks.

• Hormone therapy does not need to be routinely discontinued in women aged older than 60 or 65 years and can be considered for continuation beyond age 65 for persistent VMS, quality-of-life issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks.

• For women with GSM, vaginal estrogen (and systemic if required) or other nonestrogen therapies may be used at any age and for extended duration, if needed.

Abstract

Cardiovascular disease (CVD) is the leading cause of death in women, who have a notable increase in the risk for this disease after menopause and typically develop coronary heart disease several years later than men. This observation led to the hypothesis that the menopause transition (MT) contributes to the increase in coronary heart disease risk. Over the past 20 years, longitudinal studies of women traversing menopause have contributed significantly to our understanding of the relationship between the MT and CVD risk. By following women over this period, researchers have been able to disentangle chronological and ovarian aging with respect to CVD risk. These studies have documented distinct patterns of sex hormone changes, as well as adverse alterations in body composition, lipids and lipoproteins, and measures of vascular health over the MT, which can increase a woman’s risk of developing CVD postmenopausally. The reported findings underline the significance of the MT as a time of accelerating CVD risk, thereby emphasizing the importance of monitoring women’s health during midlife, a critical window for implementing early intervention strategies to reduce CVD risk. Notably, the 2011 American Heart Association guidelines for CVD prevention in women (the latest sex-specific guidelines to date) did not include information now available about the contribution of the MT to increased CVD in women. Therefore, there is a crucial need to discuss the contemporary literature on menopause and CVD risk with the intent of increasing awareness of the significant adverse cardiometabolic health–related changes accompanying midlife and the MT. This scientific statement provides an up-to-date synthesis of the existing data on the MT and how it relates to CVD.

Highlights

Position Statement on Improving Bone Health and Osteoporosis Management in Australia312.93 KB

Forum participants included patients living with osteoporosis, GPs, medical specialist groups, hospital clinicians, National and State policy-makers, professional associations, health organisations, community support groups and bone health-related organisations. The Forum affirmed that bone health needs to be a much higher health priority in Australia.

The Position Statement identifies four main priorities and includes actions and messaging for each:

• Increase Community Awareness and Education

• Improve Risk factor Identification and Diagnosis

• Improve First Fracture Identification and Management

• Enhance Bone Health Strategic Engagement and Advocacy

Healthy Bones Australia would like to acknowledge the many individuals and participating organisations which made the development of the Position Statement possible.

The recommendations in this Position Statement will guide the focus of Healthy Bones Australia working with partners to improve bone health outcomes nationally.

Content created May 2021

Please find a summary of the Statement below.

The full Statement can be found here:

Summary of the HRT and Breast Cancer Risk Position Statement

Menopausal symptoms

The menopause transition can have a significant impact on many women, with more than 75% experiencing menopausal symptoms, a quarter describing severe symptoms, and a third experiencing long-term symptoms.

Treatments 

MHT, compared with placebo, has been consistently shown to improve menopausal symptoms and overall quality of life and remains the most effective treatment for menopausal symptoms. For some women, MHT may not be suitable, and alternative treatments are available.

MHT and breast cancer risk – the CGHFBC meta-analysis

Results from the CGHFBC meta-analysis show a small increase in the absolute risk of breast cancer:

5-years intake of MHT starting at the age of 50 years and risk of breast cancer at age 50-69 years

For continuous combined MHT
Increase from a baseline risk of 3/50 women not on MHT to 4/50 (i.e., 1 extra case in 50 women).

For sequential combined MHT
Increase from a baseline risk of 4/70 women to 5/70 (i.e., 1 extra case in 70 women).

For estrogen only MHT
Increase from a baseline risk of 13/200 women to 14/200 (i.e., 1 extra case in 200 women).

10-year intake of MHT starting at the age of 50 years and risk of breast cancer risk at age 50-69 years

For continuous combined MHT
Increase from a baseline risk of 3/50 women not on MHT to 5/50 (i.e., 2 extra cases in 50 women).

For sequential combined MHT
Increase from a baseline risk of 4/70 women to 6/70 (i.e., 2 extra cases in 70 women).

