1. General principle

Use the lowest effective dose of menopausal hormone therapy for symptom control.

Exception:
Women with early menopause <45 years or premature ovarian insufficiency <40 years usually require higher-dose and longer-term therapy until at least the average age of natural menopause, around 50–51 years, unless contraindicated.

Treatment response is mainly monitored by symptom improvement rather than routine hormone levels.

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2. Main hormones used in MHT

Hormone	Main purpose
Oestrogen	Treats vasomotor symptoms, vaginal symptoms, sleep disturbance, mood symptoms, and helps prevent bone loss
Progestogen / progesterone	Protects the endometrium if the woman has a uterus
Testosterone	May be considered for persistent low libido after other causes are addressed, especially in premature menopause

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3. Key rule: uterus or no uterus

If the woman has a uterus

Oestrogen must be combined with a progestogen to reduce the risk of:

• Endometrial hyperplasia
• Endometrial cancer

Unopposed oestrogen in a woman with an intact uterus significantly increases endometrial cancer risk.

If the woman has had a hysterectomy

Usually use:

• Oestrogen alone, or
• Tibolone

Progestogen is usually not required, unless there is residual endometriosis or other specific clinical reason.

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4. Benefits and risks of MHT

Benefits

MHT may:

• Reduce hot flushes and night sweats
• Improve sleep and quality of life
• Improve vaginal dryness and dyspareunia
• Reduce bone loss
• Reduce osteoporotic fractures
• Reduce colorectal cancer risk

Risks

Risks depend on:

• Age
• Time since menopause
• Route of oestrogen
• Duration of use
• Background risk factors
• Whether progestogen is used

Risk	Important points
Endometrial cancer	Increased if oestrogen is used without progestogen in women with a uterus
Breast cancer	Slight increase with combined MHT, especially with longer duration; risk reduces after stopping
VTE	Higher with oral oestrogen; lower risk with transdermal oestrogen
Cardiovascular disease / stroke	Risk depends on age, timing of initiation, and background cardiovascular risk

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5. MHT and cardiovascular disease

MHT should not be used for the primary prevention of cardiovascular disease.

However, in healthy women who start MHT close to menopause, evidence suggests it is generally cardiovascular-neutral, and may not increase cardiovascular risk in the short term.

Women with cardiovascular risk factors such as:

• Hypertension
• Diabetes
• Hypercholesterolaemia
• Smoking
• Obesity
• Previous VTE

may be better suited to transdermal oestrogen rather than oral therapy.

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6. MHT and thromboembolic risk

Form of MHT	VTE risk
Transdermal oestrogen ≤50 micrograms/day	Does not appear to significantly increase VTE risk
Higher-dose transdermal oestrogen	Risk less clear but likely lower than oral oestrogen
Oral oestrogen	Approximately doubles VTE risk, especially if other risk factors are present

Transdermal options are preferred if the woman has:

• Increased VTE risk
• Obesity
• Smoking history
• Hypertriglyceridaemia
• Poor gut absorption
• Migraine or other risk considerations where oral therapy is less ideal

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7. MHT is not contraception

MHT does not provide contraception.

Women may still ovulate during the menopausal transition.

Contraception is generally required:

• For 12 months after the last menstrual period if menopause occurs after age 50
• For 24 months after the last menstrual period if menopause occurs before age 50

The combined oral contraceptive pill may be considered in low-risk women up to around age 50, but this depends on cardiovascular and VTE risk.

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8. Contraindications to MHT

Absolute contraindications

• Known or suspected oestrogen-dependent cancer, e.g. breast or endometrial cancer
• Undiagnosed abnormal vaginal bleeding
• Active or recent thromboembolic disease
• Recurrent thromboembolism
• Acute ischaemic heart disease
• Active liver disease

Relative contraindications / caution

• History of coronary artery disease
• Uncontrolled hypertension
• Active systemic lupus erythematosus
• Significant liver disease
• High baseline VTE risk
• Otosclerosis

In complex cases, liaise with the relevant specialist.

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9. Choosing the MHT regimen

A. Menopausal transition / perimenopause

Usually less than 12 months since last menstrual period

Ovulation may still occur, so contraception may still be required, even if periods are irregular.

Treatment choice depends on:

• whether uterus is present
• symptom pattern: vasomotor symptoms, PMS-like symptoms, mastalgia, irregular/heavy bleeding
• need for contraception
• cardiovascular/VTE risk
• contraindications to oestrogen or COCP

