Abstract
Menopause care now spans established hormone therapy, mechanism-based non-hormonal drugs, behavioural interventions, and emerging microbiome- and biomarker-guided approaches. This state-of-the-art narrative review evaluated which dimensions of personalisation are clinically actionable and which remain hypotheses of precision medicine. A structured PubMed/MEDLINE search (January 2020–July 2026), updated to August 2026 and supplemented by landmark studies, current guidelines, and regulatory sources, was synthesized using a four-tier clinical-actionability framework (A, established; B, evidence-supported off-label; C, emerging; D, experimental). Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms and prevents bone loss during use; the 2025–2026 FDA labelling revisions altered risk communication rather than the underlying evidence, and professional responses diverged. Fezolinetant and elinzanetant provide mechanism-based non-hormonal options, while SSRIs/SNRIs, gabapentin, cognitive behavioural therapy (CBT), CBT for insomnia, and clinical hypnosis remain evidence-supported. Exercise, yoga, acupuncture, soy, and equol are not guideline-recommended for reducing vasomotor symptom frequency despite benefits in other domains. Gut and genitourinary microbiome findings should not be conflated: pooled evidence identifies no consistent postmenopausal gut signature, whereas vaginal Lactobacillus depletion is more reproducible but does not reliably predict symptom resolution. Evidence-based personalisation therefore remains principally clinical; microbiome sequencing, equol testing, and multi-omic treatment selection require prospective test-guided validation.