Menopause/perimenopause 

Stages of Menopause:

• Pre-Menopause:
  • Characterized by regular menstrual cycles.
  • No changes in symptoms or hormonal fluctuations related to the menopausal transition.
• Peri-Menopause:
  • Definition: The transitional period “around menopause.”
  • Average Duration: Approximately 5 years.
  • Typical Age Range: Between 39 and 51 years.
  • Cycle Changes: Increased cyclic irregularities, including prolonged ovulatory and anovulatory cycles.
  • Hormonal Changes:
    • Levels of follicle-stimulating hormone (FSH) and oestradiol oscillate, with declining luteal function.
  • Symptoms:
    • 10-20% experience no symptoms.
    • 10-20% experience severe symptoms.
    • The remainder have varying levels of symptoms.
• Menopause:
  • Definition: Cessation of menstruation for over 12 months.
  • Hormonal Changes: Reduced oestrogen and progesterone; increased FSH and LH.
  • Typical Age Range: Between 45-55 years.
  • Average Age: 50-51 years.
• Early Menopause:
  • Definition:
    • Early Menopause: Menopause occurring before 45 years.
    • Premature Menopause: Menopause occurring before 40 years.

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Stopping Contraception at (and after) the Menopausal Transition

• note: Ovulation may still occur for up to 12 months after the final menstrual period (FMP) ≥ 50 yrs and 24 months if the FMP < 50 yrs (“12-/24-month rule”).

1. Universal exit rules

Rule	Rationale
Stop all contraception at age 55 regardless of bleeds or FSH	By 55 yrs natural fertility is effectively zero. menopause.org.au
If relying on natural cycles (no hormonal interference): • FMP ≥ 50 yrs → stop after 12 mths amenorrhoea • FMP < 50 yrs → stop after 24 mths amenorrhoea	Established by AMS, RACGP, FSRH. menopause.org.auf srh.org

2. Method-specific recommendations after 50 yrs

Contraceptive method	Key age rule	How to confirm loss of fertility	When to stop
Combined hormonal contraception (CHC) (COCP, ring, patch)	Cease by 50 yrs (↑ VTE/arterial risk)	FSH unreliable (oestrogen suppresses)	Switch to non-hormonal or progestogen-only method, then follow that method’s rule
Depot medroxy-progesterone acetate (DMPA)	Last injection by 50 yrs (bone, CV risk)	Amenorrhoea unreliable; ovulation delay up to 12 mths	• Switch to non-hormonal → wait 24 mths amenorrhoea* OR • Switch to POP / implant / LNG-IUD and follow their rule fsrh.org
Progestogen-only pill (POP)	May continue ≥ 50 yrs	Once ≥ 50 yrs and amenorrhoeic ≥ 12 mths → one FSH ≥ 30 IU/L (some services still request 2 tests 6 wks apart) ⇒ continue POP for 12 mths then cease. menopause.org.au fsrh.org
Etonogestrel implant (ENG)	If inserted ≥ 45 yrs leave in situ until 55 yrs (off-label but supported).	Same FSH strategy as POP if earlier removal requested. fsrh.orgfsrh.org
LNG-IUD (52 mg)	Inserted ≥ 45 yrs → keep until 55 yrs; also supplies endometrial protection for MHT.	≥ 50 yrs & amenorrhoeic ≥ 12 mths → one FSH ≥ 30 IU/L ⇒ leave IUD for 12 mths then remove. fsrh.org
Copper IUD	Device inserted ≥ 40 yrs can remain until 55 yrs (off-label).	If removed earlier follow natural 12-/24-month rule.
Barrier / natural methods	Follow natural 12-/24-month rule based on age at FMP.

*Ovulation may be delayed after the last DMPA dose; the 24-month wait prevents premature cessation.

3. FSH-testing algorithm (for non-oestrogen methods)

1. Ensure at least 6 weeks since last progestogen-related withdrawal bleed (if any).
2. Draw FSH:
   • ≥ 30 IU/L → menopause likely.
3. Repeat only if local policy requires a second test (≥ 6 wks later).
4. Once criterion met, continue current contraception for 12 months then stop.
5. If FSH < 30 IU/L, repeat in 1 year or at 55 yrs (whichever comes first). fsrh.org

4. Special clinical considerations

Issue	Practical tip
Menopausal hormone therapy (MHT)	A 52 mg LNG-IUD can act as the progestogen component of systemic oestrogen therapy but oestrogen alone is not contraceptive → maintain contraception until menopause confirmed.
Bone health with DMPA	DMPA reduces BMD in hypo-oestrogenic mid-life women; consider switching earlier if additional osteoporosis risk factors present. fsrh.org
CHC risks	CHC after 50 yrs associated with rising VTE, stroke and MI risk; benefits rarely outweigh risks.
STI protection	Age ≠ immunity — advise condoms when new partners.
Counselling	Emphasise: declining-but-not-zero fertility, unintended-pregnancy consequences, method pros/cons, shared decision making, universal “stop-at-55” safety net.