from – a-practitioners-toolkit-for-managing-menopause.pdf guide

Option	Examples	Useful when	Benefits / key points	Limitations / cautions
1. Combined oral contraceptive pill — COCP	Zoely — estradiol/nomegestrol Qlaira — estradiol valerate/dienogest Nextstellis — estetrol/drospirenone Low-dose EE pills, e.g. Microgynon 20 ED, Levlen ED, Yaz, Yasmin	Useful when: • contraception is required • patient is generally <50 years • low cardiovascular/VTE risk • no contraindications to combined hormonal contraception Symptoms may include: • irregular bleeding • heavy bleeding • PMS-type symptoms • mastalgia • vasomotor symptoms	• Provides contraception • Can regulate bleeding • May improve cyclical symptoms • Low-dose ethinylestradiol COCP is commonly used • 17β-oestradiol or estetrol-containing COCP may be considered	Review contraindications carefully, especially: • smoking age >35 • migraine with aura • previous VTE • breast cancer • uncontrolled hypertension • significant cardiovascular risk
2. Continuous oestrogen + levonorgestrel IUD	Systemic oestrogen + Mirena LNG-IUD Oestrogen options: • Estrogel • Sandrena gel • Estradot patch • Estraderm MX patch • Climara patch • Zumenon — oral estradiol	Useful when: • contraception is required • patient has an intact uterus • bleeding control is needed • oestrogen is needed for vasomotor symptoms	LNG-IUD: • provides endometrial protection • provides contraception • may reduce or eliminate bleeding • may avoid systemic progestogen side effects in some women	• May not fully control cyclical symptoms such as PMS or mastalgia • Irregular bleeding/spotting can occur initially
3. Continuous oestrogen + cyclical progestogen	Daily oestrogen + progestogen for 10–14 days/month Oestrogen options: • Estrogel • Sandrena gel • Estradot patch • Estraderm MX patch • Climara patch • Zumenon Cyclical progestogen options: • Prometrium / micronised progesterone • Primolut N / norethisterone • Provera / medroxyprogesterone acetate	Useful when: • contraception is not required, or is provided separately • patient has an intact uterus • patient is perimenopausal or within 12 months of last menstrual period • sequential MHT is preferred to reduce unpredictable bleeding	• Treats vasomotor symptoms • Protects the endometrium when progestogen is taken adequately • Usually produces a predictable withdrawal bleed	• Not contraceptive • Irregular bleeding may occur • Cyclical progestogen may cause PMS-like symptoms, breast tenderness, bloating or mood symptoms
4. Continuous oestrogen + desogestrel-POP ± separate progestogen for endometrial protection	Mentioned in A Practitioner’s Toolkit for Managing Menopause However, this is not a standard Australian regimen	This should generally not be listed as a routine Australian option for MHT endometrial protection	Key clarification: • POPs are used for contraception • POPs should not be relied on for endometrial protection when systemic oestrogen is prescribed • If systemic oestrogen is used in a woman with a uterus, adequate endometrial protection is required	Not standard in Australia because: • desogestrel 75 microgram POP is not a usual Australian POP option • Australian POPs are contraceptive options, not approved MHT endometrial-protection regimens • if systemic oestrogen is used with a uterus, use an accepted option such as: – Mirena 52 mg LNG-IUD – cyclical oral progestogen – continuous oral progestogen as per MHT regimen

B. Postmenopause

Usually more than 12 months since last menstrual period

Option	Regimen	examples	When / notes
Option1	Continuous oestrogen + continuous progestogen	Estrogel Pro Bijuva Femoston-conti Kliovance / Kliogest Estalis Continuous patch	Standard option if uterus intact and clearly postmenopausal. Avoids scheduled withdrawal bleeding. Irregular bleeding may occur initially
Option2	Oestrogen-only MHT	Estrogel Sandrena Estradot / Estraderm MX / Climara Zumenon	Only if no uterus, unless special situation such as residual endometriosis where specialist advice is needed
Option3	Oestrogen + Mirena LNG-IUD	Oestrogen: Estrogel Sandrena Estradot Estraderm MX Climara Zumenon PLUS Mirena	Useful if Mirena already in situ or preferred. Mirena provides endometrial protection; also provides contraception if still required
Option4	Tibolone	Livial Livilan Xyvion	Postmenopausal option. Has oestrogenic, progestogenic and androgenic effects. Not contraceptive. Can reduce HDL; avoid in women with current/past breast cancer unless specialist-directed
Option5	TSEC — tissue-selective oestrogen complex	Duavive — conjugated oestrogens + bazedoxifene	for selected postmenopausal women with uterus intact

Continuous combined MHT is generally preferred once the woman is clearly postmenopausal because it avoids regular withdrawal bleeding.

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10. Types of oestrogen

Systemic oestrogen — treats whole-body menopausal symptoms

Local vaginal oestrogen — mainly treats vaginal and urinary symptoms only

Systemic oestrogen

Used for systemic menopausal symptoms such as:

• Hot flushes
• Night sweats
• Sleep disturbance
• Mood symptoms
• Bone protection

Systemic options include:

Route	Examples	Notes
Oral oestrogen	Tablets	Suitable for healthy, low-risk women who prefer tablets
Transdermal oestrogen	Patches	Lower VTE risk than oral oestrogen useful if cardiovascular/VTE risk factors
Transdermal oestrogen	Gels	Same benefits as patches useful if patient prefers gel instead of patch

Vaginal oestrogen

Used for genitourinary symptoms, including:

• Vaginal dryness
• Dyspareunia
• Vulvovaginal atrophy
• Urinary urgency/frequency related to atrophy
• Recurrent UTI symptoms related to vaginal atrophy

Forms include:

• Cream – Ovestin cream
• Pessary – Ovestin pessary, Vagifem Low

If using vaginal oestrogen only, a progestogen is generally not required.

