Menopause & perimenopause (MHT)
The menopausal transition, and evidence-based menopausal hormone therapy.
1. Clinical overview & diagnosis
Menopause is diagnosed clinically after 12 months of amenorrhoea; perimenopause is the symptomatic transition. Diagnosis in women over 45 with typical vasomotor symptoms is clinical and does not require FSH testing (RACGP 2023).
Red flags for urgent referral
- • Postmenopausal bleeding — requires urgent investigation to exclude endometrial cancer
- • Symptoms before age 40 — investigate for premature ovarian insufficiency (POI)
2. Patient diagnostic pathway
- 1History — Vasomotor symptoms, sleep disturbance, mood changes, urogenital symptoms, cycle changes.
- 2Examination — Blood pressure, BMI, breast awareness, consider pelvic exam if urogenital symptoms.
- 3Investigations — None routinely needed over 45; FSH only if under 45 or diagnosis unclear; baseline cardiovascular and breast screening as appropriate.
3. Treatment & management plan
First-line — For bothersome vasomotor symptoms — MHT (RACGP/RANZCOG 2023), no arbitrary time limit with shared decision-making. Preferred: transdermal estradiol (lower VTE risk) plus micronised progesterone if uterus intact. Estradiol patches (Estradot, Climara) and gels (Sandrena, Estrogel) are PBS-listed.
Second-line — Non-hormonal options (SSRIs/SNRIs, gabapentin) where MHT contraindicated. Vaginal estrogen for genitourinary symptoms.
- • Cardiovascular window: initiate within 10 years of menopause or before age 60 for favourable benefit-risk.
4. Patient pathway & referral
When & where to refer
- • Complex cases
- • Contraindications to MHT
- • Persistent symptoms
- • Always investigate postmenopausal bleeding urgently
Patient education & resources
Clinical decision support only. Not a substitute for independent clinical judgement. HerPath informs, it does not replace the treating practitioner.