Clinical Practice Guidelines for Menopause: *An Executive Summary and Recommendations: Indian Menopause Society 2026

*This is a summary and recommendations from the detailed monograph on Clinical Practice Guidelines for Menopause 2026, available at the Indian Menopause Society Website: www.indianmenopausesociety.org. RESOURCE FACULTY Akrishti Gupta Alka Kumar Anjan Pyal Anita Kant Annil Mahajan Anita Shah Asha Kapadia Asif Sultan Atul Munshi Bipasa Sen Bina Tandon B Chandrashekar Reddy Chellamma VK Cherunur Ambuja Ch Ratna Kishore CH Trivedi Duru Shah Hara P Pattanaik Hepshiba Khurabani Jagmeet Madan Jaideep Malhotra Jignesh Shah Jyotika Desai Jyoti Hak Jyoti M Shah Jyothi Unni K Madhulika Agarwal Lakshmi Ratna Madhu Babu Madhukar Reddy Mala Raj Maninder Ahuja Monal Shah Navneet Takkar Neelam Agarwal Nidhi Gupta C Nikhileshwar Reddy N. Vivek Padma Kurada Pooja Shah Prem Blaise Rejula Pushpa Sethi Rama A Vaidya Rashmi Shah Rashmi Banerjee Ravi R Hebballi Rohit Raina Saroj Srivastava Sabahat Rasool Sai Deepak Yaranagula Sai Praveen Haranath Saket Kumar Sharad Kumar Sheela Mane Shobhana Mohandas Smrity Shailly Bagde Sonia Malik Sudha Sharma Sunila Khandelwal Suvarna Khadilkar Tanmaya Talukdar Thanuja Mannava Tripti Nagaria Tushar Patel Usha Rani Poli Urvashi Prasad Jha Urvashi Yavalkar Vishal R Tandon Yashodhara Pradeep SECTION 1 GENERAL CONSIDERATIONS Definition and biosociocultural aspects of menopause 1. Menopause is a dynamic physiological transition from the reproductive to the nonreproductive stage of a woman’s life. It involves systemic physiological adaptations affecting the neuroendocrine, cardiovascular, metabolic, musculoskeletal, genitourinary, and immune systems.[1,2] 2. Each woman experiences menopause uniquely, with distinct symptom trajectories varying in timing, severity, and duration. This individualized nature of the menopausal experience underscores the need for personalized care and understanding.[3,4] 3. All mammals undergo reproductive senescence and oophause, the irreversible depletion of ovarian follicles, and typically progress until the end of life, but only humans and a few cetaceans experience true menopause, the loss of fertility decades before death (<0.1% of mammals). Menopause continues to raise important evolutionary and biological questions.[5,6] 4. In India’s classical Ayurvedic tradition, menopause is described as Rajonivṛtti, a normal physiological transition. The text suggests that it typically occurs around the age of fifty. This unique cultural perspective on menopause in India adds a distinct layer to the understanding of menopause.[7,8] Medicalization of menopause 5. The basis of the debate on menopause medicalization gained significance in the 1930s and 40s, in response to the popularization of menopause as a hormone deficiency state, with the isolation of estrogen and the rise of hormone replacement therapy (HRT) as an “elixir of youth”.[9,10] Meyer’s 2001 analysis documented how menopause is in the process of becoming medicalized, with midlife women being told that “natural menopause is a deficiency condition requiring replacement hormones.”[11] 6. However, substantial scientific evidence supports the view of menopause as a biological change with significant pathological potential, paralleling other life transitions such as puberty and pregnancy.[12,13] 7. Bell’s three models of menopause care: biological (physiological changes helped by hormone therapy), psychological (women’s inherent personalities relieved by cognitive behavioral therapy), and environmental (self-help) form the basis for guiding medical practice.[14] 8. Hickey et al. well described the final word on this debate in The Lancet 2024 that for most women, menopause should be viewed as a part of healthy aging rather than “framing this natural period of transition as a disease of estrogen deficiency” and prevent “overmedicalization” by promoting hormone therapy as empowerment.[15] 9. Rama Vaidya, Founder, President of the Indian Menopause Society (IMS), envisaged that the menopause society should work toward a holistic approach to menopausal health and not restrict research and implementation of menopausal health to medication (personal communication). Menopause and the aging continuum 10. Menopause is associated with menopause symptoms and diverse physiological changes affecting multiple organ systems and metabolic processes, setting the stage for aging and increasing susceptibility to noncommunicable diseases (NCDs).[16] 11. Menopausal and age-related biological changes overlap substantially, making it challenging to distinguish menopause-specific effects from those of chronological aging.[17] Early screening and preventive health 12. The menopause transition (MT) constitutes a biological window for preventive intervention, as highlighted by longitudinal studies and systematic reviews demonstrating that cardiovascular and metabolic risk trajectories accelerate around the final menstrual period (FMP) (Grade A).[18,19] 13. Suggested screening threshold for NCDs: In India, the “Start at 35” (awareness from age 35 and universal screening from 40 years) approach is based on the relatively early age at natural menopause (ANM) and the sharp rise in the prevalence of hypertension, diabetes, and low bone mass (Grade C).[20] 14. This recommendation is supported by national surveys, such as the National Family Health Survey, Round 5 (2019–21) (NFHS-5)[21] and the Longitudinal Ageing Study in India, Wave 1 (2017–18) (LASI),[22] and the Women’s Health Initiative (WHI; USA randomized clinical trial [RCT] program),[23] as well as large international cohorts, including the Study of Women’s Health Across the Nation (SWAN; USA longitudinal cohort).