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11. Progestogen options

Progestogens are used for endometrial protection in women with a uterus.

Options include:

Type	Examples / notes
Oral progestogens	Medroxyprogesterone acetate norethisterone
Micronised progesterone	Body-identical progesterone commonly used cyclically or continuously depending on regimen
Levonorgestrel IUD	Provides endometrial protection and contraception useful if heavy bleeding or need for contraception
Combined MHT patches	Contain both oestrogen and progestogen

Avoid relying on:

• Progesterone creams
• Troches

These are not considered reliable for endometrial protection.

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12. Cyclical vs continuous combined MHT

Regimen	How it works	Best suited for
Cyclical MHT	Oestrogen daily + progestogen for 10–14 days/month	Perimenopause or within 12 months of final period
Continuous combined MHT	Oestrogen + progestogen every day	Postmenopause, usually >12 months since last period

Cyclical MHT

• Causes a regular withdrawal bleed
• Useful during menopausal transition
• Helps avoid irregular bleeding from starting continuous combined therapy too early

Continuous combined MHT

• Designed to avoid bleeding
• May cause irregular bleeding initially
• Unscheduled bleeding after the first 6 months should be investigated

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13. Tibolone

Tibolone is a synthetic steroid with:

• Oestrogenic effects
• Progestogenic effects
• Androgenic effects

Effects

Tissue / symptom	Effect
Brain	Reduces hot flushes
Bone	Reduces bone loss
Vaginal tissue	Helps vaginal dryness and soreness
Uterus	Protects against endometrial thickening
Libido / mood	May improve libido and mood in some women

When to use tibolone

Usually suitable if:

• Postmenopausal
• No natural period for at least 12 months
• Wants an alternative to standard combined MHT
• Has symptoms including low libido

Additional progestogen is not usually required if the uterus is intact.

Side effects

Possible side effects include:

• Headache
• Dizziness
• Nausea
• Abdominal pain
• Ankle swelling
• Itching
• Initial spotting or bleeding

Most women become amenorrhoeic after several months.

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14. Common side effects and management

Problem	Possible management
Breast tenderness	Reduce oestrogen dose
Nausea	Reduce oestrogen dose or change route
Heavy bleeding	Review oestrogen dose; assess need for investigation
Breakthrough bleeding	Consider increasing or adjusting progestogen
Irregular bleeding	Investigate if persistent, heavy, or occurring after 6 months
Premenstrual-type symptoms	Reduce or change progestogen
Leg cramps	Consider lowering oestrogen dose
No bleeding on continuous combined MHT	Reassure if otherwise well and no red flags

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15. Abnormal bleeding on MHT

Investigate bleeding if:

• Heavy
• Persistent
• New after being established on therapy
• Occurs after 6 months of continuous combined MHT
• Associated with pain, risk factors, or concerning symptoms

Consider:

• Pelvic examination
• Cervical screening status
• Pelvic ultrasound
• Endometrial sampling if indicated

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16. Follow-up after starting MHT

Initial review

Review at around 3 months to assess:

• Symptom response
• Side effects
• Bleeding pattern
• Blood pressure
• Breast screening status
• Ongoing contraindications or risk factors

Ongoing review

Review every 6–12 months.

At review, assess:

• Ongoing need for treatment
• Dose
• Route
• Risks and benefits
• Breast screening
• Cervical screening
• Cardiovascular risk
• Bone health
• Contraceptive needs

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17. Duration of treatment

There is no single fixed duration for all women.

A practical approach:

• Start with the lowest effective dose
• Review regularly
• Consider continuing if benefits outweigh risks
• Trial reduction or cessation every 1–2 years if appropriate

Many women use MHT for around 2–5 years, but longer use may be reasonable in selected women after shared decision-making.

Breast cancer risk becomes more relevant with longer duration of combined MHT, particularly beyond 5 years.

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18. Stopping MHT

MHT can be stopped:

• Abruptly, or
• Gradually tapered

Gradual tapering may reduce recurrence of symptoms.

Suggested tapering approach:

Symptom severity	Possible taper
Mild symptoms	Reduce over about 6 weeks
Severe symptoms	Reduce slowly over several months

Symptoms may return after stopping, and ongoing management should be individualised.

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19. Practical prescribing framework

Step 1: Confirm indication

Common indications:

• Troublesome vasomotor symptoms
• Sleep disturbance due to menopause
• Genitourinary syndrome of menopause
• Premature ovarian insufficiency
• Early menopause
• Bone protection where appropriate

Step 2: Check uterus status

• Uterus present → oestrogen + progestogen
• Hysterectomy → oestrogen alone usually suitable

Step 3: Choose route

Oestrogen can be given orally, transdermally, or vaginally. The route depends on symptoms, patient preference, risk factors, and comorbidities.

