Menopause and perimenopause: the Australian general practice guide

Menopause and perimenopause are universal biological transitions that affect every woman — yet they are still frequently dismissed, undertreated, or attributed to other conditions. Around 80% of Australian women experience vasomotor symptoms, and roughly a quarter have symptoms severe enough to affect daily work, sleep, and relationships. General practice is the gateway to effective management.

The average age of natural menopause in Australia is 51 years. The perimenopause — the transition phase leading up to the final menstrual period — typically spans four to eight years, often beginning in the mid-40s. During this window, the ovaries progressively reduce oestrogen and inhibin output, FSH rises, and cycles become irregular before stopping. The Australasian Menopause Society (AMS) is the primary AU specialist body setting clinical standards, supported by RANZCOG and the Therapeutic Guidelines.

The central clinical question is not just “is this menopause?” but “what is the symptom burden, what are the risks, and what does this woman want to do about it?” Treatment decisions are individualised, shared, and revisited annually.

A. Core clinical — the AU general-practice framework

Diagnosis

Menopause is a clinical diagnosis in women aged 45 or over with typical symptoms and menstrual change. FSH testing is not routinely needed — eTG: Reproductive health and the AMS advise against it in this age group because FSH fluctuates widely during perimenopause and a single result is unreliable. Reserve FSH for women under 45 where premature ovarian insufficiency (POI) needs to be confirmed (FSH >40 IU/L on two occasions at least four weeks apart).

History

Gather a symptom inventory covering:

• Menstrual pattern — last period, cycle changes, intermenstrual or postmenopausal bleeding
• Vasomotor symptoms — hot flush frequency, night sweat severity, sleep impact, work impact
• Genitourinary symptoms — dryness, dyspareunia, urgency, recurrent urinary tract infections
• Mood and cognition — depression screen (PHQ-9), anxiety (GAD-7), cognitive fog
• Musculoskeletal — joint pain, early-morning stiffness
• Risk factors for MHT — personal or family history of breast cancer, VTE, stroke, ischaemic heart disease, liver disease, oestrogen-sensitive cancer, active thrombophilia
• Medications — anticoagulants, tamoxifen, anti-epileptics, herbal products

Examination

• Blood pressure, weight, BMI
• Vaginal examination if genitourinary symptoms — assess atrophy signs
• Breast examination as clinically indicated alongside BreastScreen Australia pathway
• Thyroid palpation if clinical concern (hyperthyroidism and hypothyroidism are common mimics)

Investigations

In women aged 45 or over with typical symptoms, investigations are selectively useful rather than routine. Before starting MHT: baseline blood pressure; FBC; liver function tests; fasting lipids; HbA1c if at cardiometabolic risk. DXA per Healthy Bones Australia and RACGP 2024 osteoporosis guideline fracture-risk criteria. Transvaginal ultrasound for any postmenopausal bleeding. Cervical screening and mammography via BreastScreen continue per standard intervals.

Management overview

Treatment follows a hierarchy:

1. Lifestyle — the foundation: weight management, aerobic and resistance exercise (≥150 min/week), alcohol moderation (alcohol worsens hot flushes and breast cancer risk), smoking cessation, sleep hygiene, cooling strategies (layers, fans, cool bedroom)
2. MHT — for moderate to severe vasomotor symptoms in eligible women
3. Non-hormonal alternatives — for contraindications, declining MHT, or as adjuncts
4. Topical vaginal oestrogen — for genitourinary syndrome of menopause (GSM), regardless of systemic MHT status

B. Menopausal hormone therapy — evidence and calibration

The evidence base for MHT has been substantially reappraised since the Women’s Health Initiative (WHI) 2002 publication, which significantly alarmed prescribers and patients. The original WHI findings applied to older women (average age 63) using oral conjugated equine oestrogen with medroxyprogesterone — not to the modern transdermal regimens used in younger perimenopausal women.

The AMS comprehensive position and international consensus from the International Menopause Society now affirm that MHT in healthy women under 60 or within 10 years of menopause has a neutral to favourable benefit–risk profile. This is the “timing hypothesis” or “window of opportunity” — initiating MHT later (older women more than 10 years post-menopause) is associated with different, potentially unfavourable cardiovascular effects.

