Menopausal hormone therapy (MHT)

Download: Complementary Medicines and Therapies for Hot Flushes | Information Sheet Many women experience hot flushes and night sweats around the time of menopause. Menopausal hormone therapy (MHT) has been proven to be effective in alleviating these symptoms. 1 However, some women choose to explore complementary medicines and therapies (CM&T) for relief of symptoms. There have been many studies on CM&T; some have suggested benefits, and others have shown no benefit. It can be difficult for consumers and doctors to interpret this mixed information. 2 This information sheet provides a brief overview of the current evidence for the use of CM&T.CM&T are sometimes referred to as “natural” and may be derived from plants and other sources. Some people believe that these products are safer than prescription products. However, scientific studies of these compounds do not always support this belief.2 Extracts from plants and other so-called “natural” products may actually cause harm and interact with prescribed medicines. 3 They do not necessarily act like the hormones normally produced by women. Some over-the-counter treatments, including plant extracts, are not subject to the rigorous testing for content, safety and effectiveness that prescription treatments are subject to. Herbal products may contain heavy metals, illegal ingredients and toxic chemicals as well as naturally occurring organic toxins.Any product used for the treatment of menopausal symptoms should have clinical studies showing it to be effective. This usually requires a placebo-controlled trial or a head-to-head comparison with a known effective treatment, or both. The placebo comparison is important because there is often a temporary placebo that commonly lasts around three months. 1Unless the product is tested for more than three months, it is not possible to say it is truly effective for menopausal symptoms. This short-term placebo effect is quite different from the prolonged improvement in menopausal symptoms demonstrated by treatments such as MHT. MHT reduces hot flushes by around 90% and continues to be effective for as long as they are used.4 Prescription drugs cannot be licensed until they have been shown to be safe and effective. This is not the case for over-the-counter remedies for menopausal symptoms.The AMS advocates that all therapies, whether prescription or alternative, should not be used unless there is good research evidence for their effectiveness and safety over the short and long term.CM&T use in AustraliaIn a national representative sample of 10,011 Australian women aged 59-64 years:539% of menopausal women consulted CM&T practitioners.75% used self-prescribed CM&T.95% consulted general practitioners (GP) and 50% consulted specialists during the previous year, and 12% were current menopausal hormone therapy (MHT) users.Similarly, a cross-sectional questionnaire-based study of 2020 Australian women aged 40-65 years living independently in the community found that the prevalence of CM&T use to manage menopausal vasomotor symptoms (VMS) was 13.22%.6Specific herbal and botanical therapiesBlack cohosh (Cimicifuga racemosa or Actaea racemosa)Specific extracts of black cohosh (isopropanolic), and higher therapeutic doses may improve menopausal symptoms, including hot flushes, as shown in a recent systematic review and meta-analysis.7 It should be noted that most of the included studies were conducted over short time frames (i.e. 3-6 months) and on small numbers of patients. In addition, although many were placebo-controlled trials, no studies compared black cohosh to conventional MHT.There were originally reports of liver toxicity from the use of black cohosh.8 A review of the 69 cases of suspected black cohosh-induced liver disease concluded that data does not support a direct causal relationship, with no signal of safety concern.9 Another meta-analysis found no evidence of black cohosh adversely affecting liver function, although studies were only up to 6 months of treatment.10Phytoestrogens (including red clover, below)A wide range of products containing plant or phytoestrogens, including soy products, are available as over the counter remedies for hot flushes. The active product of these is thought to be isoflavones which bind to the oestrogen receptor.  