Route	When useful
Oral oestrogen	Healthy low-risk women who prefer tablets and have no concerns with – significant VTE – cardiovascular – liver – gallbladder – triglyceride – absorption
Transdermal oestrogen — patch or gel	Preferred if – increased VTE risk – obesity – smoking – migraine with aura – hypertriglyceridaemia – diabetes – hypertension – liver/gallbladder concerns, or gut absorption issues
Vaginal oestrogen	Best for isolated – vaginal dryness – dyspareunia – urinary symptoms, or – recurrent UTI symptoms related to vulvovaginal atrophy

Step 4: Choose regimen

The regimen depends on:

• Menopause stage
• Whether the woman has a uterus
• Bleeding pattern
• Contraceptive need
• Comorbidities and risk factors
• Patient preference

Stage	Suggested regimen
Perimenopause	Cyclical MHT
Recently postmenopausal	Cyclical or continuous depending on bleeding pattern
Clearly postmenopausal	Continuous combined MHT
Hysterectomy	Oestrogen alone

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20. Common MHT options

Continuous combined MHT

Used if postmenopausal, usually >12 months since final menstrual period or after 12 months cyclical MHT and uterus is present

Product	Route	Dose / composition	PBS?
Estalis continuous 50/140	Patch	Oestradiol 50 microg/24 h + norethisterone acetate 140 microg/24 h Applied twice weekly	Yes
Estalis continuous 50/250	Patch	Oestradiol 50 microg/24 h + norethisterone acetate 250 microg/24 h Applied twice weekly	Yes
Estrogel Pro	Gel + capsule co-pack	Oestradiol gel 0.06% = 750 microg/actuation + progesterone 100 mg capsules x30	Yes
Bijuva 1/100	Oral capsule	Oestradiol 1 mg + progesterone 100 mg	No — private
Femoston-conti 1/5	Oral tablet	Oestradiol 1 mg + dydrogesterone 5 mg	No — private
Kliovance	Oral tablet	Oestradiol 1 mg + norethisterone acetate 0.5 mg	No — private
Kliogest	Oral tablet	Oestradiol 2 mg + norethisterone acetate 1 mg	No — private
Angeliq 1/2	Oral tablet	Oestradiol 1 mg + drospirenone 2 mg	No — private

Cyclical MHT

Used in perimenopause (<12 months amenorrhoea.)

Cyclical MHT usually involves:

• Oestrogen daily, plus
• Progestogen for 12–14 days per month, causing a withdrawal bleed.

Product	Route	Dose / composition	PBS?
Femoston 1/10	Oral tablet	14 tablets oestradiol 1 mg, then 14 tablets oestradiol 1 mg + dydrogesterone 10 mg	Yes
Femoston 2/10	Oral tablet	14 tablets oestradiol 2 mg, then 14 tablets oestradiol 2 mg + dydrogesterone 10 mg	Yes
Estalis sequi 50/140	Patch	4 patches oestradiol 50 microg/24 h, then 4 patches oestradiol 50 microg/24 h + norethisterone acetate 140 microg/24 h	Yes
Estalis sequi 50/250	Patch	4 patches oestradiol 50 microg/24 h, then 4 patches oestradiol 50 microg/24 h + norethisterone acetate 250 microg/24 h	Yes
Trisequens	Oral tablet	12 tablets oestradiol 2 mg then 10 tablets oestradiol 2 mg + norethisterone acetate 1 mg, then 6 tablets oestradiol 1 mg	Private / not PBS-listed
Estrogel Pro used cyclically	Gel + capsule co-pack	1-2 pumps (0.75mg oestradiol) daily + Progesterone 100 mg capsules. (200 mg nocte(2 capsules) for 12 days/month)	Yes

Oestrogen-only therapy

Use only if:

• Hysterectomy, or
• Combined with adequate progestogen or Mirena if the uterus is present.

Product	Route	Dose / composition	PBS?
Progynova	Oral	Oestradiol valerate 1 mg or 2 mg	Yes
Zumenon	Oral	Oestradiol 2 mg	Yes
Estradot 25 / 37.5 / 50 / 75 / 100	Patch	Oestradiol 25–100 microg/24 h	Yes
Estraderm MX 25 / 50 / 100	Patch	Oestradiol 25, 50, or 100 microg/24 h	Yes
Estraderm MX 75	Patch	Oestradiol 75 microg/24 h	No / private
Sandrena	Gel sachet	Oestradiol 0.1% = 1 mg/g, usually 1 g sachet	Yes
Estrogel	Gel pump	Oestradiol 0.06% = 750 microg/actuation	Yes
Climara	Patch	Oestradiol patch, e.g. 25 / 50 / 75 / 100 microg/24 h	Not current PBS / supply uncertain
Estrofem	Oral	Oestradiol 1 mg or 2 mg	Private / check current PBS
Premarin	Oral	Conjugated equine oestrogens, e.g. 0.3 mg or 0.625 mg	Private / check current PBS

Vaginal oestrogen

Progestogen is not usually required when using vaginal oestrogen alone.

