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In the United States, nearly 10 million women are currently in the menopause transition and 2.25 million women are 51 years of age, which is the average age of menopause. Approximately 75% of these women will experience vasomotor symptoms such as hot flashes and night sweats. Menopause hormone therapy (HT) remains the most effective treatment for menopausal symptoms, but the decision to use HT is complex and requires balancing the benefits and risks for the individual patient. The decision also requires clinical judgment and shared decision making with the patient. In this review, we discuss the current guidelines for HT use, the benefits and risks for the individual patient and a novel algorithm and clinical decision support tool for menopausal symptom management that facilitates shared decision making between clinician and patient.