The Menopause

Last updated 1 Jun 2026 · Women's Health / Endocrinology

📋 Key Information Summary

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Menopause is defined as the final menstrual period, confirmed after 12 consecutive months of amenorrhoa, with a median age of 51 years in Australian women.
The perimenopause (menopausal transition) may last 4–8 years and is characterised by cycle irregularity, vasomotor symptoms (hot flushes, night sweats), and fluctuating hormone levels.
Vasomotor symptoms (VMS) affect up to 80% of women and are the most common reason for presentation; urogenital symptoms (vaginal dryness, dyspareunia, recurrent UTI) are often under-recognised.
Menopausal hormone therapy (MHT) remains the most effective treatment for moderate-to-severe VMS and urogenital atrophy, with benefits generally outweighing risks when initiated within 10 years of menopause or before age 60.
Unopposed oestrogen is contraindicated in women with an intact uterus due to endometrial hyperplasia risk; a progestogen must be added for endometrial protection.
Transdermal oestradiol (patches, gel) carries a lower VTE and stroke risk than oral oestrogen and is preferred in women with BMI >30, migraines with aura, or VTE risk factors.
Micronised progesterone (Prometrium®) and dydrogesterone have a more favourable breast-cancer risk profile than synthetic progestogens (medroxyprogesterone acetate, norethisterone) based on E3N cohort data.
Absolute contraindications to MHT include oestrogen-receptor-positive breast cancer (current), active VTE, undiagnosed vaginal bleeding, active liver disease, and untreated endometrial cancer.
Non-hormonal options for VMS include SSRIs/SNRIs (venlafaxine 37.5–75 mg, escitalopram 10–20 mg), gabapentin, clonidine, and fezolinetant (Veozah®), the first NK3 receptor antagonist approved in Australia (2024).
Vaginal oestrogen (cream, pessary, ring) is safe long-term for urogenital symptoms and does not require concurrent progestogen; vaginal DHEA (prasterone/Intrarosa®) is an alternative.
Cardiovascular risk assessment should be performed before and during MHT, as premature menopause (<40 years) and early menopause (40–45 years) independently increase CVD risk.
Lifestyle modification (regular exercise, weight management, smoking cessation, limiting alcohol) is a cornerstone of menopause management and long-term bone and cardiovascular health.
Aboriginal and Torres Strait Islander women experience earlier menopause on average and have higher rates of chronic disease; culturally safe, community-based care models improve engagement.

Introduction & Australian Epidemiology

The menopause marks the permanent cessation of ovarian follicular activity and menstruation, resulting from declining oestradiol and inhibin B production. It is a physiological transition, not a disease, yet its symptoms can significantly impair quality of life, workplace productivity, and long-term health. General practitioners are uniquely positioned to provide evidence-based, individualised management through the perimenopause and postmenopausal years.

In Australia, the median age of natural menopause is 51 years (range 45–55 years). Approximately 1.5 million women are currently postmenopausal, and an estimated 60–80% experience vasomotor symptoms (VMS), with 20–30% reporting severe symptoms that interfere with daily function. The average duration of VMS is 7.4 years, though some women experience symptoms for more than a decade.

Surgical menopause (bilateral oophorectomy) induces an abrupt hormonal withdrawal and typically causes more severe symptoms. Chemotherapy and pelvic radiotherapy can cause iatrogenic ovarian failure at any age. Premature ovarian insufficiency (POI), defined as loss of ovarian function before age 40, affects approximately 1% of women and requires specific management including MHT at least until the median age of natural menopause.

The burden of menopausal symptoms in Australia is substantial. A 2023 Jean Hailes for Women's Health national survey found that nearly 50% of women aged 45–64 had not discussed menopause with their GP, and only 15% were using MHT despite moderate-to-severe symptoms. Barriers include misinformation about MHT safety following the 2002 Women's Health Initiative (WHI) publication, clinician knowledge gaps, and stigma around ageing and women's health.

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Key epidemiological fact: Australia has one of the highest MHT utilisation rates globally, yet significant under-treatment persists. The Australasian Menopause Society (AMS) recommends individualised risk–benefit discussion for every symptomatic woman, and encourages MHT use when benefits outweigh risks.