For estrogen-only MHT

Increase from a baseline risk of 13/200 women to 15/200 (i.e., 2 extra cases in 200 women).

Interpretation of the evidence on the risk of breast cancer with MHT 

The findings from the CGHFBC meta-analysis are in keeping with the NICE guidance 2015 analysis of the observational data on the risk of breast cancer and MHT.

The findings from the CGHFBC meta-analysis should be explained to women when discussing the benefits and risks of MHT. However, discussions on the risk of breast cancer with MHT should also include the findings from the WHI placebo-controlled randomized trials and the large E3N observational studies, which reported on the risk of breast cancer risk in users of micronized progesterone compared with other progestogens. Neither of the latter two studies was included in the CGHFBC meta-analysis.

The recently published WHI data showed a significant decrease in the risk of diagnosis of breast cancer with estrogen-only MHT and a significant reduction in breast cancer mortality compared with placebo. Women who took combined estrogen and progestogen MHT had an increased risk of breast cancer compared to placebo, in keeping with NICE guidance conclusions, but showed no significant difference in breast cancer mortality compared with placebo.

The E3N observational studies suggested a lower breast cancer risk in users of micronized progesterone compared to users of more androgenic progestogens.

Recommendations on the risk of breast cancer with MHT should take into consideration the findings from the WHI randomized trials and the observational data on micronized progesterone from the E3N study and those from the CGHFBC meta-analysis.

Informed consent

The risk of breast cancer should be considered in the context of the overall benefits and risks associated with MHT intake including menopausal symptom control, improved quality of life and the long-term impact on bone and cardiovascular health.

The decision whether to take MHT, the dose of MHT and the duration of its use should be made on an individualized basis after discussing the benefits and risks with women to help them make an informed choice about their health and care.

MHT benefits and risks

Quality of life

Key points summary

• Menopausal symptoms affect 70-80% of all women.
• 25% of women describe their symptoms as severe.
• The average duration of menopausal symptoms is 7 years.
• 50% of women said their symptoms impacted their home life and 36% said the menopause impacted their social lives

MHT and breast cancer risk - The CGHFBC meta-analysis

Key points summary:

• Duration-dependent increase in the risk of breast cancer diagnosis with both unopposed estrogen and combined MHT.
• The risk is higher with continuous combined MHT regimens compared to cyclical.
• The risk of breast cancer remains elevated more than 10 years after discontinuing MHT.
• No estrogen dosage effect on the risk of breast cancer with MHT.
• Vaginal estrogen exposure did not increase the risk of breast cancer diagnosis.
• Only a small number of women on micronized progesterone were included. Therefore, conclusions regarding its impact on the risk of breast cancer diagnosis could not be determined from this meta-analysis.

Osteoporosis

Key points summary

• Evidence from RCTs and meta-analysis shows that women using MHT have a significant reduction in the risk of any fracture compared with women not using MHT.

Cardiovascular disease (CVD)

Key points summary

• The timing MHT is initiated, referred to as the ‘timing hypothesis’ and ‘the cardiovascular window of opportunity’, can have a significant impact on the risk of CVD with MHT intake.
• Cochrane data-analysis shows that MHT initiated within 10 years of the menopause is likely to be associated with a reduction in coronary heart disease and cardiovascular mortality.
• Evidence from the Cochrane data-analysis and that from the long-term follow-up data of the WHI showed no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated MHT more than 10 years after the menopause.

Risk of venous thromboembolism

Key points summary

• Compared with women not on MHT, the risk of venous thromboembolism is increased by oral intake MHT.
• Transdermal administration of estradiol is unlikely to increase the risk of venous thrombosis above that in non-users and is associated with a lower risk compared with oral administration of estradiol.

Content created 18 August 2020

The first Global Position Statement on the use of testosterone in the treatment of women, led by the International Menopause Society (IMS), was published in four leading international medical journals today. The statement has been authored by a diverse team of leading experts based around the world and has been endorsed by internationally-esteemed medical societies. .

Global Consensus Position Statement on the Use of Testosterone Therapy for Women549.15 KB

The Global Position Statement was developed to inform health care professionals of the known benefits and potential risks of testosterone therapy for women. The aims were to provide clear guidance as to which women might benefit from testosterone therapy; identify symptoms, signs, and conditions for which evidence does not support the prescribing of testosterone; explore areas of uncertainty; and to identify any prescribing practices that have the potential to cause harm.