Isoflavones have a greater affinity for ER-? than for ER-? and possess both oestrogen agonist and antagonist properties. There are study limitations and differences in the interventions and the findings are mixed. Some studies demonstrated efficacy of soy in reducing VMS or severity and others showing no benefit from soy compared to placebo.11   Efficacy of soy may be influenced by whether an individual is able to metabolize the soy isoflavone daidzein to the more potent phytoestrogen, equol. Around 20-30% of Caucasians (compared to 40-70 % of Asians) are equol producers.12 Equol supplements are not readily available in Australia. Compared to placebo, equol supplementation was found to be superior to placebo for reducing VMS frequency in 3 of the 5 trials assessed in a 2019 systematic review and meta-analysis.13Updated information by the Cancer Council of Australia, influenced by the World Cancer Research Fund (WCRF) state that the available evidence suggests that soy and other isoflavone-containing foods are unlikely to increase cancer risk, and recommend that people, including those who have been diagnosed with breast cancer, who consume soy foods, should continue to do so.14,15Red clover (Trifolium pratense)Specific extracts of red clover may be useful in reducing the daily frequency of hot flushes, particularly in post-menopausal women, if taken for a period of 12 weeks and with higher doses of isoflavones (?80 mg/day,) and when the formulations contained a higher proportion of biochanin A.16Preliminary evidence suggests there may be some benefit from use of red clover in reducing cholesterol and low-density lipoprotein (LDL).17Siberian rhubarb (Rheum rhaponticum)A systematic review and meta-analysis of the standardised extract of Rheum rhaponticum root, ERr 731® significantly reduced the Menopause Rating Scale score compared with control.18 Ffurther research is needed to establish long-term efficacy and safety.11 St John’s wort (Hypericum perforatum)Combined with black cohosh, St John’s Wort can be effective for menopausal mood symptoms. A small, randomised control-trial (n=301) compared isopropanolic black cohosh extract and ethanolic St John’s wort against a placebo. Scores on the Menopause Rating Scale decreased by 50% in the treatment group compared to 19% in the placebo group. Depression also significantly decreased compared with placebo.19It is important to note that this therapy may interact with many prescription medicines. A lack of long-term safety data limits recommendations for its use.11Evening primrose oilVery few studies have addressed whether evening primrose oil improves hot flushes. Existing data shows no benefit in one study,20 and another small study showed a reduced frequency and severity of night sweats, but not hot flushes, compared to placebo at a dose of 1000 mg twice a day for 8 weeks (n=170).21 Evening primrose oil lowers the seizure threshold in people with epilepsy and interferes with the actions of anti-epileptic medication.3FlaxseedTwo small recent studies have shown flaxseed (also known as linseed) may be beneficial in improving hot flushes, night sweats and vaginal dryness in perimenopausal women, with the longest study conducted over 8 months.22,23 More evidence is needed before flaxseed can be recommended for use.Ashwaganda (Withania somnifera)Ashwaganda is an herbal product used in Ayurvedic medicine for its supposed adaptogenic and anti-stress properties. Only one small study, undertaken in 100 women over only 8 weeks, looked at its use for management of perimenopausal symptoms, with significant reductions in menopause symptom scores noted.24Importantly, the Therapeutic Goods Association (TGA) issued a safety advisory for Withania somnifera in 2024 due to reports of severe gastrointestinal symptoms and liver damage in patients taking the herb, several of whom required hospitalisation.25 Use of medicines or herbal supplements containing Withania somnifera should be avoided in patients with existing or previous liver pathologies.25Non-herbal medicines and therapiesVitamin ETwo very small and short-term studies have shown that Vitamin E (800 iu per day for 4 weeks) decreased the number of hot flushes by 1 per day when used by women who have had breast cancer (n=120),26 and reduced the number of hot flushes by 2 per day in other women (400 iu vitamin E daily, n= 51).27Omega-3Use of Omega-3 showed no difference in the frequency and severity of hot flushes, insomnia severity, sleep quality compared to placebo in a systematic review and meta-analysis (n=183).28Supplementation with omega-3 can improve the lipid profile of postmenopausal women,29 and the Heart Foundation of Australia recommend fish oils as part of an adult diet to help lower the risk of coronary heart disease.30Cognitive behavioural therapy, hypnosis, yoga and non-prescription medicinesThe AMS information sheet ‘Nonhormonal treatments for menopausal symptoms’ covers this.Compounded bioidentical menopausal hormone therapy (including progesterone cream)There is no evidence to support the efficacy or safety claims of compounded “bioidentical” hormones, or the superiority claims of these over conventional MHT. These products also pose the additional risks of variable purity and potency. All major national and international menopause societies have raised concerns about the safety and efficacy of these products and recommend that patients be counselled to avoid their use.31 The AMS information sheet Bioidentical hormones for menopausal symptoms has more information.Other CM&T with little or no evidence of