Physiology & Clinical Features

Hormonal Physiology of the Menopausal Transition

The perimenopause begins with declining ovarian follicular reserve. As the number of antral follicles decreases, inhibin B and anti-Müllerian hormone (AMH) fall, leading to rising follicle-stimulating hormone (FSH). Oestradiol levels may initially increase (oestrogen dominance phase) before ultimately declining. The loss of negative feedback on the hypothalamic–pituitary axis results in elevated FSH (>25 IU/L in the late menopausal transition) and luteinising hormone (LH).

Oestradiol is not merely a reproductive hormone. Oestrogen receptors (ER-α and ER-β) are expressed in the hypothalamus (thermoregulatory centre), bone, cardiovascular endothelium, brain (cognition, mood), urogenital tract, skin, and colon. The systemic withdrawal of oestrogen therefore produces effects far beyond menstruation.

Vasomotor Symptoms (Hot Flushes)

Hot flushes are the hallmark symptom of menopause, affecting 75–80% of Australian women. The pathophysiology involves narrowing of the thermoneutral zone in the hypothalamus due to oestrogen withdrawal, leading to inappropriate heat-dissipation responses (peripheral vasodilation, sweating) triggered by minor core temperature fluctuations. Kisspeptin/neurokinin B/dynorphin (KNDy) neurons in the arcuate nucleus play a central role — this is the target of the new NK3 receptor antagonist fezolinetant.

A hot flush typically lasts 1–5 minutes and is characterised by sudden warmth spreading over the face, neck, and chest, followed by profuse sweating and sometimes chills. Nocturnal hot flushes (night sweats) cause sleep fragmentation, fatigue, irritability, and impaired concentration.

Other Clinical Features of Menopause

System	Symptoms / Features	Prevalence
Vasomotor	Hot flushes, night sweats, palpitations	60–80%
Urogenital (genitourinary syndrome of menopause, GSM)	Vaginal dryness, dyspareunia, urinary urgency, frequency, recurrent UTI	50–70%
Musculoskeletal	Arthralgia, myalgia, accelerated bone loss (osteoporosis)	40–60%
Psychological	Low mood, anxiety, irritability, brain fog, poor memory, reduced libido	35–50%
Cardiovascular	Accelerated atherogenesis, unfavourable lipid profile, increased central adiposity	Progressive
Dermatological	Skin thinning, dryness, loss of elasticity, hair thinning	30–50%

Diagnosis

Menopause is a clinical diagnosis in women aged ≥45 years with typical symptoms and cycle changes. Routine hormonal testing (FSH, oestradiol) is not required for diagnosis in this age group. FSH measurement may be considered in women aged 40–45 with atypical symptoms or in younger women to investigate POI. In women using hormonal contraception (which masks cycle changes), AMH and FSH may assist, though interpretation is limited.

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Stages of Reproductive Aging (STRAW+10 criteria): The STRAW+10 classification divides the reproductive lifespan into stages: early and late menopausal transition (variable cycle length, ≥7-day difference in consecutive cycles), perimenopause (12 months after the final period), and postmenopause. These stages guide clinical assessment and management.

Menopausal Hormone Therapy — Benefits, Risks & Contraindications

Benefits of MHT

MHT is the most effective treatment for vasomotor symptoms, reducing hot flush frequency and severity by 75–90%. The Australasian Menopause Society, NICE (NG23), and the International Menopause Society all endorse MHT as first-line for moderate-to-severe VMS in women without contraindications.

Vasomotor symptoms: 75–90% reduction in hot flush frequency and severity (number needed to treat [NNT] ~2–3).
Urogenital atrophy (GSM): Systemic MHT improves vaginal dryness, dyspareunia, and urinary symptoms; vaginal oestrogen is preferred for isolated GSM.
Bone protection: MHT reduces vertebral and hip fracture risk by 30–50% and prevents postmenopausal bone loss. Effect is maintained only during use.
Cardiovascular (timing hypothesis): MHT initiated within 10 years of menopause or before age 60 is associated with reduced coronary heart disease and all-cause mortality (the "window of opportunity" hypothesis).
Mood and cognition: MHT may improve depressive symptoms in perimenopausal (not postmenopausal) women and may support cognitive function when started early, though evidence is mixed.
Colorectal cancer: Combined MHT is associated with a reduced risk of colorectal cancer (WHI data: HR 0.63).
Quality of life: Significant improvements in sleep, energy, sexual function, and work productivity.

