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

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Clinical Approach to Menopause

Menopause is a gradual transition rather than a single event. Hormonal changes occur over several years and can affect physical, emotional, sexual, and long-term health.

Before Menopause (Reproductive Years)

During the reproductive years, the ovaries usually release one egg each month (ovulation). This results in predictable hormonal fluctuations that produce:

• Regular menstrual periods
• Cyclical physical and emotional changes
• Stable oestrogen and progesterone production

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Menopausal Transition (Perimenopause)

Perimenopause is the transitional phase leading up to menopause.

During this time:

• Ovarian function becomes inconsistent
• Ovulation occurs irregularly
• Hormone levels fluctuate significantly

This hormonal fluctuation can cause:

• Irregular or unpredictable periods
• Hot flushes and night sweats
• Mood swings, irritability, anxiety
• Sleep disturbance and fatigue
• Breast tenderness
• Brain fog or difficulty concentrating

Some women notice temporary improvement in symptoms when ovulation unexpectedly occurs and hormone levels briefly rise again.

This phase is often described as a period of “hormonal fluctuation” or “hormonal chaos”.

Duration

• Commonly lasts 4–5 years
• May be shorter or considerably longer in some women

Important Contraception Point

Ovulation may still occur during perimenopause, even when periods are irregular.

Contraception is therefore still required until:

• 12 months after the final menstrual period if ≥50 years old
• 24 months after the final menstrual period if <50 years old

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Postmenopause

Postmenopause begins once menopause has occurred.

Menopause Definition

Menopause is diagnosed retrospectively after:

• 12 consecutive months without menstruation
• In the absence of another cause

At this stage:

• The ovaries stop releasing eggs
• Oestrogen and progesterone levels fall permanently
• FSH and LH levels rise
• Menstrual periods cease completely

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Symptoms of Menopause

Every woman experiences menopause differently.

Approximate prevalence:

• ~20% have minimal or no symptoms
• ~60% experience mild to moderate symptoms
• ~20% experience severe or disabling symptoms

Common Symptoms

Vasomotor Symptoms

• Hot flushes
• Night sweats

Psychological Symptoms

• Mood changes
• Anxiety
• Irritability
• Reduced concentration
• Sleep disturbance

Genitourinary Symptoms

• Vaginal dryness
• Dyspareunia
• Urinary urgency/frequency
• Recurrent UTIs

Other Symptoms

• Fatigue
• Reduced libido
• Muscle and joint aches
• Reduced wellbeing

Factors Influencing Symptom Severity

Symptoms may be influenced by:

• Smoking
• Alcohol intake
• Physical inactivity
• Psychological stress
• Poor sleep
• Depression/anxiety
• Thyroid disease
• Chronic medical conditions
• Cultural and social factors
• Relationship and workplace stressors

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Holistic Management of Menopause

Menopause management should be individualised and consider the whole person, not just hormone levels.

Management may include:

• Education and reassurance
• Lifestyle optimisation
• Menopausal hormone therapy (MHT)
• Non-hormonal therapies
• Bone health assessment
• Cardiovascular risk reduction
• Sexual health support
• Mental health support
• Sleep optimisation
• Weight management
• Relationship and psychosocial support

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Investigations

In otherwise healthy women aged over 45 years, perimenopause and menopause are usually diagnosed clinically, based on symptoms and menstrual history. Routine blood tests, including FSH, are generally not required.

In otherwise healthy women aged over 45 years, perimenopause and menopause are usually diagnosed clinically, based on symptoms and menstrual history.

Routine blood tests, including FSH, are generally not required.

Diagnosis is based on:

• Age
• Menstrual pattern
• Vasomotor symptoms, such as hot flushes and night sweats
• Associated symptoms, such as sleep disturbance, mood changes and vaginal dryness

Diagnosis of Menopause

Women aged >45 years

Perimenopause

Perimenopause is likely when there are:

• Irregular menstrual cycles
• Vasomotor symptoms
• Sleep disturbance
• Mood changes
• Genitourinary symptoms

Blood tests are usually not needed in otherwise healthy women with typical symptoms.

Menopause

Menopause is diagnosed retrospectively after:

• 12 months of amenorrhoea
• No other obvious cause for absent periods

When FSH Testing Is Useful

FSH testing may be useful in selected situations.

Women aged 40–45 years

Consider FSH testing if there are:

• Menopausal symptoms
• Irregular periods or amenorrhoea
• Suspicion of early menopause

Women aged <40 years

FSH testing is used when assessing for premature ovarian insufficiency (POI).