[24] Multiple meta-analyses and global studies have also demonstrated the early onset and higher burden of cardiometabolic risk factors in South Asian populations; however, prospective RCT evidence in Indian women remains limited.[25-27] 15. IMS “Club 35” initiative, active since 2007, is a nationwide public awareness program that promotes preventive midlife health among women aged ≥35 years. It emphasizes early screening, lifestyle changes, and health empowerment before menopause.[28] Policy gaps and advocacy priorities 16. Menopause remains a critically underrepresented area in both undergraduate and postgraduate medical curricula and receives insufficient attention from policymakers. 17. This gap highlights the urgent need for structured sensitization and formal training of healthcare professionals in menopause medicine.[29,30] 18. Currently, there are no dedicated national health programs addressing the needs of women aged 40–60 years, highlighting a critical opportunity for policy integration within ongoing women’s health and NCD initiatives.[31] Multidisciplinary models of menopause care 19. Establishing a structured three-tier healthcare system spanning primary, secondary, and tertiary levels of care would significantly reduce disability and improve the quality of life (QOL) in India’s growing aging population (Grade C).[27] 20. Menopausal health extends beyond obstetrics and gynecology and requires an integrated, multidisciplinary approach. 21. Hence, care should involve not only gynecologists but also dieticians, physiotherapists, psychologists, psychiatrists, physicians, cardiologists, endocrinologists, gynecologic oncologists, and orthopedic specialists, supported by an effective referral system.[4,32-35] Proposed three-tier model of care 22. Level I: Primary care unit – First-contact care, screening, lifestyle counseling, basic management, and referral when indicated. 23. Level II: Primary gynecological unit – Comprehensive gynecological evaluation, initiation of hormonal and nonhormonal therapies, and management of gynecological comorbidities. 24. Level III: Menopause specialist and multidisciplinary unit – Advanced, risk-stratified care by menopause specialists in collaboration with multidisciplinary teams, including cross-specialty referrals. TERMINOLOGY AND DIAGNOSIS 25. 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The menopause transition by estrogen and is a physiological and in or women, it accelerate the onset of noncommunicable diseases cardiometabolic and (Grade It be recognized that are in in of or estrogen are but as of disease risk and 4. The that menopause hormone therapy is most effective when the or early years, initiation beyond this window or cardiovascular 5. This is supported by the Early with and from models and clinical 6. of Health Initiative and of supported by the Study the understanding of the window of 7. that estrogen and effects only in healthy and In estrogen or in aged or 8. The and healthy the in cardiovascular, musculoskeletal, and metabolic 9. models that both the of initiation and the metabolic health of the understanding of and guiding individualized 10. within of menopause or before the age of is associated with and cardiovascular a of this is not with initiation (Grade 11. lifestyle management healthy lifestyle the of metabolic, cardiovascular, and cognitive and the of by health and (Grade 12. including structured lifestyle menopausal and significantly reduce symptom improve quality of life and as effective to (Grade 13. Menopausal symptoms are spanning and as by such as the Menopause 14. evidence for and of menopause for and (Grade 15. such as and are the and with in from longitudinal such as suggests that the effects of estrogen changes in and and metabolic rather than hormonal change (Grade 16. that are most in and such as and in Asian including India, and This cultural and biological underscores the need for and management in Indian women (Grade 17. is a prevalence of menopausal symptoms with by psychological symptoms symptoms the The prevalence of highlighting the need for and in Indian 18. A global a prevalence of of among Indian that the of from to in to at and in 19. and be by or to to 20. the by with work and in and 21. in the with and hormone for on and and the 22. and studies that in midlife women are associated with menopause and 23. evidence supports the with and (Grade 24. in the are associated with in midlife women, with of around a but significant to symptom 25. of is important to management, and The of are as of of with and of with and that need to other of before The most effective for is (Grade and be when is (Grade are and therapies, cognitive behavioral therapy and nonhormonal to 6. in the paralleling estrogen and and the early to and of symptoms are to be and when are or to with of such symptoms to menopause, should medical such as or management and such as management, and for women both and however, for or symptoms is and The by and systemic rather than symptoms changes in and and symptoms typically a to rise in the early the and to improve within 1 or after the final menstrual period changes are by estrogen and and a of or described as with for or and rather than cognitive is and it from pathological cognitive such as cognitive or are by and cognitive The is the hormonal changes of the estrogen or and (Grade Longitudinal including the that cognitive in and with within after menopause in early (Grade for cognitive as including and by lifestyle including cognitive and and symptoms management, to health (Grade evidence not the of for the of cognitive or (Grade is for symptom management in women, but not or after