Risks of MHT

Risk	Oestrogen-Only MHT	Combined (O + P) MHT	Absolute Risk (per 10,000 women-years)
Breast cancer	No increase (may decrease — WHI)	Increased after 3–5 years of use (RR ~1.2–1.7, varies by progestogen)	Baseline ~30; +5–8 with combined MHT after 5 years
VTE (DVT/PE)	Oral: ~2× increased; transdermal: no significant increase	Oral: 2–3× increased; transdermal: minimal/no increase	Baseline ~5; oral MHT → ~10–15
Stroke	Oral: slight increase; transdermal: no significant increase at standard doses	Similar to oestrogen-only	Baseline ~8; oral MHT → ~12
Endometrial cancer	Increased (2–10×) without progestogen	No increased risk (adequate progestogen)	Unopposed oestrogen significantly elevates risk
Ovarian cancer	Possible small increase (RR ~1.2)	Possible small increase	Baseline ~3; +1 with MHT

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Critical — the timing hypothesis: Risks of MHT are lowest and benefits greatest when initiated within 10 years of menopause onset or before age 60. Initiating MHT after age 60 or >10 years post-menopause confers higher cardiovascular and breast cancer risk, and is generally not recommended unless symptoms are severe and alternatives have failed. Transdermal routes minimise VTE and stroke risk at any age.

Absolute Contraindications to MHT

Known, past, or suspected oestrogen-dependent cancer (breast cancer — ER-positive, current or recent)
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia or endometrial cancer
Active or recent (within 12 months) venous thromboembolism (DVT, PE)
Active or recent arterial thromboembolic event (MI, stroke, TIA within 6–12 months)
Active liver disease or liver tumour (benign or malignant)
Known thrombophilia (e.g., Factor V Leiden homozygous, antiphospholipid syndrome) — relative; may use transdermal with haematology input
Porphyria cutanea tarda (absolute contraindication to oral oestrogen)

Relative Contraindications / Cautions

Migraine with aura (transdermal oestrogen preferred, avoid oral)
BMI >30 kg/m² (transdermal preferred — oral has increased VTE risk)
Hypertriglyceridaemia (transdermal preferred — oral may raise triglycerides)
Gallbladder disease (oral oestrogen increases risk; transdermal preferred)
Uterine fibroids (MHT may stimulate growth)
Endometriosis (residual disease may be stimulated; combined MHT preferred over unopposed)
Family history of breast cancer (not an absolute contraindication; individualise risk with risk-assessment tools such as IBIS or CanRisk)

MHT Regimens — Oestrogens & Progestogens

Principles of MHT Prescribing

Use the lowest effective dose for the shortest duration consistent with treatment goals (reassess annually).
Women with an intact uterus must receive a progestogen for endometrial protection — unopposed oestrogen increases endometrial cancer risk 2–10 fold.
Transdermal oestradiol is preferred in women with VTE risk factors, obesity, migraine with aura, hypertriglyceridaemia, or gallbladder disease.
Micronised progesterone (Prometrium®) and dydrogesterone carry a lower breast cancer risk than synthetic progestogens based on observational data (E3N French cohort).

Oestrogen Preparations

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Oestradiol oral (E2)

Estrofem® · Zumenon® · Oestradiol

Adult dose 1–2 mg orally once daily

Route Oral

Notes First-line oral oestrogen. First-pass hepatic metabolism increases VTE risk vs transdermal.

PBS status ✔ PBS General Benefit

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Oestradiol transdermal patch

Estraderm® · Climara® · Estradot® · Femtran®

Adult dose 25–100 mcg/day; applied twice weekly (Estraderm, Estradot) or weekly (Climara)

Route Transdermal (apply to lower abdomen or buttock)

Notes Preferred route in women with VTE risk, obesity, migraine with aura, hypertriglyceridaemia. No first-pass hepatic effect. Avoid applying to breasts.

PBS status ✔ PBS General Benefit

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Oestradiol gel

Estrogel® · Sandrena® sachets

Adult dose Estrogel®: 1.5–3 g gel daily (0.75–1.5 mg E2); Sandrena®: 0.5–1 mg daily

Route Transdermal gel (apply to thighs/arms, rotate sites)

Notes Useful when patches cause skin irritation. Avoid skin-to-skin transfer to children/partners — allow to dry and cover with clothing.

PBS status ✔ PBS General Benefit

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Conjugated equine oestrogen (CEE)

Premarin®

Adult dose 0.3–0.625 mg orally once daily

Route Oral

Notes Used in WHI trials. Contains multiple equine oestrogen metabolites. Higher VTE risk than oestradiol. Oestradiol now generally preferred.