benefit in treating menopausal symptomsWild yam creamGinseng (Panax ginseng or Panax quinquefolius)Maca (Lepidium Meyennii Walp or Lepidium peruvianum Chacon)Pine bark (Pyncogenol)Pollen extractMagnesiumCombination botanical therapiesHomeopathyAcupunctureUpdated April 2025Additional ReadingManagement of menopausal symptoms in women with a history of breast cancer | Cancer AustraliaThe 2023 Nonhormone Therapy Position Statement of The North American Menopause Society Advisory Panel: https://pubmed.ncbi.nlm.nih.gov/37252752/Memorial Sloan Kettering Cancer Center information on Integrative medicine including the “About Herbs” database. Note this is a USA website and not all of the products mentioned will be available in Australia: https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/searchReferencesMacLennan AH et al. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev 2004; 4:18.Nedrow AJ et al. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006;166(14):1453-65.Byard RW et al. What risks do herbal products pose to the Australian community? MJA 2017;206(2):86-90.MacLennan AH. Evidence-based review of therapies at the menopause. International Journal of Evidence Based Healthcare 2009;7(2):112-23.Peng et al. Complementary/alternative and conventional medicine use amongst menopausal women: results from the Australian Longitudinal Study on Women’s Health. Maturitas 2014; 79(3):340-42.Gartoulla et al. Use of complementary and alternative medicines for menopausal symptoms in Australian women aged 40-65 years. MJA 2015; 203(3):146.Castelo-Branco, C et al. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms - an update on the evidence. Climacteric 2021; 24(2): 109–119. https://doi.org/10.1080/13697137.2020.1820477Whiting PW et al. Black cohosh and other herbal remedies associated with acute hepatitis. MJA 2002;177(8):440-3.Teschke R. Black cohosh and suspected hepatotoxicity: inconsistencies, confounding variables, and prospective use of a diagnostic causality algorithm. A critical review. Menopause 2010; 17(2): 426–440. https://doi.org/10.1097/gme.0b013e3181c5159cNaser B et al. Suspected black cohosh hepatotoxicity: no evidence by meta-analysis of randomized controlled clinical trials for isopropanolic black cohosh extract. Menopause 2011;18(4):366-75.“The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society” Advisory Panel (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society.  Menopause 2023; 30(6): 573–590. https://doi.org/10.1097/GME.0000000000002200Cui C et al. Effects of soy isoflavones on cognitive function: a systematic review and meta-analysis of randomized controlled trials. Nutrition reviews 2020; 78(2), 134–144. https://doi.org/10.1093/nutrit/nuz050Daily J et al. Equol Decreases Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Journal of medicinal food 2019; 22(2):127–139. https://doi.org/10.1089/jmf.2018.4265World Cancer Research Fund / American Institute for Cancer Research. Wholegrains, vegetables and fruit and the risk of cancer [Internet]. London; 2018. Available from: https://www.wcrf.org/dietandcancer/exposures/wholegrains-veg-fruitInformation sheet: Soy & isoflavones | Cancer CouncilKanadys W et al. Evaluation of Clinical Meaningfulness of Red Clover (Trifolium pratense L.) Extract to Relieve Hot Flushes and Menopausal Symptoms in Peri- and Post-Menopausal Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2021; 13(4), 1258. https://doi.org/10.3390/nu13041258)Yigit E et al. Isoflavones obtained from red clover improve both dyslipidemia and menopausal symptoms in menopausal women: a prospective randomized placebo-controlled trial. Climacteric 2024; 1–7. Advance online publication. https://doi.org/10.1080/13697137.2024.2393121)Dubey VP et al. Efficacy evaluation of standardized Rheum rhaponticum root extract (ERr 731 ®) on symptoms of menopause: A systematic review and meta-analysis study. Journal of biomedical research 2024; 38(3):278–286. https://doi.org/10.7555/JBR.37.20230219Uebelhack et al. Black cohosh and St Johns’ wort for climacteric complaints. Obstet Gyn 2006; 107(2):247-55.Chenoy R et al. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ 1994;308(6927):501-3.Kazemi F et al. The Effect of Evening Primrose Oil Capsule on Hot Flashes and Night Sweats in Postmenopausal Women: A Single-Blind Randomized Controlled Trial. Journal of menopausal medicine 2021; 27(1), 8–14. https://doi.org/10.6118/jmm.20033Dizaye K et al. Effects of flaxseed (Linum usitatissimum) on climacteric symptoms and clinical parameters in post-menopausal women: Flaxseed effects on menopause associated symptoms and biochemical parameters. Iraqi Journal of Pharmaceutical Sciences 2023; 32:257-265.Shrivastava R et al. Effects of Flaxseed on Perimenopausal Symptoms: Findings From a Single-Blind, Randomized, Placebo-Controlled Study. Cureus 2024; 16(9): e68534. https://doi.org/10.7759/cureus.68534Gopal S et al. Effect of an ashwagandha (Withania Somnifera) root