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SYMPTOMS

• Vasomotor:
  • hot flushes – typically lasts 5-7 years, but can persist for 10+ years in some women.
  • night sweat
  • palpitations
  • lightheadedness/dizziness
  • migraine
• Psychogenic:
  • irritability, depression
  • anxiety/tension
  • tearfulness, loss of concentration
  • poor memory, unloved feelings, sleep changes, loss of self confidence
  • Typically lasts for 1-2 years around menopause, but for some can persist longer.
• Urogenital:
  • atrophic vaginitis
  • vaginal dryness
  • dyspareunia
  • decline in libido
  • bladder dysfunction (dysuria)
  • stress incontinence/prolapse
  • Symptoms can continue indefinitely, particularly if related to vaginal dryness, which often requires ongoing treatment.
• MSK:
  • aches + pains
• Skin:
  • dry skin, formication, new facial hair, breast glandular tissue atrophy
• Weight Gain and Metabolic Changes:

Symptoms potentially present at menopause and differential diagnoses
Assessment	History and examination findings		Could this be due to…?	Investigations in specific circumstances (some may be specialist initiated)
General menopausal symptoms	Flushes	Excessive or not relieved with oestrogen Associated factors: weight loss, hypertension, diarrhoea, anxiety, goitre, thyroid nodule	Thyroid disease Phaeochromocytoma Carcinoid syndrome	Thyroid stimulating hormone (TSH) 24 hour urinary catecholamines 24 hour urinary 5 HIAA
	Night sweats	Lymphadenopathy Hepatosplenomegaly Weight loss	Malignancies (eg. lymphoma, myeloma)	Appropriate blood work up, chest X-ray, node biopsy, serum and urine protein electrophoresis
	Palpitations	Associated cardiac symptoms	Cardiac arrythmia	Electrocardiogram (ECG), 24 hour Holter monitor
	Formication (‘ants crawling on skin’)	Presence of rash New sexual partner (ie. risk sexually transmissible infections [STIs])	Scabies Dermatitis	Skin examination
	Myalgia and arthralgia	Associated joint swelling, inflammation	Rheumatological disorders arthritis	ESR. CRP.  autoimmune serology, joint X-ray
	Migraine/headaches	Unusual, focal neurological symptoms and signs	Intracranial lesion	CT MRI brain
Gnaecological symptoms	Menorrhagia	Persistent (ie. not a one-off heavy bleed) Flooding at night Clots Anaemia or iron deficiency	Fibroid Uterine polyp Endometrial hyperplasia Uterine cancer Adenomyosis Thyroid dysfunction Coagulopathies	Transvaginal ultrasound  Endometrial sampling (Pipelle biopsy, hysteroscopy) Full blood examination (FBE), Fe studies, TSH, coagulation profile
	Amenorrhoea	Recent unprotected intercourse Associated factors, eg: galactorrhoea, headache, visual field defects thyroid symptoms androgen excess recent weight changes, eating disorders, exercise intensity, pelvic pain, mass	Pregnancy Hypothalamic dysfunction Pituitary dysfunction Ovarian tumours Thyroid disease Polycystic ovary syndrome (PCOS)	Beta human chorionic gonadotrophin (HCG) Transvaginal ultrasound CT/MRI brain/pituitary TSH, androgen screen, prolactin
	Hysterectomy Mirena™ IUD in situ	Oestrogen deficiency symptoms	Menopause	Follicle stimulating hormone (FSH) and oestradiol (if not on oral contraceptive pill [OCP] or HT; measured ~ day 3 of cycle)
	Postcoital bleeding	Cervical polyp Abnormal Pap smear/history	Cervical cancer	Biopsy
	Family history	Relevant family history of cancer (CA): ovary, breast, uterus, bowel	Cancer ovary, uterus (familial)	Transvaginal ultrasound CA 125, inhibin, genetic testing
	Pelvic pain	Palpable mass Deep dyspareunia Per vaginal (PV) discharge, febrile Known history endometriosis	Cancer ovary/uterus Endometriosis/ adenomyosis Ovarian cyst Pelvic inflammatory disease (PID)	Transvaginal ultrasound Laparoscopy Swabs
Genitourinary symptoms	Incontinence	Stress incontinence Urge incontinence Faecal incontinence	Pelvic floor dysfunction Detrusor instability Fistula	Urodynamics Physiotherapy assessment
	Urinary symptoms	Fever, dysuria, haematuria Polyuria/oliguria Polydipsia	Urinary tract infection Renal insufficiency Diabetes	Midstream specimen of urine (MSU) Renal function tests Fasting blood glucose
	Vulval irritation	Vaginal discharge Superficial dyspareunia Abnormal vulval appearance: lichenification, absent labia minora, inflammation, lesions	Vaginal infections: thrush, STI Lichen sclerosus Candidiasis Vulval cancer	Swabs Vulval biopsy
Sexual symptoms	Loss of libido	Relationship issues Associated lethargy, tiredness, depression Bilateral oophorectomy Superficial dyspareunia Use of medications (eg. selective serotonin reuptake inhibitors [SSRIs], OCP, oestrogen)	Androgen insufficiency syndrome Mood disorder Atrophic vaginitis Medication side effects Relationship breakdown	Sensitive testosterone (T), sex hormone binding globulin > calculated free T (measured in morning, ~ day 7 of cycle)Trial of local oestrogen Trial off/change medication
	Sexual partner	New partner, not using condoms Partner in another sexual relationship	STI	STI screen: serology syphilis, HIV, hepatitis, urine PCR for chlamydia
Breast symptoms	Family history	Relevant family history of breast or ovarian cancer	Breast cancer (familial)	Diagnostic mammogram +/–Ultrasound Genetic testing
	Breast changes	Palpable lump or skin distortion Nipple discharge/eczema Abnormal screening mammogram	Breast cancer Fibroadenoma Breast cyst/abscess Mammary duct ectasia	Diagnostic mammogram Ultrasound Biopsy (eg. fine needle, core, excisional)
Psychosocial symptoms	Depression/anxiety	Family/past history mood disorders including premenstrual syndrome (PMS) postnatal depression (PND) Panic attacks phobias sleep disturbance Loss of motivation loss of libido appetite suicidal thoughts Current use of medications (eg. SSRIs)	Major depressive disorder Generalised anxiety disorder Specific phobias Panic disorder Bipolar disorder Schizophrenia	Psychological assessment
	Memory loss	Poor concentration Disorientation	Cognitive disorder Dementia	Mini Mental State Examination Neuropsychological testing