PBS status ✔ PBS General Benefit

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Vaginal oestradiol (cream/pessary)

Ovestin® cream · Vagifem® pessaries

Adult dose Ovestin® cream: 0.5 mg/g, 1 g intravaginally nightly for 2 weeks then 1 g twice weekly; Vagifem®: 10 mcg tablet intravaginally nightly for 2 weeks then twice weekly

Route Intravaginal

Notes First-line for isolated GSM. Does NOT require concurrent progestogen. Safe for long-term use. Does not significantly raise serum oestradiol levels.

PBS status ✔ PBS General Benefit

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Vaginal oestradiol ring

Estring® (low dose, 7.5 mcg/day)

Adult dose One ring intravaginally, replaced every 90 days

Route Intravaginal

Notes Convenient long-acting option for GSM. No progestogen required. Some women find insertion difficult.

PBS status ✔ PBS General Benefit

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Prasterone (vaginal DHEA)

Intrarosa®

Adult dose 6.5 mg pessary intravaginally once nightly

Route Intravaginal

Notes Converts locally to oestradiol and testosterone. TGA-approved for dyspareunia due to vulvovaginal atrophy. No progestogen required. Newer option with limited PBS access.

PBS status ✘ Not PBS listed

Progestogen Preparations

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Micronised progesterone

Prometrium® · Utrogestan®

Adult dose 100 mg orally at night (continuous) or 200 mg orally nightly for 14 days/month (cyclical)

Route Oral (take at bedtime — causes drowsiness)

Notes Bioidentical progesterone. More favourable breast cancer risk profile than synthetic progestogens (E3N data). May cause drowsiness — advise bedtime dosing. Peanut allergy: Prometrium contains peanut oil — use Utrogestan or alternative.

PBS status ✔ PBS General Benefit

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Medroxyprogesterone acetate (MPA)

Provera®

Adult dose 2.5 mg orally daily (continuous) or 5–10 mg orally daily for 12–14 days/month (cyclical)

Route Oral

Notes Synthetic progestogen. Associated with higher breast cancer risk than micronised progesterone in observational studies. Used in WHI trial (with CEE). Still widely prescribed in Australia.

PBS status ✔ PBS General Benefit

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Dydrogesterone

Duphaston®

Adult dose 10 mg orally twice daily for 14 days/month (cyclical) or 5–10 mg daily (continuous)

Route Oral

Notes Retrosteroidal progestogen, structurally similar to natural progesterone. Favourable breast cancer profile (DERISH study data). Used in Femoston® combinations internationally.

PBS status ⚠ Not PBS listed for MHT (PBS for other indications)

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Norethisterone acetate (NETA)

Primolut N® · Aygestin®

Adult dose 0.7–1 mg orally daily (continuous) or 5 mg daily for 12 days/month (cyclical)

Route Oral

Notes Synthetic progestogen with androgenic activity. Higher breast cancer risk profile. Used in Kliovance® combined preparation. May worsen acne or hirsutism.

PBS status ✔ PBS General Benefit

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Levonorgestrel intrauterine system (LNG-IUS)

Mirena® 52 mg

Adult dose One IUD provides endometrial protection for 5 years (replaced at 5 years for MHT use)

Route Intrauterine

Notes Provides excellent endometrial protection + contraception. Allows systemic oestrogen (oral, patch, or gel) to be used without oral progestogen. Also treats heavy menstrual bleeding in perimenopause. Widely used in Australian practice.

PBS status ✔ PBS General Benefit

Combined MHT Regimens

For women with an intact uterus, MHT must include both oestrogen and a progestogen. Two main schedules are used:

Regimen	Schedule	Bleeding Pattern	Best For
Cyclical (sequential)	Oestrogen daily + progestogen for 12–14 days/month	Monthly scheduled withdrawal bleed	Perimenopausal women or those within 12 months of last period
Continuous combined	Oestrogen + progestogen every day	No regular bleed (spotting common in first 3–6 months)	Women >12 months post-menopause
Long-cycle / quarterly	Oestrogen daily + progestogen for 14 days every 3 months	Quarterly bleed	Alternative for those who prefer less frequent bleeding

Fixed-Dose Combined Preparations (PBS-listed in Australia)

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Kliovance®

Oestradiol 1 mg / NETA 0.5 mg

Regimen Continuous combined, 1 tablet daily

Best for Postmenopausal women (>12 months since last period)

PBS status ✔ PBS General Benefit

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Angeliq®

Oestradiol 1 mg / Drospirenone 2 mg

Regimen Continuous combined, 1 tablet daily

Notes Drospirenone has antimineralocorticoid activity (mild diuretic effect). Monitor potassium if on spironolactone or ACE inhibitors. Relatively newer option.

