Menopause and perimenopause: the modern AU general-practice framework

What menopause actually is

Menopause is the final menstrual period, confirmed retrospectively after 12 consecutive months without a period. It is a single point in time, not a phase. In Australia the average age is around 51 years, with most women reaching menopause between 45 and 55. Everything before that 12-month threshold is perimenopause; everything after is postmenopause.

Perimenopause is the transition — typically a 4–8 year stretch of menstrual irregularity, fluctuating oestrogen, vasomotor symptoms, mood and sleep changes, and rising follicle-stimulating hormone. Early menopause is between 40 and 45 years. Premature ovarian insufficiency (POI) is menopause before age 40, affecting about 1% of women, and carries higher long-term cardiovascular, bone, and cognitive risks because of extended oestrogen deficiency. Surgical menopause (bilateral oophorectomy) and iatrogenic menopause (chemotherapy, radiation) tend to produce more abrupt and severe symptoms than natural menopause.

A. Core clinical — the AU general practice framework

History to take

The Australasian Menopause Society, Jean Hailes, and eTG Reproductive Health: Menopause recommend a structured approach. The Stages of Reproductive Aging Workshop (STRAW) framework distinguishes early perimenopause (variable cycle length), late perimenopause (interval of amenorrhoea between 60 days and 12 months), and postmenopause.

History domains:

• Menstrual pattern — date of last period, cycle regularity, flow change, intermenstrual or postcoital bleeding
• Vasomotor symptoms — frequency, severity, impact on sleep and work; about 80% of women experience them and around 25% find them severe
• Genitourinary syndrome of menopause (GSM) — vaginal dryness, painful sex (dyspareunia), urinary urgency, recurrent urinary tract infection
• Sleep — night sweats, sleep maintenance insomnia
• Mood and cognition — depression, anxiety, irritability, the so-called “brain fog”
• Joint pain, weight gain, libido
• Cardiovascular and bone risk factors — family history, smoking, body mass index, blood pressure, lipid history, previous fracture
• Personal and family breast cancer history
• Venous thromboembolism (VTE) history, thrombophilia, stroke, ischaemic heart disease, migraine with aura
• Medications — current hormonal therapy, anticoagulants, anti-epileptics, tamoxifen
• Sexual history
• Mental health screen — PHQ-9, GAD-7

Investigations — what is and is not useful

For women aged 45 or older with typical symptoms and menstrual changes, menopause is a clinical diagnosis. FSH testing in this group is generally unnecessary because FSH fluctuates substantially during perimenopause and a single normal value does not rule out perimenopause.

FSH is useful in younger women — particularly under 45 with suspected early menopause, or under 40 with suspected POI, where two elevated FSH measurements (over 40 IU/L) at least 4 weeks apart support the diagnosis. Anti-Müllerian hormone (AMH) has limited clinical utility in confirming menopause and is not recommended for routine menopause diagnosis by RACGP or AMS — it is more useful in fertility assessment.

Differentials worth excluding when presentation is atypical:

• Thyroid disease (TSH) — particularly when sweating, palpitations, weight change, or anxiety dominate
• Pregnancy (β-hCG) — in any sexually active person of reproductive age with amenorrhoea
• Anaemia (FBC) — when fatigue is disproportionate
• Hyperprolactinaemia — when amenorrhoea is the dominant feature
• Major depressive disorder — when mood and sleep dominate without vasomotor or menstrual change

Pre-MHT baseline workup typically includes blood pressure, FBC, liver function, fasting lipids, HbA1c, cervical screening currency, and mammography per BreastScreen Australia (free 2-yearly from age 50; eligible from 40).

Any postmenopausal bleeding requires urgent investigation — transvaginal ultrasound and consideration of endometrial biopsy — to exclude endometrial cancer. This is non-negotiable regardless of how trivial the bleeding seems.