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CLINICAL APPROACH

Before Menopause (Reproductive Years)

• The ovaries release one egg each month.
• This triggers predictable hormone changes that result in monthly periods and regular physical and emotional cycles.

Menopausal Transition (Perimenopause)

• The ovaries begin to function less consistently.
• Egg release becomes sporadic, leading to fluctuating hormone levels.
• Common effects include:
  • Irregular periods
  • Hot flushes, mood swings, night sweats, and sleep issues
  • Temporary symptom relief when the ovaries randomly release an egg, briefly restoring hormone levels
• This phase is often called a time of “hormonal chaos”.
• It can last up to 4–5 years, sometimes longer.
• Because ovulation can still occur, contraception is still needed until at least 12 months after your final natural period.

Postmenopause (Ovarian Failure)

• Eventually, the ovaries stop releasing eggs completely.
• Hormone levels (especially oestrogen and progesterone) fall to postmenopausal levels.
• Menstrual periods stop entirely.

Symptoms During Menopause

• Every woman’s experience is different:
  • ~20% have no symptoms
  • ~60% have mild to moderate symptoms
  • ~20% have severe or disabling symptoms
• Common symptoms include:
  • Hot flushes and night sweats
  • Mood changes, anxiety, or irritability
  • Vaginal dryness, discomfort with intercourse
  • Reduced libido, fatigue, and sleep disturbance
• Symptom severity and type are influenced by:
  • Lifestyle (e.g. smoking, alcohol, physical activity)
  • Psychological stress
  • Medical conditions (e.g. thyroid dysfunction, depression)
  • Social supports and cultural background

Holistic Management of Menopause

Menopause is not just about hormone decline—it’s a whole-person health transition.
Management should be individualised and may involve:

• Hormonal management (e.g. MHT where appropriate)
• Non-hormonal treatments for specific symptoms
• Bone health assessment and fracture risk reduction
• Mental health and psychosocial support
• Lifestyle interventions: physical activity, diet, smoking/alcohol reduction
• Support with relationships, work, and body image

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Investigations

• For women less than 45 years of age, FSH testing is  Recommended
• but for women older than 45 diagnostic blood tests including FSH are not necessary

1. Cardiovascular Risk

Significant Risk Factors:

• Family history of IHD, stroke, or premature CVD
• Personal history of IHD or stroke
• Hypertension, diabetes, hyperlipidaemia, obesity
• Smoking
• Obstructive sleep apnoea