PBS status ⚠ Authority Required

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Climesse®

Oestradiol valerate 2 mg / NETA 1 mg

Regimen Cyclical (sequential), 1 tablet daily for 28 days (last 10 days include NETA)

Best for Perimenopausal or recently postmenopausal women

PBS status ✔ PBS General Benefit

Tibolone

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Tibolone

Livial®

Adult dose 2.5 mg orally once daily

Notes Synthetic steroid with oestrogenic, progestogenic, and androgenic properties. Does not require separate progestogen. Not suitable for perimenopausal women (causes irregular bleeding). The LIFT trial showed increased stroke risk — use with caution in women with cardiovascular risk factors. Reduces VMS, improves libido, and preserves bone density.

PBS status ✘ Not PBS listed

Testosterone Supplementation

Low-dose testosterone may be considered for postmenopausal women with hypoactive sexual desire dysfunction (HSDD) that has not responded to MHT and non-pharmacological strategies. The Australasian Menopause Society and International Menopause Society support a trial of testosterone for HSDD where appropriate.

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Testosterone 1% cream

AndroFeme® 1

Adult dose 5 mg (0.5 mL) applied to inner thigh daily; titrate to maintain serum total testosterone in the mid-normal premenopausal range

Route Transdermal cream

Notes TGA-approved compounding product in Australia. Monitor serum testosterone at 3–6 weeks then every 6 months. Target: upper half of female reference range. AndroFeme® is supplied via compounding pharmacies. Discontinue if no benefit after 3–6 months. Watch for acne, hirsutism, voice changes.

PBS status ✘ Not PBS listed

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Peanut allergy and Prometrium®: Prometrium® capsules contain arachis (peanut) oil. In women with confirmed peanut allergy, prescribe Utrogestan® (soy-derived) or compounded micronised progesterone, or switch to a different progestogen such as dydrogesterone or MPA.

Non-Hormonal Options

Non-hormonal pharmacological therapies are indicated when MHT is contraindicated (e.g., oestrogen-receptor-positive breast cancer, active VTE), declined by the patient, or insufficient alone. Lifestyle measures should underpin all management.

Lifestyle & Behavioural Measures

Cognitive behavioural therapy (CBT): RCT evidence supports CBT (group or online) for reducing bother from hot flushes and night sweats. The Menopause CBT programme (UK) has Australian adaptations available.
Exercise: Regular moderate-intensity exercise (≥150 min/week) reduces VMS severity, improves mood, preserves bone density, and reduces cardiovascular risk.
Weight management: Weight loss of ≥5% body weight reduces VMS frequency. Higher adiposity initially provides peripheral oestrogen but worsens flushing via insulation effects.
Cooling strategies: Layered clothing, fans, cooling pillows, cold water, breathable fabrics. Simple but effective adjuncts.
Smoking cessation: Smoking worsens VMS, accelerates bone loss, and increases cardiovascular risk.
Alcohol reduction: Alcohol is a known VMS trigger. Limit to ≤10 standard drinks/week per NHMRC guidelines.

Pharmacological Non-Hormonal Options

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Fezolinetant

Veozah® — NK3 receptor antagonist

Adult dose 45 mg orally once daily

Mechanism Blocks KNDy neuron signalling in the hypothalamus — targets the pathophysiology of VMS directly without hormonal effects

Efficacy Reduces moderate-to-severe VMS frequency by ~50–60% and severity by ~30% (SKYLIGHT trials). Non-inferior to SSRIs/SNRIs.

Key precautions Contraindicated with CYP1A2 inhibitors (fluvoxamine). Check LFTs at baseline, 3 months, 6 months, 9 months, and 12 months, then periodically. Discontinue if ALT/AST >5× ULN. Avoid in severe hepatic impairment (Child-Pugh C).

PBS status ✘ Not PBS listed (TGA-approved 2024; private prescription ~A/month)

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Venlafaxine

Effexor XR® · Venlor XR®

Adult dose 37.5–75 mg orally once daily (start 37.5 mg for 1 week, increase to 75 mg)

Efficacy Reduces hot flush frequency by ~50–60%. Most evidence-based SNRI for VMS.