extract on climacteric symptoms in women during perimenopause: A randomized, double-blind, placebo-controlled study. The Journal of Obstetrics and Gynaecology Research 2021; 47(12): 4414–4425. https://doi.org/10.1111/jog.15030https://www.tga.gov.au/news/safety-alerts/medicines-containing-withania-somnifera-withania-ashwagandhaBarton DL et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 1998; 16(2): 495–500. https://doi.org/10.1200/JCO.1998.16.2.495Ziaei S et al. The effect of vitamin E on hot flashes in menopausal women. Gynecologic and obstetric investigation 2007; 64(4): 204–207. https://doi.org/10.1159/000106491Mohammady M et al. Effect of omega-3 supplements on vasomotor symptoms in menopausal women: A systematic review and meta-analysis. European journal of obstetrics, gynecology, and reproductive biology. 2018; 228:295–302. https://doi.org/10.1016/j.ejogrb.2018.07.008Wang J et al. Does Omega-3 Fatty Acid Supplementation Have Favorable Effects on the Lipid Profile in Postmenopausal Women? A Systematic Review and Dose-response Meta-analysis of Randomized Controlled Trials. Clinical therapeutics 2023; 45(1): e74–e87. https://doi.org/10.1016/j.clinthera.2022.12.009https://assets.contentstack.io/v3/assets/blt8a393bb3b76c0ede/blt30294411bd96bdd3/65ea8b022b979deb55896f8b/Summary_Evidence_FISH_FISH-OILS_FINAL.pdf“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794. doi: 10.1097/GME.0000000000002028. PMID: 35797481.

Download: Bleeding – perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT | Information Sheet Key pointsA change in bleeding pattern is common during perimenopause.Heavy bleeding, prolonged bleeding, and any bleeding more than 12 months after the last menstrual period needs investigation.Endometrial ultrasound is the initial investigation of choice, and the findings determine the need for tissue sampling and/or hysteroscopy.Medical management, after excluding a localised or neoplastic lesion, involves modification of the MHT dose or regimen.Perimenopausal bleedingIn the menopausal transition, hormonal fluxes may be erratic with vaginal bleeding being both ovulatory or non-ovulatory, light, or heavy, reasonably regular, or entirely irregular (1). For women considering menopausal hormone therapy (MHT), abnormal bleeding should be investigated before prescribing. Heavy menstrual bleeding, rather than irregular bleeding itself is a hallmark of abnormal build-up of the endometrium. Heavy bleeding after a prolonged interval without bleeding, or prolonged bleeding of any amount should be investigated. A lower investigative threshold should apply for high-risk women.Postmenopausal bleedingPostmenopausal bleeding (PMB) refers to any vaginal bleeding that occurs in a menopausal woman, i.e. 12 months after their final menstrual period. This does not include the regular withdrawal bleed that occurs on MHT.Any postmenopausal bleeding requires investigation to exclude a sinister cause. The likelihood of endometrial carcinoma for a woman presenting with PMB is 10% (2). However, around 95% of women with endometrial malignancy will present with PMB (3). Risk factors for endometrial cancer include age, obesity, use of unopposed oestrogen, polycystic ovary syndrome (PCOS), Type 2 diabetes mellitus, atypical glandular cells on screening cervical cytology and family history of gynaecologic malignancy(4). Nulliparity is also a risk factor. Patients taking non-conventional MHT, such as troches and transdermal progestogen are at risk of endometrial hyperplasia and cancer (5).Women on menopausal hormone therapyIn women taking cyclical MHT, a withdrawal bleed is expected, and the patient should be counselled as such. The withdrawal bleed should occur toward the end of, or after the progestogen containing phase of the cyclical regimen. Bleeding, which is unpredictable, occurring outside the expected time, or excessively heavy should be investigated.For women taking continuous combined MHT (CCMHT), the significance of breakthrough bleeding depends upon the recency of her LMP and on how long she has been taking CCMHT. Women within 12 months of the last natural menstrual period often do not achieve amenorrhoea, presumably because some residual endogenously oestrogen-stimulated endometrium is present. Unpredictable breakthrough bleeding is common in this situation and does not need investigation unless it is unusually heavy. To avoid this, it is recommended that cyclical MHT be used for the first 12 months at least following the LMP. A similar diagnostic and therapeutic approach applies to tibolone.Bleeding should be investigated if it occurs after six months use of CCMHT or tibolone or starts after amenorrhoea has been established on this regimen. Amenorrhoea in this setting depends upon the balance between the oestrogenic effect and progestogenic effect of the MHT components on the endometrium. Oestrogen stimulation of the endometrium causes proliferative histological features and progesterone