B. Menopausal hormone therapy (MHT / HRT) — the modern AU framework

Where the field landed after the WHI reframe

The Women’s Health Initiative trials in the early 2000s produced an initial signal of harm that led to a steep drop in MHT prescribing worldwide. Subsequent re-analyses by age stratum, route of administration, and progestogen type substantially changed the picture. For a forensic, absolute-risk read of what that 2002 trial actually showed — and how its headline was misapplied — see What the WHI study actually showed about HRT and breast cancer. The current position of the Australasian Menopause Society — aligned with NICE NG23 (2024 update) and the International Menopause Society 2022 white paper — is that for healthy women within 10 years of menopause or under age 60, with moderate-to-severe vasomotor symptoms, the benefits of MHT outweigh the risks for most women. This is sometimes called the “timing hypothesis.”

Components of MHT

Oestrogen is the active ingredient for symptom control. Oestradiol is the molecule used in modern AU practice.

• Transdermal patch (Estradot 25–100 mcg/day, Climara) — preferred route: lower VTE and stroke risk than oral; better for women with migraine, raised BMI, or metabolic risk
• Transdermal gel (Sandrena, Estrogel) — flexible dosing; same favourable profile as patch
• Oral oestradiol (Estrofem, Progynova) — first-pass hepatic metabolism; higher VTE risk; less preferred when an alternative route is feasible

Progestogen is required in any woman with an intact uterus to protect the endometrium from oestrogen-driven hyperplasia and cancer.

• Micronised progesterone (Prometrium 100–200 mg) — preferred for the most favourable breast and cardiovascular safety signal; bioidentical and TGA-registered
• Synthetic progestogens — medroxyprogesterone, norethisterone, dydrogesterone; effective but carry a slightly less favourable breast signal than micronised progesterone
• Levonorgestrel intrauterine device (Mirena) — excellent endometrial protection plus contraception during perimenopause; a reasonable option, particularly when contraception is also wanted

Tibolone (Livial) is a synthetic steroid with mixed oestrogenic, progestogenic, and androgenic activity; useful when bleeding is unacceptable and combined HRT is not preferred. A modest stroke signal exists in older women.

Risks to discuss, in absolute terms

• Breast cancer. Combined MHT carries a modest increase in breast cancer incidence after about 5 years of use, mostly driven by progestogen exposure. Oestrogen-only therapy in women after hysterectomy carries minimal or no increase. The absolute risk increase is small — usually framed as fewer than 1 additional case per 1000 women per year of combined use. NICE NG23 (2024) clarified that mortality is not increased. If breast cancer develops, MHT is discontinued.
• Venous thromboembolism. Oral oestrogen approximately doubles VTE risk above background. Transdermal oestrogen does not appear to increase VTE risk meaningfully, which is why it is preferred for women with raised BMI, prior VTE, thrombophilia, or migraine.
• Stroke. Modest increase with oral; minimal with transdermal.
• Cardiovascular. Within the 10-year window or under 60, MHT is cardiovascular-neutral or slightly favourable. Initiation more than 10 years after menopause or after age 60 increases cardiovascular risk and is generally avoided.
• Endometrial cancer. Oestrogen alone in a woman with a uterus substantially increases risk. Adequate progestogen exposure neutralises this. This is why endometrial protection is non-negotiable.

Contraindications

Per AMS and eTG: current or recent breast cancer, oestrogen-sensitive cancer, undiagnosed vaginal bleeding, active or recent VTE, ischaemic heart disease or stroke, severe liver disease, untreated endometrial hyperplasia.

Benefits

• Vasomotor symptoms — most effective intervention
• Bone — fracture prevention; effective osteoporosis prophylaxis in the postmenopausal window
• GSM — systemic MHT improves vaginal symptoms, though topical vaginal oestrogen is usually preferred for GSM-predominant presentations
• Mood — perimenopausal mood symptoms often improve, though MHT is not a substitute for treatment of established depression
• Possible cognitive benefit in the perimenopausal and early postmenopausal window — under active investigation

C. Non-hormonal options

When MHT is contraindicated, declined, or has not worked, non-hormonal pharmacotherapy has a role. Per eTG and AMH:

Agent	Use	Notes
Paroxetine 7.5 mg	Vasomotor symptoms	TGA-approved at low dose specifically for vasomotor symptoms; avoid in women taking tamoxifen — paroxetine inhibits CYP2D6 and reduces tamoxifen effectiveness
Venlafaxine 37.5–75 mg	Vasomotor symptoms	Useful when mood symptoms coexist
Escitalopram	Vasomotor symptoms; mood	Better tolerated in some women than paroxetine
Gabapentin 300–900 mg nocte	Night-time vasomotor symptoms and sleep	Sedating — can be useful for sleep maintenance
Clonidine	Vasomotor symptoms	Modest effect; older agent; postural hypotension risk
Fezolinetant (Veozah)	Vasomotor symptoms	Neurokinin-3 receptor antagonist; TGA-approved 2024; not yet PBS-listed for vasomotor symptoms at time of writing (verify current status); LFT monitoring required

CBT-Meno — cognitive behavioural therapy adapted for menopause — has supportive UK trial data for vasomotor symptom bother (the distress component) and for sleep. Australian access is via This Way Up and via psychologist under a Mental Health Treatment Plan.

Lifestyle measures sit underneath every other intervention:

• Mediterranean dietary pattern — cardiovascular and metabolic benefit
• Regular exercise including weight-bearing and resistance training — cardiovascular, bone, mood, sleep, body composition
• Alcohol moderation — alcohol exacerbates flushing and contributes to breast cancer risk
• Smoking cessation — accelerates bone loss and earlier menopause
• Sleep optimisation — see related articles on insomnia
• Cooling strategies — layered clothing, fans, cool drinks, cool bedroom

A cognitive shift matters — accurate framing of what menopause is reduces the catastrophic interpretation that compounds the experience.

D. Australian operations

PBS-listed therapies

• Oestradiol patches (Estradot, Climara) — general schedule
• Oestradiol gels (Sandrena, Estrogel) — general schedule
• Oral oestradiol (Estrofem, Progynova) — general schedule
• Micronised progesterone (Prometrium) — PBS listed (Authority Required for some indications; verify current PBS status via pbs.gov.au)
• Combined MHT products — Femoston, Kliogest, Trisequens; general schedule
• Tibolone (Livial) — general schedule
• Topical vaginal oestrogen — Vagifem pessary, Estring ring, Ovestin cream; general schedule; minimal systemic absorption and considered safe for most women including most with breast cancer history (case-by-case oncology input)
• Mirena — Authority for menorrhagia; general schedule for contraception
• SSRI / SNRI — general schedule
• Paroxetine 7.5 mg (Brisdelle) — general schedule

Testosterone in women

The International Menopause Society 2024 testosterone position statement endorses transdermal testosterone for low sexual desire (hypoactive sexual desire disorder) in postmenopausal women when general factors and MHT optimisation have been addressed. Dosing in Australia typically uses a fraction of a male testosterone preparation off-label, with monitoring of total testosterone to keep levels within the female physiological range. There is no female-specific TGA-registered testosterone preparation in Australia at time of writing — verify current TGA status. Specialist input is reasonable for initiation.

MBS structure

Standard general practice consults for assessment and ongoing review. Gynaecologist referral is appropriate when MHT decisions are complex (high-risk history, recurrent bleeding, refractory symptoms), when POI is suspected, or for surgical consideration. The Better Access initiative supports mental health care via Mental Health Treatment Plans for the depression, anxiety, and CBT-Meno components.

Compounded “bioidentical” hormone therapy — naming the gap honestly

A clarification matters here. Bioidentical TGA-registered preparations — micronised progesterone (Prometrium), oestradiol patches and gels — are bioidentical, on-label, and standard modern AU practice. There is no controversy about using them.

Compounded bioidentical hormone therapy (BHRT) — custom-prepared troches, creams, and pellet implants from compounding pharmacies — is a different product. These are not TGA-registered, dosing consistency is not assured, and there is no quality-controlled evidence of efficacy or safety. The Australasian Menopause Society, RANZCOG, and international menopause societies do not endorse compounded BHRT for routine use. Women wanting bioidentical hormones can have them through TGA-registered prescriptions rather than compounded preparations.