Notes Dual benefit if comorbid anxiety/depression. Discontinuation syndrome risk — taper slowly. Avoid abrupt cessation. Can be used in breast cancer patients on tamoxifen with caution (mild CYP2D6 inhibition).

PBS status ✔ PBS General Benefit

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Escitalopram

Lexapro® · Escitalopram

Adult dose 10–20 mg orally once daily

Efficacy Reduces hot flush frequency by ~40–50%. Less effective than venlafaxine but better tolerated.

Notes SSRI. Good option when SNRI not tolerated. Avoid with tamoxifen (CYP2D6 inhibition) — use citalopram or venlafaxine instead in breast cancer patients. Dual benefit for comorbid depression/anxiety.

PBS status ✔ PBS General Benefit

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Gabapentin

Neurontin® · Gabapentin

Adult dose 300 mg TDS (titrate from 100 mg TDS over 1–2 weeks); maximum 900 mg TDS

Efficacy Reduces hot flush frequency by ~45–55%.

Notes Particularly useful if concurrent neuropathic pain or sleep disturbance. Sedation, dizziness, and peripheral oedema are common side effects. Renally cleared — dose adjust in renal impairment. Taper on cessation.

PBS status ✔ PBS General Benefit (for neuropathic pain; off-label for VMS)

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Clonidine

Catapres®

Adult dose 25 mcg orally BD, increasing to 50 mcg BD if needed (maximum 75 mcg BD)

Efficacy Modest reduction in VMS (~20–30%); inferior to SSRIs/SNRIs and fezolinetant.

Notes Alpha-2 agonist. Side effects include dry mouth, drowsiness, constipation, postural hypotension. Avoid in severe bradycardia or recent MI. Taper on cessation to avoid rebound hypertension.

PBS status ✔ PBS General Benefit (for hypertension; off-label for VMS)

Complementary & Alternative Therapies

Many Australian women use complementary therapies for menopause. Evidence is generally limited or inconsistent:

Phyto-oestrogens (isoflavones, red clover): Small reduction in hot flush frequency (~1–2 fewer/day). May be acceptable for women who cannot or choose not to use MHT. Interactions with tamoxifen and thyroid medications — use with caution.
Evening primrose oil: No evidence of benefit beyond placebo for VMS.
Black cohosh: Mixed evidence; some trials show modest VMS reduction. Hepatotoxicity reported rarely. Not recommended by most guidelines.
Acupuncture: Mixed RCT evidence. May reduce subjective severity of hot flushes. Safe adjunct.
St John's Wort: Some evidence for mild VMS. Significant drug interactions (CYP3A4 inducer) — avoid with MHT, warfarin, anticonvulsants, SSRIs.

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Key non-hormonal comparison: Fezolinetant (Veozah®) targets the underlying neuroendocrine mechanism of VMS and has the strongest efficacy data among non-hormonal options. It avoids the SSRI/SNRI side-effect profile and does not interact with endocrine therapy for breast cancer. Cost and need for LFT monitoring are current limitations.

Monitoring & Review

Initial review: 3 months after starting MHT to assess symptom response, side effects, and bleeding pattern.
Annual review: All women on MHT should have an annual review discussing ongoing need, risk–benefit re-evaluation, and consideration of dose reduction or cessation.
Bleeding assessment: Any unscheduled bleeding on continuous combined MHT should be investigated. If breakthrough bleeding persists beyond 6 months, refer for endometrial assessment (ultrasound ± biopsy) to exclude endometrial pathology.
Breast screening: Mammographic screening via BreastScreen Australia (free biennial screening for women 50–74 years, available from age 40). MHT increases breast density, which may reduce mammographic sensitivity — consider additional imaging (ultrasound) if dense breasts.
Cardiovascular risk: Assess BP, lipids (fasting lipid profile), HbA1c, and 5-year CVD risk (Australian CVD Risk Calculator) before MHT initiation and periodically.
Bone density: DEXA scan recommended for women with POI, early menopause (<45 years), prolonged amenorrhoa, or clinical risk factors for osteoporosis.
Testosterone monitoring: If testosterone therapy is used, check serum total testosterone and SHBG at 3–6 weeks, then every 6 months. Monitor for androgenic side effects (acne, hirsutism, voice change).
Fezolinetant monitoring: LFTs at baseline, 3, 6, 9, and 12 months, then periodically. Discontinue if ALT/AST >5× ULN or if symptoms of liver injury develop.