secretory. Inadequate progestogenic effect can therefore result in endometrial proliferation and possibly hyperplasia and bleeding. It may, like unopposed oestrogen therapy, lead to endometrial malignancy. However, more commonly in women taking pharmaceutical preparations of CCMHT, excessive progestogenic effect may produce bleeding from an atrophic endometrium.Diagnostic evaluation of postmenopausal bleeding (PMB)The primary goal of investigation is to exclude malignancy, and secondarily to elucidate a treatable non-malignant cause (6).A detailed history should be taken:When does the bleeding occur?Is it post-coital?What medications is the patient taking, e.g. anticoagulants, herbal therapies, tamoxifen?Is the patient taking so-called “bioidentical” hormones?Has the patient missed MHT doses?When was the last cervical screening test?Are there any bladder or bowel symptoms?Physical examination should include inspection of the vulva, vagina, and the cervix for visual evidence of lesions or bleeding, taking note of any signs of atrophy. Bleeding from the perineum, urethra and anus is also a possibility. A cervical co-test (HPV test and liquid based cytology) or cervical smear should be done.Endometrial ultrasoundEndometrial ultrasound is the initial investigation of choice. This should be done by an experienced specialist gynaecological ultrasonographer and with transvaginal ultrasound (TVUS). In women taking cyclical MHT, it should be done immediately after the withdrawal bleed (7). The ultrasound should be able to identify any localised uterine lesion which may contribute to bleeding – endometrial polyp, submucosal fibroid, hyperplasia, or cancer. The significance of PMB for the risk of malignancy differs with use of MHT and endometrial thickness on TVUS. Subsequent investigations depend on the ultrasound findings, so the experience of the ultrasonographer is critical. After excluding localised lesions, the following algorithm is useful (8). Note that this algorithm does not apply to women taking tamoxifen.Figure 1.  Management algorithm for patients with post-menopausal bleeding (8).  ECC= Endometrial echo complex, EC= Endometrial carcinoma, EMB= Endometrial biopsyTamoxifen therapyTamoxifen therapy is associated with stimulation of the endometrium and an increased risk of endometrial cancer (9). Tamoxifen therapy invariably produces a thickened appearance to the endometrium which is not always indicative of neoplasia. Therefore, TVUS is not useful for the investigation of PMB in a woman on tamoxifen therapy and examination of the uterine cavity by hysteroscopy is recommended (6).Histological assessmentThere has been some debate for what is regarded as the upper limit of normal endometrial thickness. Many groups have recently used a cut-off of 4mm (4,10,11). An endometrial thickness of ?4mm has a 99% negative predictive value for malignancy (4).Endometrial biopsy should be performed in women who meet the following criteria(4):Endometrial thickness >4mmNot easy display of the endometrium e.g. fibroidsPersistent PMBSuspicion of polyp or mass on transvaginal ultrasoundEndometrial thickness  ?  3mm with fluid in the endometrial cavityBlind tissue sampling such as Pipelle or D&C may be sufficient for pathology that affects the entire endometrial surface, but it is inadequate for detecting localised lesions such as endometrial polyps, which may be malignant (6). Hysteroscopy is superior to endometrial biopsy and ultrasonography for the identification of these structural lesions and is recommended.ManagementMedical managementWhen a localised or neoplastic lesion is found, the management is surgical. However, when the findings are benign and the patient is taking MHT, some modification of the MHT dose or regimen is required. While there is an abundance of literature about the incidence of bleeding on MHT and the histological findings, there are no evidence-based recommendations guiding therapeutic intervention. Therefore, the following recommendations are based on clinical practice advice from the literature and based on the patterns of histology seen in women with breakthrough bleeding (12-15). They are made here with the proviso that continued bleeding should prompt re-investigation, as above.Cyclical MHT with unpredictable bleeding and negative histological screen for pathologyThis may respond to a change in the progestogen component of the MHT such as altering the dose, type of progestogen or the mode of delivery e.g. intrauterine.CCMHT with breakthrough bleeding, endometrium >4mm and negative histologyIf less than 12 months post LMP, change to cyclical MHT or intrauterine progestogen. If more than 12 months post LMP, change oestrogen/progestogen balance by reducing oestrogen or changing progestogen dose, type, or delivery.CCMHT with breakthrough bleeding, endometrium <4mmThis is the most difficult scenario to manage, especially in a patient who wants to have no withdrawal bleeding. The