Suggested Investigations:

• Absolute CVD risk calculator (e.g. Australian CV Risk Calculator)
• Fasting glucose / Oral glucose tolerance test
• Urine microalbumin and renal function (U&E)
• 24-hour ambulatory blood pressure monitoring
• ECG ± Echocardiogram
• Chest X-ray (if clinically indicated)
• Sleep study (if OSA suspected)

2. Osteoporosis and Fracture Risk

Major Risk Factors:

• Prior minimal trauma (fragility) fracture
• Age >65 years
• Family history of hip fracture
• Low BMI (<20 kg/m²)
• Low bone mineral density (T-score ≤ -2.5 on DXA)
• 3 months systemic corticosteroid use
• High falls risk: frailty, poor vision, neuromuscular disorders, sedatives
• Lifestyle: smoking, alcohol >3 units/day, physical inactivity, low calcium/vitamin D

Secondary Causes of Osteoporosis:

• Endocrine: hyperthyroidism, hyperparathyroidism, hypogonadism (incl. premature menopause), type 1 DM
• GI: malabsorption (e.g. coeliac), chronic liver disease
• Renal: CKD
• Others: multiple myeloma, RA

Suggested Investigations:

• DXA scan (lumbar spine, femoral neck)
• Plain spinal X-ray (if height loss or back pain)
• Exclude secondary causes:
  • Serum calcium, phosphate, ALP, PTH
  • Vitamin D
  • TSH
  • LFTs, U&E
  • ESR
  • Serum and urine protein electrophoresis
  • Coeliac serology
• Bone turnover markers (for monitoring treatment)

Risk Tools:

• FRAX® (WHO): 10-year probability of fracture (with/without BMD)
  www.shef.ac.uk/FRAX

3. Thrombophilia Risk

Risk Factors:

• Family or personal history of DVT, PE (especially if spontaneous or <40 years)
• Known inherited thrombophilia (e.g. Factor V Leiden)
• Age >60 years, obesity, smoking
• Recent surgery, fracture, immobilisation, long travel
• Recurrent pregnancy loss
• Comorbidities: SLE, cancer
• Medications: tamoxifen, raloxifene

Suggested Investigations:

• Thrombophilia screen (especially if unprovoked thrombosis or young age):
  • Activated protein C resistance (APCR)
  • Factor V Leiden
  • Prothrombin gene mutation
  • Homocysteine
  • Protein C, S, antithrombin III
  • Antiphospholipid antibodies: anticardiolipin, lupus anticoagulant
  • Coagulation profile

4. Cancer Risk

Breast Cancer

Risk Factors:

• Age, obesity
• Early menarche, nulliparity, late first childbirth, no breastfeeding
• High mammographic density
• Alcohol >3 drinks/day
• Personal or family history of:
  • Breast cancer (especially early onset or bilateral)
  • DCIS or atypical ductal hyperplasia
  • BRCA1/BRCA2 mutation
  • Ovarian cancer or HNPCC
• Ashkenazi Jewish ancestry
• In utero exposure to diethylstilbestrol (DES)

Ovarian Cancer

Risk Factors:

• Age >65 years
• Nulliparity, early menarche, late menopause
• Family history of ovarian or breast cancer
• Known BRCA1/BRCA2 or HNPCC

Endometrial Cancer

Risk Factors:

• Age >50 years
• Nulliparity
• Use of tamoxifen or unopposed oestrogen
• Endometrial hyperplasia
• HNPCC family history

Suggested Investigations (as per presentation):

• Transvaginal ultrasound (for abnormal uterine bleeding)
• Tumour markers: CA-125 (ovarian), inhibin
• Genetic testing (BRCA1/2, HNPCC-related)
• Laparoscopy (as indicated by specialist)