The panel concluded that:

1. a testosterone blood level should not be used to diagnose HSDD. HSDD should be diagnosed following a careful medical assessment that elicits lowered sexual desire with associated personal distress and no other treatable cause. Read more here.
2.  there is only evidence for beneficial effects of testosterone therapy in postmenopausal women, and specifically those suffering with HSDD
3.  there is insufficient data to support the use of testosterone for the treatment of any other symptom or clinical condition or for disease prevention
4. testosterone treatment should only be with formulations that achieve blood concentrations of testosterone that approximate what is normal for premenopausal women
5. although treatment of postmenopausal women with doses that result in blood levels seen in premenopausal women was associated with mild increases in acne and body/facial hair in some women, it was not associated with scalp hair loss or voice change
6. as no approved testosterone for women is presently approved by any national regulatory body, male formulations can be used judiciously in small doses with blood testosterone concentrations monitored regularly
7. compounded testosterone should not be used if a regulatory approved product is available
8. larger studies are needed to inform clinical recommendations regarding the use of testosterone for HSDD in premenopausal women
9. studies must be undertaken to establish the longer-term cardiometabolic and breast safety of testosterone therapy for women.

The advice was developed by nine leading medical organisations including The International Menopause Society, The International Society for Sexual Medicine, The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia, The American College of Obstetricians and Gynecologists, The North American Menopause Society, The European Menopause and Andropause Society, The International Society for the Study of Women’s Sexual Health, The Royal College of Obstetricians and Gynaecologists, and The Endocrine Society, and endorsed by several additional Societies.

It was published on 2 September 2019 in four leading international medical journals: Climacteric, Maturitas, The Journal of Sexual Medicine, and The Journal of Clinical Endocrinology and Metabolism.

The Global Position Statement is based on the world wide published literature in this field, including a recent systematic review and meta-analysis of clinical trials of testosterone therapy in women published in the Lancet Diabetes and Endocrinology on 25th July 2019, and where data were not available, on expert opinion of international leaders in this field.

There are no clearly established indications for testosterone therapy for women prior to the publication of the consensus statement.

There was no external funding for this process which was entirely supported by grants from the participating societies.

Translated versions of the Global Position Statement are available on the International Menopause Society website: you can also view the statement here.

Visit   to find out more.

Introduction (from White Paper)

Sexual wellbeing following menopause may seem anunattainable goal for many women. Dependent upon thepsychosocial circumstances, the biological changes atmenopause may be associated with significant personaland relationship distress. Studies across a number of countrieshave shown that women place high value on sexualintimacy in their relationships^1,2. Sexual problems at midlifecan be divided into chronic sexual symptoms involvingsexual desire, arousal, orgasm, and pain. Screening for female sexual concerns is often short changed during the clinical encounter because of a multitude of factors including,but not limited to, misinformation, absent orinadequate physician/practitioner training in sexual medicine, the belief that such menopausal changes are a normal and inevitable part of ageing, and time constraints.The purpose of this review is to provide clinicians with aframework for:

(1) Approaching the discussion of female sexual wellbeing following menopause;

(2) Clinically identifying women with sexual dysfunctionthrough patient symptoms, physical signs and validated instruments;

(3) Managing sexual difficulties in postmenopausal womenwith the available biopsychosocial therapies.

To see more download paper...

Download Paper

The IMS grants permission to individuals only to reproduce the copies of the review for their own personal use.