TVUS suggests adequate, if not excessive, progestogenic effect, especially if tissue sampling demonstrates an atrophic sample. Increasing the dose or changing the progestogen formulation does not always address the underlying problem. Continuous progestogen effect on the endometrium exposes superficial dilated blood vessels which predispose to bleeding (16). The same may occur with prolonged tibolone therapy. A change back to cyclical MHT, at least for a while, is recommended or an increase in the oestrogen dose may be effective.Surgical managementSurgical management is appropriate for neoplastic and local lesions causing bleeding. However, women who have heavy or unmanageable breakthrough bleeding in the absence of pathology, may prefer to have a hysterectomy, after which they need take only oestrogen as MHT. The alternative is endometrial ablation. This may resolve the PMB but it should be noted that progestogen is still necessary since there will be residual endometrium left. Moreover, the above investigations – TVUS, hysteroscopy, endometrial sampling - will be difficult if there is subsequent PMB (17).ReferencesHale GE, Hughes CL, Burger HG, Robertson DM, Fraser IS. Atypical estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition. Menopause. 2009;16(1):50-9.van Hanegem N, Breijer MC, Khan KS, Clark TJ, Burger MP, Mol BW, et al. Diagnostic evaluation of the endometrium in postmenopausal bleeding: an evidence-based approach. Maturitas. 2011;68(2):155-64.van Hanegem N, Prins MM, Bongers MY, Opmeer BC, Sahota DS, Mol BW, et al. The accuracy of endometrial sampling in women with postmenopausal bleeding: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;197:147-55.ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women with Postmenopausal Bleeding. Obstet Gynecol. 2018;131(5):e124-e9.Eden JA, Hacker NF, Fortune M. Three cases of endometrial cancer associated with "bioidentical" hormone replacement therapy. Med J Aust. 2007;187(4):244-5.Munro MG, Southern California Permanente Medical Group's Abnormal Uterine Bleeding Working G. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. Perm J. 2014;18(1):55-70.Affinito P, Palomba S, Sammartino A, Bonifacio M, Nappi C. Ultrasonographic endometrial monitoring during continuous-sequential hormonal replacement therapy regimen in postmenopausal women. Maturitas. 2001;39(3):239-44.Carugno J. Clinical management of vaginal bleeding in postmenopausal women. Climacteric. 2020;23(4):343-9.Mourits MJ, De Vries EG, Willemse PH, Ten Hoor KA, Hollema H, Van der Zee AG. Tamoxifen treatment and gynaecologic side effects: a review. Obstet Gynecol. 2001;97(5 Pt 2):855-66.Saccardi C, Spagnol G, Bonaldo G, Marchetti M, Tozzi R, Noventa M. New Light on Endometrial Thickness as a Risk Factor of Cancer: What Do Clinicians Need to Know? Cancer Manag Res. 2022;14:1331-40.Papakonstantinou E, Adonakis G. Management of pre-, peri-, and post-menopausal abnormal uterine bleeding: When to perform endometrial sampling? Int J Gynaecol Obstet. 2022;158(2):252-9.Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011.de Medeiros SF, Yamamoto MM, Barbosa JS. Abnormal bleeding during menopause hormone therapy: insights for clinical management. Clin Med Insights Women's Health. 2013;6:13-24.Spencer CP, Cooper AJ, Whitehead MI. Management of abnormal bleeding in women receiving hormone replacement therapy. BMJ. 1997;315(7099):37-42.Hillard TC, Siddle NC, Whitehead MI, Fraser DI, Pryse-Davies J. Continuous combined conjugated equine estrogen-progestogen therapy: effects of medroxyprogesterone acetate and norethindrone acetate on bleeding patterns and endometrial histologic diagnosis. Am J Obstet Gynecol. 1992;167(1):1-7.Thomas AM, Hickey M, Fraser IS. Disturbances of endometrial bleeding with hormone replacement therapy. Hum Reprod. 2000;15 Suppl 3:7-17.Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387-95.End of documentLast updated in September 2026

Download: Osteoporosis | Information Sheet Key PointsOsteoporosis is a common condition which increases the risk of fracture leading to significant morbidityThe menopausal transition is associated with significant bone loss due to the decline in oestrogenLifestyle management of osteoporosis includes ensuring adequate calcium intake, optimising Vitamin D levels, weight bearing exercise, reducing alcohol and smoking cessationMedical therapies include menopausal hormone therapy, SERMS, anti-resorptive medications (bisphosphonates and denosumab) and anabolic agents (teriparatide and romosozumab)The decision to initiate therapy depends on an individual’s risk of fracture. The FRAX and Garvan risk calculators can be used as a guide to inform who should receive medical treatmentBackground Osteoporosis is a condition characterised by weakened bones that fracture easily. Worldwide, osteoporosis causes more than 8.9 million fractures annually (1) and one in three women over the age of 50 will experience a fracture (2). Osteoporotic fractures lead to significant morbidity and reduced quality of life. Because osteoporosis itself is asymptomatic, it is often only diagnosed at the time of a fracture.Osteoporosis is diagnosed on dual energy X-ray absorptiometry (DEXA) when there is a T-score of ?2.5 at the spine or hip, where T-score is the standard deviation based on normative data for a young healthy adult population. Alternatively, osteoporosis may also be diagnosed if an individual has a minimal trauma fracture, which is defined as a fall from a standing height (or equivalent trauma). Minimal trauma fractures most commonly occur in the hip, spine, forearm, humerus and pelvis. Fractures of the hands and feet are not considered minimal trauma. A prior minimal trauma fracture puts an individual at higher risk of further fractures.Secondary causes of osteoporosis include hyperparathyroidism, coeliac disease, hyperthyroidism and glucocorticoid excess.The role of oestrogenOestrogen plays an important role in maintaining bone strength. Bone density rapidly rises after puberty under the influence of oestrogen and peak bone mass is reached around age 30. After menopause, oestrogen levels drop and this results in accelerated bone loss. The average woman loses up to 10 per cent of her bone mass in the first five years after menopause (3). Data from Healthy Bones Australia suggest that 27% of women age ?60 are osteoporotic and 51% of women ?60 are osteopaenic. Women with premature ovarian insufficiency are particularly at risk of osteoporosis and it is recommended that these women are treated with hormone replacement therapy until the age of 50-51 (see AMS Information Sheet:Spontaneous Premature Ovarian Insufficiency).Lifestyle management of osteoporosisTo reduce the risk of developing osteoporosis, a number of lifestyle factors should be addressed:Ensure adequate dietary calcium. The recommended intake is1300mg/day for women over 50 (equivalent to 3-4 serves of dairy food per day). Some individuals are unable to reach this requirement and calcium supplements can be taken (see AMS Information Sheet: Calcium Supplements)Maintain adequate Vitamin D levels. Vitamin D has a key role in calcium absorption from the gut. Normal bone mineralisation cannot occur if Vitamin D deficiency is severe. Healthy Bones Australia recommends a Vitamin D level of at least 50nmol/L at the end of winter.Weight bearing exercise. Exercises which require the muscles and bones to work against gravity are effective in maintaining bone mass. This may take the form of weight bearing impact loading aerobic exercise (walking, stair climbing, jogging, volleyball, tennis and dancing) or strength/ resistance exercises (eg. free weights).Smoking cessation. Smokers tend to be at higher risk of any fracture including hip fractures (4). Longitudinal studies show smokers to have accelerated bone loss compared to non-smokers (5,6).Reduce alcohol intake. More than 2 standard drinks of alcohol per day is associated with an increased risk of fracture (7).Fracture Risk CalculatorsAlthough osteoporosis indicates a high risk of fracture, many fragility fractures occur in people with bone density levels above a T-score of -2.5.  Fracture risk calculators such as FRAX and GARVAN help stratify fracture risk and are used to help guide clinicians as to which patients should be commenced on osteoporosis medications. These tools factor in a variety of established clinical risk factors including the bone density to calculate an individual’s risk of developing a major osteoporotic and hip fracture in the next 5 and 10 years. An accepted recommendation is to initiate treatment if the risk or a major osteoporotic and hip fracture is ³ 20% and 3% respectively (8).Links to the fracture calculators can be found here: FRAX and GARVAN.Medical therapies for osteoporosisA number of medical treatments are available for the management of osteoporosis. Treatments aim to strengthen existing bone; help prevent further bone loss and most importantly reduce the risk of fracture.Treatments include the following:  Antiresorptive agentsBisphosphonatesDenosumabHormone therapy / SERMsHormone therapy (MHT) including TiboloneSelective oestrogen receptor modulators (SERMs)Anabolic agentsTeriparatideRomosozumabBisphosphonatesBisphosphonates reduce bone resorption by inhibiting osteoclast action as well as increasing osteoclast apoptosis. They are effective in reducing vertebral, hip and other fractures. Oral bisphosphonates such as alendronate and risedronate may be taken daily, weekly or monthly. The intravenous form, zoledronic acid, is given every 12-24 months.Possible side effects of treatment include gastrointestinal upset and reflux. A rare side effect is osteonecrosis of the jaw – the incidence is estimated to be 1 in 10,000 to 1 in 100,000 patient years for patients taking bisphosphonates for osteoporosis (11). Patients should be advised to have a dental review prior to