POI should not be diagnosed from a single blood test. Diagnosis usually requires:

• Oligomenorrhoea or amenorrhoea
• Menopausal symptoms, which may or may not be present
• Elevated FSH on two separate samples
• Samples taken 4–6 weeks apart

When FSH Testing Is Not Useful

FSH should not be used:

• Routinely in women aged >45 years with typical symptoms
• To monitor response to menopausal hormone therapy
• In women using combined hormonal contraception
• In women using high-dose progestogen contraception

This is because hormonal contraception can suppress FSH and make results difficult to interpret.

Practical point

FSH is often elevated after menopause, commonly >30 IU/L, but this should not be used as a strict diagnostic cut-off in isolation.

FSH levels fluctuate during perimenopause, so results must be interpreted in the clinical context.

Tests Not Routinely Helpful for Diagnosing Menopause

The following hormone tests are generally not useful for routine diagnosis of menopause:

• LH
• Oestradiol
• Progesterone
• Testosterone

These levels fluctuate and do not reliably diagnose menopause or ovarian failure.

Ovarian Reserve Tests

Markers of ovarian reserve are not routine menopause tests.

They may be used in fertility or specialist settings, particularly when assessing ovarian reserve or premature ovarian insufficiency.

Examples include:

• Anti-Müllerian hormone
• Inhibin A and inhibin B
• Antral follicle count
• Ovarian volume

Practical point

AMH may indicate ovarian reserve, but it should not be used alone to diagnose menopause.

Further Investigations for Premature Ovarian Insufficiency

If premature ovarian insufficiency is suspected or confirmed, further testing may be required to identify an underlying cause.

Consider:

• Karyotype, especially if Turner syndrome is suspected
• Testing for Y chromosome material
• Fragile-X premutation testing
• Autoimmune screen, including thyroid and adrenal antibodies

Specialist gynaecology or endocrinology referral is usually appropriate for confirmed POI.

Tests to Exclude Alternative Diagnoses

Other conditions can mimic menopausal symptoms, especially when the presentation is atypical.

Pregnancy test

Consider if pregnancy is possible, especially with:

• Amenorrhoea
• Irregular bleeding
• Contraceptive failure risk

Thyroid function tests

Check:

• TSH
• Free T4

Useful if symptoms include:

• Palpitations
• Sweating
• Weight change
• Anxiety
• Menstrual irregularity

Prolactin

Consider if there is:

• Amenorrhoea
• Galactorrhoea
• Headache
• Visual symptoms

Other selected tests

Only if clinically indicated:

• Testosterone, if androgen excess is suspected
• Plasma or urinary metanephrines, if phaeochromocytoma is suspected
• Urinary 5-HIAA or chromogranin A/B, if carcinoid syndrome is suspected

FSH testing may be helpful when early menopause or premature ovarian insufficiency is suspected.

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Cardiovascular Risk Assessment

Menopause is associated with increased cardiovascular risk due to declining oestrogen levels.

Important Risk Factors

• Family history of premature cardiovascular disease
• Hypertension
• Diabetes
• Hyperlipidaemia
• Smoking
• Obesity
• Previous IHD or stroke
• Obstructive sleep apnoea

Suggested Investigations

• Australian Absolute CVD Risk Calculator
• Fasting glucose / HbA1c
• Lipid profile
• Renal function and urine ACR
• Blood pressure monitoring
• ECG ± echocardiogram
• Sleep study if OSA suspected

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Osteoporosis and Fracture Risk

Declining oestrogen accelerates bone loss after menopause.

Major Risk Factors

• Previous fragility fracture
• Age >65 years
• Family history of hip fracture
• Low BMI
• Smoking
• Excess alcohol intake
• Physical inactivity
• Long-term corticosteroid use
• Premature menopause

Secondary Causes

Consider:

• Hyperthyroidism
• Hyperparathyroidism
• Coeliac disease
• CKD
• Rheumatoid arthritis
• Multiple myeloma

Suggested Investigations

• DXA scan
• Vitamin D
• Calcium/phosphate
• ALP/PTH
• TSH
• Renal and liver function
• Coeliac serology

Fracture Risk Tools

• FRAX® calculator

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Thrombosis (VTE) Risk Assessment

Before prescribing MHT, assess thromboembolic risk.