Sexual wellbeing after menopause: An International Menopause Society White Paper1.28 MB

Abstract

Sexual well-being frequently declines following the menopause transition and can be associated withSexual well-being frequently declines following the menopause transition and can be associated withsignificant personal and relationship distress. This distress is the hallmark of female sexual dysfunction(FSD). FSD is highly prevalent in postmenopausal women. The prevalence of sexual problemsincreases with age, but conversely this is associated with decreasing distress with advancing age.This pattern has been seen across multiple international populations with varied cultural norms.While the etiology of FSD is multifactorial, the physiological changes of sex hormone insufficiencyand postmenopausal symptoms, such as dyspareunia, are primary factors contributing to FSD at midlife.The International Menopause Society is working to increase awareness of FSD and to provide aframework for practitioners to address sexual medicine concerns. This White Paper aims to reviewthe process of care for female sexual well-being following menopause, from initially approaching thediscussion of FSD, to identifying clinical signs and symptoms, and ultimately determining the bestavailable biopsychosocial therapies. As with most processes of care, the first step is often the mostdifficult. Health-care practitioners need to broach the topic of sexuality in the clinical setting. Lack ofinformation on, comfort with, and biases about the topic of sexuality after menopause are significanthurdles that the International Menopause Society addresses in this document. Each member of theWriting Group remains committed to continued advocacy for the validity of FSD as a diagnosis, theneed for therapies for women to be both available and included in health insurance coverage, andcontinued therapeutic research to provide evidence-based solutions.

Reference

J. A. Simon, S. R. Davis, S. E. Althof, P. Chedraui, A. H. Clayton, S. A.J. A. Simon, S. R. Davis, S. E. Althof, P. Chedraui, A. H. Clayton, S. A.Kingsberg, R. E. Nappi, S. J. Parish & W. Wolfman (2018): Sexual well-being after menopause: AnInternational Menopause Society White Paper, Climacteric, DOI: 10.1080/13697137.2018.1482647

Content created October 2018

Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman on tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally denosumab has proven anti-fracture benefit.

Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women < 50 years) of < -2.0 at any site, or if annual bone loss is ≥ 5%, considering baseline BMD and other fracture risk factors.

Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by non-pharmacological intervention and, where indicated, antiresorptive treatment, in an individualized, multidisciplinary approach.

Reference

Grossmann M, Ramchand S, Milat F, et al. Assessment and management of bone health in women with oestrogen receptor-positive breast cancer receiving endocrine therapy: Position statement of the Endocrine Society of Australia, the Australian and New Zealand Bone & Mineral Society, the ��ݮ��Ƶ and the Clinical Oncology Society of Australia. Clin Endocrinol (Oxf) 2018 May 9. Epub ahead of print

The first nationally agreed standard of care for women with heavy menstrual bleeding was launched by the Australian Commission on Safety and Quality in Health Care on 20 October 2017. The new standard aims to improve women’s health across Australia for this potentially debilitating and under-recognised condition.

The Commission developed the () in collaboration with women’s health experts and consumers, and it has endorsement from eighteen leading professional organisations including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the ��ݮ��Ƶ.

Heavy menstrual bleeding is a common problem affecting about 25% of women of childbearing age. Although many women seek medical help because of pain, others do not seek help despite significant impact on their social, emotional and physical wellbeing, possibly because they are unaware of the wide range of effective treatment options that are available.

While surgical removal of the uterus (or hysterectomy) was the mainstay of treatment at one time and is sometimes still appropriate, a range of other evidence-based treatment options have been more recently developed and are – or should be – available when clinically appropriate. These include pharmaceutical treatments and ‘minimally invasive’ gynaecological procedures.

Evidence suggests that many women in Australia may not be aware of these newer, less invasive treatments, or are not being offered them. The Commission’s Australian Atlas of Healthcare Variation shows that women in some parts of Australia are up to seven times more likely to have their uterus removed than in others.¹ Regional areas have higher age-standardised rates of hysterectomy than major metropolitan cities² and Australia has higher rates of hysterectomy than the UK and New Zealand.³ In contrast, rates of endometrial ablation vary twenty-one fold with some regions having very low rates compared to other similar regions. The developed by the Commission can be used for local area comparisons of these hysterectomy and endometrial ablation rates.¹

In view of the Atlas findings, the Commission developed the Heavy Menstrual Bleeding Clinical Care Standard to support high-quality, safe and appropriate care for all Australian women with this problem regardless of where they live. The standard aims to ensure that all women with heavy menstrual bleeding are aware of their treatment options and are able to participate in decisions about their treatment.

Health services, local hospital networks and primary health networks and clinicians can use the standard and supporting quality indicators to support best practice care and service delivery.