Examples include:

Product	Route	Dose / composition	PBS?	Usual dosing pattern
Vagifem Low	Vaginal pessary/tablet	Oestradiol 10 microg modified-release pessary	Yes	Commonly daily for 2 weeks, then twice weekly maintenance. PBS lists pack of 18.
Estro-Pess	Vaginal pessary/tablet	Oestradiol 10 microg	Yes	Same active/dose group as Vagifem Low.
Ovestin cream	Vaginal cream	Oestriol 0.1% = 1 mg/g; one applicator commonly gives 0.5 mg	Yes	Often nightly for 2–3 weeks, then 1–2 times weekly.
Ovestin ovula/pessary	Vaginal pessary	Oestriol 500 microg		Often nightly for 2–3 weeks, then 1–2 times weekly

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21. Progestogen options to combine with oestrogen

Cyclical progestogen is commonly given for 12–14 days per month

Option	Typical MHT use	Common dose / regimen	PBS
Provera / Ralovera — medroxyprogesterone acetate	Continuous or cyclical endometrial protection	Continuous: 2.5–5 mg daily. Cyclical: 5–10 mg daily for 12–14 days/month	10 mg PBS-listed; lower strengths may be private/variable
Primolut N — norethisterone  (1/4 of 5mg tablet)	Continuous or cyclical endometrial protection	Continuous: 1.25–2.5 mg daily Cyclical: commonly 2.5–5 mg daily for 12–14 days/month	Variable / check current PBS
Prometrium — micronised progesterone	Continuous or cyclical endometrial protection	Continuous/near-continuous: 100 mg nocte for 25 days of a 28-day cycle. Cyclical: 200 mg nocte for 12 days of a 28-day cycle	PBS-listed 100 mg capsules
Mirena — levonorgestrel intrauterine system	Endometrial protection with systemic oestrogen + contraception	52 mg LNG-IUS, releases approx. 20 microg/day initially. Use for 5 years for MHT endometrial protection	PBS-listed, but not specifically for MHT indication

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22. Special notes

Mirena

Mirena can:

• Provide endometrial protection
• Provide contraception
• Reduce or eliminate bleeding

However, it may not fully control cyclical symptoms if ovarian hormonal fluctuation continues.

Patches and gels

Often preferred because they:

• Avoid first-pass liver metabolism
• Have lower VTE risk than oral oestrogen
• Are useful in women with metabolic or absorption issues

Start low

In most women:

• Start with a low dose
• Review after 3 months
• Increase only if symptoms remain troublesome and risks are acceptab

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Special considerations

After hysterectomy	Use continuous oestrogen alone or tibolone. Progestogen is usually not required unless there is a history of endometriosis or residual endometriosis is possible.
Cancers – breast/endometrial/ovarian (hormone-sensitive) cancer.	Systemic MHT is usually avoided Vaginal oestriol/oestradiol may be considered for severe vaginal or urinary symptoms after specialist discussion. Liaise with treating oncologist/gynaecologist – selected cases specialist-supported MHT or tibolone may be considered
Cardiovascular disease (hypertension, diabetes, hypercholesterolemia)	Prefer transdermal MHT. Optimise cardiovascular risk factors before and during treatment.
Endometriosis	Options include – levonorgestrel IUD + oestrogen – continuous combined MHT, or – tibolone. If post-surgical menopause or prior severe endometriosis, avoid unopposed oestrogen and consider added progestogen or tibolone
Fibroids	MHT may increase fibroid size or bleeding. This may be less likely with tibolone or transdermal oestrogen with adequate progestogen. Monitor bleeding, pain, pressure symptoms, and fibroid growth if clinically indicated
Hirsutism	Oral oestrogen can increase SHBG and reduce free androgen levels. Consider anti-androgenic options such as – cyproterone – drospirenone – dydrogesterone – oral progesterone Spironolactone may also be considered. Consider specialist advice if marked or new hyperandrogenism.
Low libido	Avoid COCP or oral oestrogen if low libido is the main concern, as they may increase SHBG and reduce free testosterone. Review contributing medicines, especially SSRI/SNRI. Prefer transdermal oestrogen. Consider tibolone or testosterone therapy after assessment.
PV bleeding	Investigate to exclude pathology before starting or changing MHT. Consider pelvic examination, cervical screening status, transvaginal ultrasound ± hysteroscopy/endometrial sampling. If the endometrium is atrophic, e.g. <4 mm, consider reducing progestogen or increasing oestrogen if clinically appropriate. Otherwise, consider increasing the progestogen dose, duration, or type, or using a levonorgestrel IUD.
Testosterone therapy	AndroFeme 1 testosterone 1% cream is TGA-approved in Australia for clinically diagnosed hypoactive sexual desire disorder (HSDD) in postmenopausal women with associated distress, after other causes have been excluded. Assess contributing factors first, including relationship issues, mood, sleep, pain, vaginal dryness, medications, alcohol/substance use, and comorbidities. Measure total testosterone and SHBG before treatment and during monitoring to avoid high/supraphysiological levels. Testosterone levels are not diagnostic of HSDD.
Liver disease, gallstones	Prefer transdermal MHT if MHT is appropriate, as it avoids first-pass hepatic metabolism. Avoid systemic MHT in active or severe liver disease unless specialist-supported.
VTE/thrombophilia	Avoid oral oestrogen Assess baseline VTE risk. Higher risk includes – previous recurrent VTE – unprovoked VTE – pregnancy- or OCP-associated VTE – strong family history – inherited thrombophilia – smoking – obesity – immobility If low risk, consider transdermal oestrogen. If high risk or inherited thrombophilia, avoid MHT unless specialist-supported, and seek haematology advice.
Headaches	Hormonally sensitive migraine may worsen in perimenopause due to fluctuating oestrogen levels. Migraine is not an absolute contraindication to MHT, but use transdermal oestrogen where possible to provide more stable hormone levels. If progestogen is required, a continuous regimen may be better than cyclical progestogen to reduce hormonal fluctuation. If new aura, worsening aura, or significant worsening headaches occur, stop MHT and reassess.
Obesity/morbid obesity	Prefer transdermal MHT because baseline VTE and cardiometabolic risk is higher. Optimise BP, diabetes risk, lipids, sleep apnoea risk, smoking, and weight-related risks.

