Synopsis
Assess bone and cardiovascular risk after menopause, distinguish symptom treatment from disease prevention, and use risk-based lifestyle, imaging and preventive-medicine pathways without inappropriate routine testing.
- Menopause is a useful point to review smoking, blood pressure, weight, diabetes, lipids, alcohol, activity, falls and fracture history, but it does not make every person high risk.
- Advise regular weight-bearing and muscle-strengthening activity, adequate dietary calcium and vitamin D, smoking cessation and alcohol within UK low-risk guidance.
- NICE recommends fracture-risk assessment for all women aged 65 or over and for younger people when risk factors such as fragility fracture, glucocorticoids, low BMI, smoking or untreated premature menopause are present.
- Use FRAX or QFracture within their validated age ranges; do not order routine DXA without first considering clinical risk, except where a major factor creates a specific indication.
- Use QRISK3 for eligible adults aged 25 to 84 without established cardiovascular disease, while recognising groups in whom the score may underestimate risk or is not the correct pathway.
- Do not prescribe systemic HRT solely for primary or secondary prevention of cardiovascular disease or for prevention of dementia.
- HRT reduces fragility-fracture risk while it is taken, but a symptom-treatment decision should still use the person's overall benefits, harms, anatomy and preferences.
- Treat hypertension, diabetes, dyslipidaemia, tobacco dependence and established osteoporosis according to their own guidelines rather than labelling them inevitable consequences of menopause.
Key red flags
Central chest pressure, acute breathlessness, syncope or focal neurological symptoms requires emergency cardiovascular or stroke assessment regardless of menopausal status.
Sudden unilateral leg swelling or pleuritic pain with hypoxaemia raises concern for venous thromboembolism and must not be attributed to HRT anxiety alone.
Hip pain after a low-energy fall, new inability to bear weight or acute spinal pain with height loss suggests fragility fracture and needs prompt imaging.
Severe back pain with weakness, saddle sensory change or bladder or bowel dysfunction requires emergency assessment for cord or cauda-equina compression.
Multiple fractures, a vertebral fracture, marked low weight or prolonged systemic glucocorticoid exposure indicates high skeletal risk requiring active assessment rather than lifestyle advice alone.
Investigation priorities
Estimate ten-year absolute fragility-fracture risk when age or clinical factors justify formal assessment.
Management branches
Age, fracture history or a clinical risk factor raises concern about fragility fracture.
- Take a fracture, falls, medicine, menstrual and secondary-cause history and examine height, gait and relevant focal symptoms.
- Use FRAX or QFracture when appropriate, arranging DXA when risk lies near an intervention threshold or a major factor creates a specific indication.
- Treat established osteoporosis or fragility fracture through the relevant pathway while adding exercise, nutrition and falls measures tailored to ability.