Route matters for VTE and stroke risk. Transdermal oestrogen (patches, gels) bypasses hepatic first-pass metabolism and does not significantly increase VTE or stroke risk, unlike oral oestrogen which raises these risks by approximately two- to three-fold above baseline. Where there is any concern about VTE, migraine with aura, or metabolic risk, transdermal is preferred — AMH and eTG both recommend this.

Progestogen choice matters for breast cancer and cardiovascular risk. Micronised progesterone (Prometrium) has the most favourable safety profile for breast and cardiovascular outcomes compared with synthetic progestogens. The Mirena LNG-IUD is also an excellent option for endometrial protection in women with an intact uterus — it provides local progestogen with negligible systemic exposure.

Regimens:

• Sequential (cyclical) combined — for perimenopausal women still having periods: oestrogen daily plus progestogen for 12–14 days per cycle; produces a withdrawal bleed
• Continuous combined — for postmenopausal women (12+ months amenorrhoea): oestrogen plus progestogen daily; usually produces amenorrhoea after six months
• Oestrogen-only — for women who have had a hysterectomy

Contraindications to MHT include current or recent breast cancer, oestrogen-sensitive cancer, undiagnosed vaginal bleeding, active or recent VTE or arterial thromboembolic event, severe liver disease, and untreated endometrial hyperplasia.

Non-hormonal alternatives for vasomotor symptoms when MHT is not suitable include: SSRI/SNRI (paroxetine, venlafaxine, escitalopram — modest effect, useful when comorbid mood disorder is present; avoid paroxetine with tamoxifen); gabapentin 300–900 mg daily; clonidine (modest, older); fezolinetant (Veozah) approved by the TGA in 2024 as a neurokinin-3 receptor antagonist targeting the hypothalamic thermoregulatory circuitry.

C. Genitourinary syndrome of menopause

GSM describes the spectrum of vulvovaginal and lower urinary tract symptoms driven by oestrogen deficiency. Unlike hot flushes, which often improve over years, GSM tends to worsen progressively unless treated. It affects up to 50% of postmenopausal women but is substantially undertreated — many women accept symptoms as inevitable rather than seeking help.

Symptoms include vaginal dryness, irritation, burning, dyspareunia, urethral discomfort, urinary urgency, frequency, recurrent urinary tract infections, and reduced vaginal lubrication.

Management steps:

1. Vaginal moisturisers (Replens, Repagyn) — used regularly two to three times per week, independently of intercourse; effective for dryness and comfort
2. Lubricants (water-based or silicone-based) — for intercourse; avoid petroleum-based products with latex
3. Topical vaginal oestrogen — pessaries (Vagifem 10 mcg twice weekly), ring (Estring 7.5 mcg/day, 90-day duration), cream (Ovestin); minimal systemic absorption (~0.1–0.4%); highly effective for all GSM symptoms and prevents recurrent urinary tract infections
4. Vaginal DHEA (prasterone) — alternative; limited PBS access

Topical vaginal oestrogen is safe in most women including many with a prior history of breast cancer — discuss on a case-by-case basis with the oncologist. The AMS provides guidance for this nuanced but common clinical scenario.

Vaginal laser treatments (MonaLisa Touch) are marketed for GSM but the TGA cautioned about their promotional claims in 2018. Evidence quality is variable — they are not first-line and should not be offered as a substitute for topical oestrogen.

D. Australian operations

MBS billing. Standard GP consultation items 23, 36, and 44 apply. A GP Chronic Condition Management Plan (GPCCMP, items 965 and 967) is appropriate when comorbid chronic conditions — osteoporosis, cardiovascular disease, perimenopausal depression — are being co-managed alongside the menopause transition. A Mental Health Care Plan (MHCP, items 2715 and 2717) is indicated for perimenopausal depression or anxiety requiring psychological therapy under Better Access. The Heart Health Check (item 699) is relevant for post-menopausal cardiovascular risk assessment. DXA (item 12306) for bone mineral density assessment follows Healthy Bones Australia criteria.