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22. Bone health in menopause

Menopause is associated with accelerated bone loss due to reduced oestrogen. Bone health assessment is important, especially in women with early or premature menopause.

Indications for bone density assessment

Consider DXA bone density assessment if there is:

• Family history of osteoporosis
• Hyperthyroidism or hyperparathyroidism
• Malabsorption, e.g. coeliac disease or inflammatory bowel disease
• Chronic inflammatory disease, e.g. rheumatoid arthritis
• Chronic liver or kidney disease
• Corticosteroid use
• Medicines associated with bone loss, e.g. some breast cancer treatments, anti-epileptics, and some antidepressants
• Early menopause or premature ovarian insufficiency
• Previous minimal-trauma fracture
• Low BMI, smoking, excess alcohol, or recurrent falls

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23. Emotional wellbeing in menopause

Women with early menopause or premature ovarian insufficiency have an increased risk of depression and anxiety. Routine emotional wellbeing screening is recommended in this group.

Menopausal symptoms such as poor sleep, hot flushes, low libido, fatigue, vaginal symptoms, and life stressors may also contribute to mood symptoms.

Initial screening questions

Ask:

1. During the past month, have you often felt down, depressed, or hopeless?
2. During the past month, have you had little interest or pleasure in doing things?
3. During the past month, have you felt excessively worried or concerned?

Screening tools

Useful screening tools include:

Tool	Use
K10	General psychological distress
DASS-21	Depression, anxiety, and stress symptoms
PHQ-9	Depression severity and self-harm screening
GAD-7	Anxiety severity

Management considerations

If emotional wellbeing concerns are identified:

• Assess severity and functional impact
• Ask about sleep, vasomotor symptoms, sexual symptoms, relationship stress, work stress, alcohol/substance use, and safety
• Screen for self-harm or suicidal ideation if depression is suspected
• Consider whether symptoms are primarily menopausal, psychological, psychosocial, or mixed
• Optimise menopausal symptom control where appropriate
• Consider psychological therapy, lifestyle strategies, and/or pharmacotherapy depending on severity
• Review current medicines that may affect mood, sleep, or libido

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Non-hormonal treatment options for menopausal symptoms

Key points

• Non-hormonal options may be useful for women who:
  • have contraindications to menopausal hormone therapy — MHT
  • do not want to use MHT
  • prefer to avoid hormones
  • have a history where MHT needs specialist input, e.g. hormone-sensitive cancer
• Non-hormonal medications are generally:
  • less effective than MHT
  • mainly useful for vasomotor symptoms, such as hot flushes and night sweats
  • not protective for bone health in the way oestrogen therapy can be
  • often limited by side effects
• Non-hormonal medications do not treat genitourinary syndrome of menopause as effectively as vaginal oestrogen.

Lifestyle measures

• Encourage:
  • healthy nutrition
  • regular exercise
  • weight management
  • sleep optimisation
  • reduction of alcohol and other flush triggers if relevant
• Benefits:
  • may improve general wellbeing
  • may improve coping capacity
  • may improve quality of life
  • weight loss in overweight/obese women may reduce flushing and sweating

When to consider non-hormonal treatment

• Useful when:
  • MHT is contraindicated
  • patient chooses not to use MHT
  • patient has hormone-dependent cancer history
  • patient prefers a non-hormonal approach
  • MHT is not tolerated
• Choice of treatment should consider:
  • efficacy
  • additional drug effects
  • side effects
  • cost
  • dose complexity
  • patient preference

Prescriptive therapies

https://www1.racgp.org.au/ajgp/2026/april/an-update-on-the-use-of-non-hormonal-therapies-for

(Off-label options)