✅

Duration of MHT: There is no arbitrary maximum duration. The decision to continue MHT should be individualised, based on ongoing symptom burden, quality of life, and risk profile. Many women benefit from MHT beyond age 50–55 if symptoms persist. Annual review is mandatory. The Australasian Menopause Society does not recommend abrupt cessation — gradual tapering (e.g., halving the dose every 3–6 months) may reduce symptom recurrence.

Special Populations

🤰 Pregnancy & Breastfeeding

Pregnancy: MHT is not contraception. Women in the perimenopause must continue contraception for 12 months after last menstrual period if aged >50, or 2 years if <50 (FSH testing may assist). Consider LNG-IUS (Mirena®) for combined endometrial protection + contraception. Barrier methods and copper IUD are non-hormonal alternatives.

Breastfeeding: Oestrogen suppresses lactation. MHT should not be used during breastfeeding. Non-hormonal options (CBT, clonidine, gabapentin) may be used cautiously. Most SSRIs/SNRIs are compatible with breastfeeding — sertraline and paroxetine are preferred SSRIs; venlafaxine is generally considered acceptable.

👶 Premature Ovarian Insufficiency (POI) & Young Women

POI (<40 years): MHT is strongly recommended until at least the median age of natural menopause (~51 years) to prevent cardiovascular disease, osteoporosis, cognitive decline, and premature mortality. Standard MHT doses are required (not low dose) to achieve physiological oestradiol levels.

Combined oral contraceptive pill (COCP): May be used as an alternative to MHT in young women with POI if contraception is also needed, providing higher and more stable oestradiol levels than standard MHT.

Psychological support: POI diagnosis can be distressing, particularly regarding fertility. Referral to fertility specialist and counselling should be offered.

👵 Older Women (≥60 years)

Initiation: Starting MHT after age 60 or >10 years post-menopause carries higher cardiovascular risk. Non-hormonal options should be trialled first. If symptoms are severe and significantly impair quality of life, MHT may be considered with informed consent, using the lowest effective dose and transdermal route.

Continuation: Women who commenced MHT before age 60 may continue beyond 60 if symptoms persist and the risk–benefit remains favourable. Annual review essential.

Bone health: DEXA screening every 1–2 years. Ensure adequate calcium (1,300 mg/day from diet + supplements if needed) and vitamin D (25–50 mcg/1,000–2,000 IU daily). Consider bisphosphonates or denosumab if osteoporosis diagnosed.

🫘 Renal Impairment

MHT: No specific dose adjustments for oral or transdermal oestrogen/progestogen in renal impairment. Standard monitoring applies.

Gabapentin: Requires dose reduction in renal impairment — eGFR 30–59: 200–300 mg BD; eGFR 15–29: 200–300 mg daily; eGFR <15: 100–200 mg daily.

Drospirenone (Angeliq®): Monitor potassium in moderate-to-severe renal impairment due to antimineralocorticoid activity.

🫁 Hepatic Impairment

Oral oestrogen: Contraindicated in active liver disease or hepatic tumour. Transdermal route is preferred as it avoids first-pass hepatic metabolism — can be used in mild-to-moderate hepatic impairment with monitoring.

Fezolinetant: Contraindicated in severe hepatic impairment (Child-Pugh C). Use with caution in mild-moderate impairment; more frequent LFT monitoring required.

🛡️ Breast Cancer Survivors

General principle: Systemic MHT is contraindicated in ER-positive breast cancer. Non-hormonal options (SSRIs/SNRIs, fezolinetant, gabapentin, CBT) are first-line for VMS management.

Drug interactions: Avoid fluoxetine/paroxetine with tamoxifen (CYP2D6 inhibition). Venlafaxine, desvenlafaxine, escitalopram, and citalopram have minimal CYP2D6 interaction. Fezolinetant has no interaction with endocrine therapy.

Vaginal oestrogen: Low-dose vaginal oestrogen (Vagifem® 10 mcg) may be considered for severe GSM in breast cancer survivors after multidisciplinary discussion, as systemic absorption is minimal. Some oncologists are comfortable with this, others are not — shared decision-making essential. Vaginal DHEA (prasterone) is an alternative.

Aromatase inhibitor-induced arthralgia: Common in breast cancer survivors on AIs. Exercise, paracetamol, and switching AI may help. MHT is not appropriate.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander women experience menopause at a slightly younger age (median ~48–49 years) compared to non-Indigenous Australian women (~51 years). Menopausal symptoms may be compounded by higher baseline rates of chronic disease, including type 2 diabetes, cardiovascular disease, chronic kidney disease, and mental health conditions. Culturally safe, trauma-informed, and community-centred approaches are essential to optimise menopause management in this population.