Risk Factors

• Personal or family history of DVT/PE
• Smoking
• Obesity
• Immobility
• Recent surgery
• Known thrombophilia
• Cancer
• SLE

Possible Investigations

If clinically indicated:

• Thrombophilia screen
• Factor V Leiden
• Antiphospholipid antibodies
• Coagulation profile

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Cancer Risk Assessment

Breast Cancer Risk Factors

• Increasing age
• Obesity
• Alcohol
• Nulliparity
• Family history
• BRCA mutations
• Dense breasts
• Previous atypia/DCIS

Ovarian Cancer Risk Factors

• BRCA mutations
• Family history
• Nulliparity
• Increasing age

Endometrial Cancer Risk Factors

• Unopposed oestrogen exposure
• Obesity
• Tamoxifen use
• Endometrial hyperplasia

Suggested Investigations

Depending on symptoms/risk:

• Mammography
• Transvaginal ultrasound
• Endometrial assessment
• CA-125 (selected cases only)
• Genetic testing where appropriate

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Lifestyle and Non-Pharmacological Management

Lifestyle measures may significantly improve menopausal symptoms and long-term health.

Weight Management

Weight loss may reduce hot flush frequency and severity in overweight women.

Physical Activity

Regular exercise may help:

• Vasomotor symptoms
• Sleep
• Mood
• Bone health
• Cardiovascular health

Cooling Strategies

Helpful practical measures include:

• Lightweight layered clothing
• Cooler room temperatures
• Fans/cooling devices
• Cold drinks
• Cooling pillows

Avoiding Triggers

Some women find symptoms worsen with:

• Alcohol
• Caffeine
• Spicy foods
• Stress

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Psychological and Mind–Body Therapies

Evidence supports several non-pharmacological approaches:

• Cognitive behavioural therapy (CBT)
• Mindfulness
• Relaxation techniques
• Yoga
• Paced breathing exercises

These may particularly help with:

• Sleep disturbance
• Anxiety
• Coping with hot flushes

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Menopausal Hormone Therapy (MHT)

Oestrogen-Only Therapy

Suitable for women:

• Without a uterus
• With significant menopausal symptoms

Benefits include improvement in:

• Hot flushes
• Sleep
• Vaginal dryness
• Mood symptoms
• Bone protection

Combined Oestrogen + Progestogen Therapy

Required for women with an intact uterus to reduce the risk of:

• Endometrial hyperplasia
• Endometrial cancer

Benefits:

• Effective symptom relief
• Bone protection

Risks:

• Breast cancer risk increases with prolonged use
• VTE risk
• Stroke risk (particularly oral preparations in older women)

Tibolone

Synthetic steroid hormone used in postmenopausal women.

May help:

• Vasomotor symptoms
• Libido
• Bone density

Not suitable for all women, particularly some with breast cancer history.

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Non-Hormonal Pharmacotherapy

Useful for women who:

• Cannot use MHT
• Prefer not to use hormones
• Have contraindications to hormones

Medication	Typical Dose	Common Uses	Important Adverse Effects
Venlafaxine	37.5–75 mg daily	Hot flushes, anxiety, mood	Nausea, dizziness, sexual dysfunction
Paroxetine	10–20 mg daily	Hot flushes	Avoid with tamoxifen
Citalopram	10–20 mg daily	Mood and vasomotor symptoms	QT prolongation risk
Gabapentin	300 mg nocte → titrate	Night sweats/hot flushes	Sedation, dizziness
Clonidine	0.1 mg nocte or BD	Hot flushes	Dry mouth, hypotension

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Genitourinary Syndrome of Menopause (GSM)

Symptoms

• Vaginal dryness
• Burning
• Dyspareunia
• Urinary frequency/urgency
• Recurrent UTIs

First-Line Non-Hormonal Options

• Vaginal moisturisers
• Lubricants (e.g. water-based lubricants)

Examples:

• Replens®
• K-Y Gel®

Vaginal Oestrogen

Low-dose vaginal oestrogen is highly effective for GSM.

Options include:

• Estriol cream
• Estradiol pessaries/tablets

Typical regimen:

• Daily for 2 weeks
• Then maintenance twice weekly

Safety

Low-dose vaginal oestrogen has minimal systemic absorption and does not significantly increase risk of:

• VTE
• Cardiovascular disease
• Breast cancer recurrence risk (although oncology input is recommended in breast cancer survivors)

It may also:

• Improve urinary symptoms
• Reduce recurrent UTIs

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Complementary and “Natural” Therapies

Phytoestrogens

Current evidence does not consistently show significant benefit for menopausal symptoms.

Long-term use may increase risk of endometrial hyperplasia.

Black Cohosh

Limited evidence for efficacy.

Use cautiously due to reports of:

• Hepatotoxicity
• Liver failure