E. Special populations

Premature ovarian insufficiency (POI, under 40 years). MHT is recommended until the average age of natural menopause (around 51) unless there is a specific contraindication. Dosing is typically higher than standard postmenopausal MHT because it is restoring physiology rather than treating symptoms. Workup includes karyotype, autoimmune screen, FMR1 premutation testing, and fertility counselling. Specialist gynaecology or endocrinology involvement is appropriate.

Surgical menopause (bilateral oophorectomy). Symptoms are typically more abrupt and severe than natural menopause. MHT is generally appropriate where there is no contraindication, often at higher doses initially. Younger women particularly benefit from continuation to around the natural-menopause age.

Breast cancer survivors. Systemic MHT is generally avoided. Non-hormonal options for vasomotor symptoms (SSRI / SNRI — but not paroxetine alongside tamoxifen; gabapentin; clonidine; fezolinetant) and CBT-Meno are the typical pathway. For GSM, topical vaginal oestrogen is often considered safe with oncology input, given minimal systemic absorption; vaginal moisturisers (Replens) and lubricants are non-hormonal alternatives. Decisions are individualised with the treating oncology team.

Aboriginal and Torres Strait Islander women. Cultural framing and access to culturally safe care matter. Local Aboriginal community-controlled health services (ACCHS) are first stop where available. General practice attentive to higher background cardiovascular and metabolic risk in this population.

Cardiometabolic considerations. Postmenopause shifts lipid profile, blood pressure, and insulin sensitivity unfavourably. Cardiovascular risk assessment per the Australian CVD risk guideline is recommended. Bone density assessment is timed against fracture risk per the Healthy Bones Australia and RACGP 2024 osteoporosis guideline.

Perimenopause-versus-menopause symptom overlap. Symptoms in perimenopause can be more severe than after menopause itself — the hormonal fluctuation matters as much as the absolute level. Women often present in late perimenopause believing they are already postmenopausal because periods have become sparse. Diagnosis is clinical and the time-since-last-period clock matters.

When to escalate

Refer or escalate when:

• Any postmenopausal bleeding — urgent gynaecology referral for transvaginal ultrasound and endometrial biopsy
• Suspected POI — specialist gynaecology or endocrinology
• MHT decision in a woman with significant medical complexity — prior VTE, prior breast cancer, severe liver disease, complex migraine
• Severe perimenopausal mood disorder with functional impairment or suicidality
• Refractory vasomotor symptoms despite appropriate MHT or non-hormonal therapy
• Suspected breast cancer — palpable lump, suspicious mammographic finding
• Complex sexual dysfunction
• Recurrent urinary tract infection not responding to standard measures and topical vaginal oestrogen

What this article is and is not

This is general health information drawn from current Australian primary tier sources — the Australasian Menopause Society, Jean Hailes for Women’s Health, RACGP, Therapeutic Guidelines, Australian Medicines Handbook, NPS MedicineWise — and from international tier sources (NICE NG23 2024 update; International Menopause Society 2022 white paper and 2024 testosterone position) where AU sources cross-reference. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about menopausal hormone therapy, non-hormonal therapy, and management of complications are made with your own general practitioner and treating clinicians.

For Australian consumer-friendly resources: Australasian Menopause Society, Jean Hailes for Women’s Health, HealthDirect — Menopause, Better Health Channel — Menopause.

For acute mental-health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

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Sources cited

1. Australasian Menopause Society (AMS)
2. Jean Hailes for Women’s Health
3. RANZCOG
4. RACGP
5. Therapeutic Guidelines (eTG) — Menopause
6. Australian Medicines Handbook
7. NPS MedicineWise
8. TGA
9. Healthy Bones Australia
10. Heart Foundation — Australian CVD risk guideline
11. This Way Up
12. HealthDirect — Menopause
13. Better Health Channel — Menopause
14. BreastScreen Australia
15. PBS
16. NICE NG23 — Menopause: diagnosis and management (2024 update)
17. International Menopause Society — 2022 white paper and 2024 testosterone position