Earlier menopause onset

Aboriginal and Torres Strait Islander women may experience menopause 1–3 years earlier than non-Indigenous women. Premature and early menopause are more common, partly driven by higher rates of surgical menopause (hysterectomy/oophorectomy) and smoking.

Higher chronic disease burden

Cardiovascular disease, diabetes, renal disease, and obesity are more prevalent. Menopause compounds cardiovascular risk. Comprehensive chronic disease management (GP Management Plans, Team Care Arrangements) should integrate menopause care.

Remote and rural access

Many Aboriginal and Torres Strait Islander women live in remote or very remote communities with limited access to GPs, gynaecologists, and pharmacies. Telehealth consultations (MBS items 91790, 91800, 91801, 91802) can bridge this gap. Remote Area Aboriginal Health Workers and Practitioners can support MHT education, adherence, and monitoring.

Cultural safety and communication

Discussing menopause requires sensitivity — some women may not use or understand the term "menopause." Using yarning-style consultations, involving female health workers or family (with consent), and using visual aids improves engagement. Avoid shame-based language. Recognise the role of women as Elders, grandmothers, and community leaders.

MHT access and adherence

PBS medications are available through Section 100 (Remote Area Aboriginal Health Services) supply at no cost. Transdermal patches may be preferred in communities with limited refrigeration (progesterone capsules). Patch adherence can be challenging in hot climates — gel formulations may be more practical. Health worker support improves adherence.

Smoking and lifestyle factors

Smoking rates remain high in some Aboriginal and Torres Strait Islander communities (~40% vs ~10% non-Indigenous). Smoking worsens VMS, accelerates bone loss, and increases cardiovascular risk. Culturally appropriate smoking cessation programmes (e.g., TIS — Tobacco in Indigenous Society) should be integrated into menopause consultations. Quitline 13 7848 provides Indigenous-specific support.

Bone health and fracture risk

Despite higher rates of falls and comorbidities, Aboriginal and Torres Strait Islander women have historically lower rates of diagnosed osteoporosis, likely due to under-screening. DEXA access is limited in remote areas — consider fracture risk assessment tools (FRAX) and arrange portable DEXA or fly-in/fly-out services. Ensure adequate calcium and vitamin D intake (many remote communities have low dietary calcium).

ℹ️

Resources for Aboriginal and Torres Strait Islander menopause care: RHDAustralia (www.rhdaustralia.org.au) provides culturally appropriate clinical resources. The Australian Indigenous HealthInfoNet (healthinfonet.ecu.edu.au) offers evidence summaries. The Jean Hailes for Women's Health website includes Indigenous women's health pages. Contact local Aboriginal Community Controlled Health Organisations (ACCHOs) for community-based support.

📚 References

1. The NICE Guideline Group. Menopause: diagnosis and management. NICE guideline [NG23]. National Institute for Health and Care Excellence; 2015 (updated 2024).
2. Baber RJ, Panay N, Fenton A; IMS Writing Group. 2023 IMS recommendations on women's midlife health and menopause hormone therapy. Climacteric. 2023;26(2):105-137.
3. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.
4. Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2008;107(1):103-111.
5. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop +10. J Clin Endocrinol Metab. 2012;97(4):1159-1168.
6. Johnson KA, Martin N, Nappi RE, et al. Efficacy and safety of fezolinetant in moderate to severe vasomotor symptoms associated with menopause: a phase 3 randomised trial (SKYLIGHT 1). JAMA Netw Open. 2023;6(2):e230165.
7. Australasian Menopause Society. MHT (HRT) — use, benefits and risks. AMS Information Sheets. 2024. Available at: www.menopause.org.au.
8. Jean Hailes for Women's Health. National Women's Health Survey 2023. Melbourne: Jean Hailes for Women's Health; 2023.
9. Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666.
10. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. AIHW; 2023.
11. Royal Australian College of General Practitioners. Clinical guideline for the management of menopause in general practice. RACGP; 2024.
12. Lumsden MA, Davies M, Sarri G. Diagnosis and management of menopause: the National Institute of Health and Care Excellence (NICE) guideline. JAMA Intern Med. 2016;176(8):1157-1158.
13. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011.
14. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan — a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. [Referenced for evidence synthesis methodology underpinning Australian guidelines.]
15. NHMRC. Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: National Health and Medical Research Council; 2020.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).