Drug class	Medication	Typical dose	Benefits / role	Possible adverse effects	Key notes / cautions
SNRI	Desvenlafaxine	25–150 mg orally daily Common practical regimen: • start 50 mg daily • increase to 100 mg daily if needed	• May modestly reduce hot flushes • May help mood and sleep symptoms • Benefit often seen within first 4 weeks	• Dizziness • Nausea • Sexual dysfunction • Headache • Insomnia • Somnolence • Sweating • Dry mouth	• Stop gradually over several weeks • Avoid or use caution with uncontrolled hypertension or ischaemic heart disease
SNRI	Venlafaxine	37.5–150 mg orally daily Common practical regimen: • start 37.5 mg daily • increase to 75 mg daily • doses >75 mg may increase side effects	• Commonly used non-hormonal option • May reduce hot flushes and sweats • Useful if co-existing anxiety/depression • Benefit often seen within first 4 weeks	• Dizziness • Nausea • Sexual dysfunction • Headache • Insomnia • Somnolence • Sweating • Dry mouth	• Stop gradually over several weeks • Avoid or use caution with uncontrolled hypertension or ischaemic heart disease
SSRI	Citalopram	10–20 mg orally daily	• Modest benefit for vasomotor symptoms • May help mood symptoms	• Dizziness • Nausea • Sexual dysfunction • Sleep disturbance	• Consider patient-specific QT risk and other interacting medicines
SSRI	Escitalopram	5–20 mg orally daily Evidence-based practical dose: • 10–20 mg daily	• May reduce vasomotor symptoms • May help sleep and mood symptoms • Evidence suggests escitalopram 10–20 mg may be comparable to venlafaxine 75 mg or gabapentin 900 mg for VMS	• Dizziness • Nausea • Sexual dysfunction • Sleep disturbance	• Often preferred SSRI option when mood/anxiety symptoms coexist
SSRI	Paroxetine	10–25 mg orally daily	• May reduce vasomotor symptoms • May help mood/anxiety symptoms	• Dizziness • Nausea • Sexual dysfunction • Sleep disturbance	Avoid with tamoxifen due to CYP2D6 inhibition, which may reduce tamoxifen efficacy
SSRI	Fluoxetine	Dose varies depending on indication	• May reduce vasomotor symptoms • May help mood/anxiety symptoms	• Nausea • Insomnia • Sexual dysfunction • Headache	Avoid with tamoxifen because it may reduce tamoxifen efficacy via CYP2D6 inhibition
SSRI	Sertraline	Dose varies depending on indication	• May help mood/anxiety symptoms • Evidence for hot flush reduction is less consistent than escitalopram/venlafaxine	• Nausea • Diarrhoea • Sexual dysfunction • Sleep disturbance	Consider if already indicated for mood/anxiety symptoms
SSRI	Fluvoxamine	Dose varies depending on indication	• May help mood/anxiety symptoms • Less commonly used for menopausal VMS	• Nausea • Sedation • Sexual dysfunction • Drug interactions	More interaction-prone SSRI; generally not a first-line VMS option
Anticonvulsant / neuropathic pain agent	Gabapentin	100–900 mg orally daily, in up to 3 divided doses Practical start: • 100–300 mg at night or in divided doses	• May reduce frequency and severity of hot flushes • Useful if night sweats affect sleep • Gabapentin 900 mg/day has evidence for hot flush reduction	• Drowsiness • Dizziness • Possible withdrawal symptoms • Rash • Weight gain • Lower limb swelling	• Take a few hours before bed to reduce morning drowsiness • Stop gradually • Caution in older patients/falls risk
Anticonvulsant / neuropathic pain agent	Pregabalin	Dose varies depending on clinical context	• May reduce vasomotor symptoms • May help sleep if nocturnal symptoms prominent	• Drowsiness • Dizziness • Weight gain • Peripheral oedema	Less commonly used than gabapentin for hot flushes; tolerability can limit use
Anticholinergic	Oxybutynin	2.5–5 mg orally twice daily	• May reduce moderate–severe hot flushes and sweating • May also help overactive bladder symptoms • Benefit can occur within first 4 weeks	• Dry mouth • Drowsiness • Blurred vision • Headache • Dizziness • Urinary retention • Confusion	Use caution in older women due to: • anticholinergic burden • cognitive risk • confusion • constipation • urinary retention
Neurokinin 3 receptor antagonist	Fezolinetant	45 mg orally daily	• Specifically developed for menopausal hot flushes and sweats • May reduce symptoms within first week • Overall symptom reduction may be up to 60–70%	• Insomnia • Headache • Diarrhoea • Elevated liver transaminases in about 2.3%	LFT monitoring: • baseline • 1 month • 2 months • 3 months • 6 months • 9 months • then as clinically indicated Stop if: • hepatotoxicity symptoms/signs • transaminases >5 × ULN • transaminases >3 × ULN plus bilirubin >2 × ULN Avoid with CYP1A2 inhibitors. Do not combine with MHT.
Alpha-2 agonist / antihypertensive	Clonidine	25–75 micrograms orally twice daily Alternative practical note: • start with lowest available dose • use at night or twice daily • max 150 micrograms/day	• May reduce hot flushes and sweats • Benefit usually seen within 4 weeks	• Dizziness • Drowsiness • Constipation • Hypotension • Insomnia	May be used, but generally no longer recommended because: • less effective than other options • adverse effects limit tolerability Stop if ineffective after 4 weeks