PBS schedule. Oral oestradiol tablets (Estrofem, Progynova), transdermal oestradiol patches (Estradot, Climara), and oestradiol gels (Sandrena, Estrogel) are general schedule — no authority required. Micronised progesterone (Prometrium) is general schedule. Combined continuous products (Femoston, Kliogest) are general schedule. Topical vaginal oestrogen (Vagifem pessaries, Ovestin cream, Estring ring) is general schedule. Tibolone (Livial) is general schedule. Fezolinetant is not yet PBS-listed; it requires a private prescription. Refer to PBS online for current authority and listing status.

Screening integration. BreastScreen Australia provides free two-yearly mammography from age 40 (actively offered from 50). Cervical screening per the National Cervical Screening Program continues five-yearly with an HPV test. These should continue throughout and beyond the perimenopause — menopause does not pause screening requirements.

Awareness resources. The NSW Agency for Clinical Innovation and state health networks are progressively developing menopause-in-the-workplace frameworks. Jean Hailes for Women’s Health publishes accessible, evidence-aligned patient materials — jeanhailes.org.au. NPS MedicineWise provides consumer decision-support on MHT choices.

E. Special populations

Premature ovarian insufficiency (POI, under 40 years). POI carries substantially elevated risks of cardiovascular disease, osteoporosis, cognitive impairment, and mental health disorders. MHT is recommended until the expected natural menopause age (~51 years) unless contraindicated — this is not “optional” HRT but appropriate physiological hormone replacement. Investigations include karyotype, autoimmune screen, and FMR1 premutation testing. Fertility counselling is essential (donor egg often required). Refer to gynaecology and/or endocrinology for specialist co-management.

Surgical and iatrogenic menopause. Bilateral oophorectomy causes abrupt oestrogen withdrawal with typically more severe symptoms than natural menopause. MHT should be considered promptly if no contraindication. Chemotherapy and radiation can cause transient or permanent ovarian suppression.

Perimenopausal depression. Perimenopause is an independent risk factor for a new depressive episode, distinct from general mood change. SSRI/SNRI therapy and structured psychological treatment via Better Access are appropriate. MHT can improve mood as an adjunct in perimenopause. Screen with PHQ-9 and GAD-7 at each review — RACGP guidelines include menopause as a mental health vulnerability period.

Aboriginal and Torres Strait Islander women. Cardiovascular risk, bone density concerns, and access to specialist services differ across populations. The ATSI Health Assessment (MBS item 715) provides an opportunity for integrated menopause screening within a culturally safe framework.

Contraception in perimenopause. As noted above, contraception is needed until 12 months amenorrhoea (age over 50) or 24 months (under 50). The Mirena IUD is ideal — contraception plus endometrial protection plus heavy bleeding management. Combined oral contraceptives are generally avoided after 50 due to VTE and cardiovascular risk unless there is a specific indication.

When to escalate

Refer or escalate when:

• Any postmenopausal bleeding — urgent gynaecology referral to exclude endometrial cancer
• Suspected POI (under 40, amenorrhoea, elevated FSH) — gynaecology and/or endocrinology
• MHT contraindication uncertainty — complex history (prior VTE, active malignancy, liver disease, thrombophilia) warrants specialist input before prescribing
• Refractory vasomotor symptoms not responding to MHT regimen changes — gynaecology menopause specialist
• Suspected breast cancer on examination or imaging — urgent breast surgery or breast physician referral
• Severe perimenopausal mental health deterioration — psychiatry, perinatal/women’s mental health services
• Complex sexual dysfunction — psychosexual specialist referral

What this article is and is not

This is general health information drawn from current Australian general practice sources — Australasian Menopause Society, Therapeutic Guidelines (eTG), AMH, RACGP, Jean Hailes, NPS MedicineWise, Healthy Bones Australia, and the Heart Foundation. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about MHT, non-hormonal treatments, investigations, and referrals are made with your own GP and treating clinicians, based on your individual history and circumstances.

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

For mental health support: Beyond Blue 1300 22 4636, Lifeline 13 11 14.

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Sources cited

1. Australasian Menopause Society
2. RANZCOG
3. Therapeutic Guidelines (eTG)
4. Australian Medicines Handbook
5. RACGP
6. Healthy Bones Australia
7. Jean Hailes for Women’s Health
8. NPS MedicineWise
9. TGA
10. Heart Foundation
11. HealthDirect — Menopause
12. Better Health Channel — Menopause
13. PBS