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MANAGEMENT

Lifestyle and Behavioural Modifications for Menopausal Symptoms

• Maintaining Healthy Weight:
  • A study involving 40 overweight/obese women showed that a 10% weight loss significantly improved hot flushes.
  • Weight loss correlated with a reduction in the frequency of hot flushes.
• Physical Activity:
  • Regular physical activity is linked to reduced menopausal symptoms, including hot flushes.
  • Exercise improves overall health, helps with weight management, and can reduce hot flush severity.
    • (Reference: Elavsky S, McAuley E. Menopause. 2007)
• Clothing and Environment:
  • Cooling Strategies:
    • Though no definitive clinical evidence supports cooling interventions for vasomotor symptoms, reducing core body temperature can help.
    • Suggested changes include:
      • Wear light, breathable clothing (layers, natural fibers).
      • Avoid heavy clothing like jumpers and scarves.
      • Lower room temperature.
      • Use a cold pack under the pillow or flip the pillow to the cooler side.
      • Drink cool liquids like iced water.
• Avoiding Triggers of Vasomotor Symptoms:
  • Certain triggers can exacerbate hot flushes for some women, including:
    • Caffeine, alcohol, and spicy foods.
• Mind- and Body-Based Therapies:
  • Cognitive Behaviour Therapy (CBT):
    • Helps manage the psychological and physical symptoms of menopause.
  • Mindfulness and Relaxation Techniques:
    • Can reduce the frequency and severity of hot flushes.
  • Yoga:
    • Promotes relaxation and helps manage menopausal symptoms.
  • Paced Breathing:
    • Controlled breathing exercises to aid in relaxation.
  • Relaxation Techniques:
    • General relaxation practices can provide symptom relief.

Menopausal Hormone Therapy (MHT)

1. Oestrogen Only Menopausal Hormone Therapy
   • Suitable for women with troublesome menopausal symptoms
   • Effective for hot flushes, vaginal dryness, loss of libido, irritability, sleep disturbances, and muscle/joint pains
2. Combined Menopausal Hormone Therapy
   • Recommended for women with an intact uterus to prevent endometrial hyperplasia and cancer
   • Includes both oestrogen and progestogen
   • Benefits: Symptom relief and bone loss prevention
   • Risks: Increased risk of breast cancer, thrombotic events, and adverse cardiovascular changes
3. Tibolone
   • Synthetic hormone therapy for post-menopausal women
   • Relieves menopausal symptoms and prevents osteoporosis

Non-Hormonal Pharmacotherapy for Menopause Symptoms

• Suitable for Women Who:
  • Do not find relief with lifestyle changes.
  • Cannot use hormones due to medical conditions.
  • Prefer to avoid hormones due to potential health risks.
• Key Considerations:
  • Includes off-label use of medications, especially for managing hot flushes/night sweats.
  • Emphasis on evidence-based prescribing for off-label use.
• Selective Serotonin Reuptake Inhibitors (SSRIs) & Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
  • Indications: Hot flashes, mood disturbances, anxiety.
  • Examples & Dosage:
    • Venlafaxine (Effexor): Start at 37.5 mg daily; may increase to 75 mg daily.
    • Paroxetine (Paxil): Start at 10 mg daily; may increase to 20 mg daily.
    • Citalopram (Celexa): Start at 10 mg daily; may increase to 20 mg daily.
  • Evidence: Shown to reduce frequency/severity of hot flashes and improve mood in menopausal women.
• Gabapentin (Neurontin):
  • Indications: Hot flashes, particularly nocturnal hot flashes.
  • Dosage: Start at 300 mg at bedtime; may increase to 300 mg three times daily.
  • Evidence: Demonstrated to significantly reduce hot flash frequency and severity in multiple clinical trials.
• Clonidine (Catapres):
  • Indications: Hot flashes.
  • Dosage: Start at 0.1 mg at bedtime; may increase to 0.1 mg twice daily.
  • Evidence: Effective in reducing hot flashes but often associated with side effects (e.g., dry mouth, drowsiness).

Vasomotor Symptoms/hot flushes 

Urinary Symptoms and Vaginal Dryness

• Urine Symptoms:
  • Oxybutynin can be used for urinary symptoms.
• Vaginal Dryness Management:
  • First Line (Non-Hormonal Options):
    • Replens or K-Y Gel as lubricants for vaginal dryness.
  • Second Line (Low-Dose Vaginal Hormonal Preparations):
    • Estriol cream, estriol pessary, or estradiol pessary:
      • Use daily for 2 weeks, then reduce to twice weekly.
    • Vaginal Moisturisers (use twice weekly):
      • Examples include Replens® and Yes®.
  • Safety of Vaginal Estrogen:
    • Vaginal estrogen does not increase the risk of:
      • Cardiovascular disease (CVD)
      • Venous thromboembolism (VTE)
      • Developing breast cancer
    • If Previous Breast Cancer:
      • Start with non-hormonal treatments.
      • If symptoms persist, consider vaginal estrogen in consultation with an oncology specialist.
  • Additional Benefits:
    • Vaginal estrogen may also improve urinary symptoms and help prevent recurrent UTIs.
• Natural Therapy Considerations:
  • Phytoestrogens:
    • No proven effect on reducing hot flushes or other menopausal symptoms.
    • Long-term use (>5 years) is associated with an increased risk of endometrial hyperplasia.
  • Black Cohosh:
    • Associated with the risk of liver failure; caution is advised.