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Genitourinary symptoms

• Genitourinary symptoms usually do not improve with time.
• Symptoms may include:
  • vaginal dryness
  • dyspareunia
  • urinary frequency
  • urinary urgency
  • recurrent UTIs
  • vulvovaginal irritation
• Non-hormonal options:
  • vaginal moisturisers
  • lubricants during intercourse
  • avoidance of irritants
  • pelvic floor therapy if indicated
• Lubricants can help with:
  • vaginal dryness
  • discomfort with intercourse
• If symptoms are persistent or moderate–severe:
  • local vaginal oestrogen is often more effective
  • systemic absorption is low
  • may be considered even when systemic MHT is not suitable, depending on clinical context

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Custom-compounded “bioidentical” hormone therapy

• Not recommended.
• Problems include:
  • limited dose regulation
  • inconsistent formulation
  • lack of safety data
  • lack of evidence that they are safer than approved MHT
  • risk of inadequate endometrial protection if oestrogen is used without appropriate progestogen

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Emerging treatments

• Estetrol
  • an oestrogen found in the fetal liver
  • may have potential safety advantages
  • possible reduced effects on liver and breast tissue
  • still an emerging area
• Neurokinin 3 receptor antagonists
  • promising non-hormonal option for vasomotor symptoms
  • target thermoregulatory pathways involved in hot flushes
• Fezolinetant
  • neurokinin 3 receptor antagonist
  • shown in a 2023 randomised placebo-controlled trial to be effective and well tolerated for vasomotor symptoms
  • relevant as an emerging non-hormonal treatment option

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Non-prescriptive therapies

Cognitive behavioural therapy — CBT

• Validated CBT programs may reduce:
  • bothersome hot flushes
  • sweats
• May also improve:
  • sleep
  • quality of life
• Can be accessed through:
  • group therapy
  • individual therapy
  • self-help books
  • online programs

Clinical hypnotherapy

• A validated program over 5 sessions, followed by self-help maintenance, may reduce:
  • flushes
  • sweats
• May improve:
  • sleep
  • mood
• Review data suggests:
  • hypnotherapy may be superior to CBT for reducing flush frequency/severity
  • both CBT and hypnotherapy may improve sleep quality

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Complementary medicines

General points

• Commonly used by women in peri-menopause and post-menopause
• Complementary therapies are not recommended routinely due to limited evidence of benefit..
• Evidence is limited because many studies are:
  • small
  • short duration
  • less than 3 months
  • inconsistent dosing
  • limited evidence of effectiveness
  • potential adverse effects
  • potential drug interactions
  • lack of robust safety data

Examples

• Black cohosh
• Phytoestrogens
• Red clover
• Ashwagandha
• Evening primrose oil
• Flaxseed
• Vitamin E
• Omega-3 preparations

Black cohosh

• Botanical name:
  • Cimicifuga racemosa
• Proposed actions:
  • serotonergic
  • dopaminergic
  • GABAergic
• Not thought to have direct oestrogenic effects on hormone receptors.
• Main possible effect:
  • reduction in vasomotor symptoms such as flushing and sweating
• Does not appear to improve:
  • mood
  • anxiety
• Side effects:
  • headache
  • dizziness
  • nausea
  • vomiting
• Side effects are usually mild.

Phytoestrogens

• Foods containing phytoestrogens include:
  • soy products
  • flax seeds
  • legumes
• Generally considered safe to eat.
• Not contraindicated in women with hormone-sensitive cancers, based on the source text.

Red clover

• Contains phytoestrogens.
• Higher doses have been shown in some studies to reduce hot flushes.
• One study showed triglyceride levels decreased compared with placebo.

Stellate ganglion block

• Involves injection of local anaesthetic near the stellate ganglion.
• Target:
  • sympathetic nerve chain
  • cervical/thoracic ganglion region
• Proposed use:
  • moderate to severe hot flushes
• Limitations:
  • rarely used
  • limited efficacy data
  • difficult to access

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Practical clinical summary

• MHT remains the most effective treatment for menopausal vasomotor symptoms.
• Non-hormonal drugs are useful when:
  • MHT is contraindicated
  • patient declines MHT
  • there is a history of hormone-sensitive cancer
  • patient wants a trial of non-hormonal therapy first
• For hot flushes/night sweats:
  • consider SSRI/SNRI, gabapentin, or oxybutynin depending on patient profile
  • avoid paroxetine with tamoxifen
  • use caution with sedating or anticholinergic medications in older patients
• For vaginal/urinary symptoms:
  • lubricants and moisturisers may help mild symptoms
  • symptoms often persist without treatment
  • local vaginal oestrogen may be required if non-hormonal measures are insufficient
• Treatment should be individualised according to:
  • symptom pattern
  • contraindications
  • cancer history
  • VTE/cardiovascular risk
  • sleep and mood symptoms
  • medication interactions
  • patient preference