commencement. Prolonged treatment on antiresorptive agents such as bisphosphonates increases the risk of atypical fractures. For this reason, some society guidelines recommend review after 3 years of intravenous and 5 years of oral bisphosphonate treatment (12). If the risk of fracture at this time is considered high then treatment should be continued; if the risk is low to moderate, then a drug holiday should be considered.DenosumabDenosumab is a monoclonal antibody against RANK ligand (RANKL); this prevents the development and maturation of osteoclasts and therefore slows bone resorption. It is given as a 6-monthly subcutaneous injection. It reduces the risk of vertebral, hip and other fractures. Like bisphosphonates, prolonged use can lead to atypical fractures. Importantly, denosumab cessation leads to a rebound effect where there is accelerated bone loss, bone turnover markers are increased, and there is an increased risk of vertebral fractures. Many clinicians now recommend avoiding denosumab as a first line agent in younger patients requiring therapy because of the need to avoid very long term antiresorptive therapy and the rebound effect associated with denosumab discontinuation.Menopausal Hormone therapyMenopausal hormone therapy (MHT) relieves menopausal symptoms such as vaginal dryness, hot flushes and night sweats. When taken at the beginning of menopause, MHT can also prevent bone loss and should be started soon after menopause for maximum benefit. Some studies have shown that MHT can increase bone density by around five per cent in two years. On average, MHT reduces the risk of spinal and hip fractures by 40%.MHT is most appropriate for use in women under age 60 who are at risk of fracture and especially those who have undergone early menopause (before 45 years of age).It is generally accepted that the risks of MHT potentially begin to outweigh the benefit in women over the age of 60. However, some women may elect to continue hormone therapy beyond age 60 – this needs to be done in consultation with the woman’s doctor and the woman needs to understand the risks and benefits of this therapy (see AMS Information Sheets: Combined MHT and Oestrogen Only MHT). It is also important to understand that bone loss will resume once MHT is stopped. The rate of bone loss is more rapid than normal for the first 4-5 years after stopping MHT. If an individual’s bone density is already low before stopping MHT, alternative treatments to preserve bone density will be needed.TiboloneTibolone is a synthetic steroid which has oestrogenic, progestogenic and androgenic actions. It is indicated for the treatment of symptoms associated with menopause and prevention of osteoporosis. The LIFT study showed that women using tibolone 1.25mg (standard dose 2.5mg) reduced the risk of both vertebral and non-vertebral fracture compared to placebo (9). Tibolone should be used in women at least 12 months after their final period (See AMS Information Sheet: Tibolone as MHT).Selective Oestrogen Receptor Modulators (SERMS)Selective oestrogen receptor modulators (SERMs) are medications that bind to oestrogen receptors and have an agonist effect at some sites (brain and bone) but are antagonistic at other sites (breast and endometrium). Raloxifene is available in Australia; it reduces the risk of vertebral fractures but not non-vertebral fractures (10). Women prescribed raloxifene should be warned that they are more likely to experience hot flushes and have a slightly increased risk of venous thromboembolism.Bazedoxifene is a third generation SERM with oestrogen agonist effects on bone and antagonises the effect of oestrogen at the endometrium. In Australia, Bazedoxifene is combined with conjugated equine oestrogens in what is referred to as a tissue selective oestrogen complex (TSEC). It is used to prevent osteoporosis and treat menopausal symptoms without the need for a progestogen, in women with a uterus and at least 12 months since last menses (see AMS Information Sheet SERMS – their role in menopause management).TeriparatideTeriparatide is a synthetic form of human parathyroid hormone. It works by stimulating osteoblastic activity leading to new bone formation. A meta-analysis comparing teriparatide with placebo showed a 74% reduction in the risk of vertebral fractures and a 39% reduction in the risk of nonvertebral fractures with teriparatide use (13). It is administered as a daily subcutaneous injection. Antiresorptive therapy should be continued after teriparatide treatment to maintain its effect. Only patients under the care of a specialist can be prescribed teriparatide and there are strict PBS and Pharmac criteria in Australia and New Zealand respectively.Treatment is limited to one 18-month course per lifetime on the PBS and Pharmac. It is effective and safe to 24 months although patients would need to privately fund the additional 6 months.RomosozumabRomosozumab is a monoclonal antibody against sclerostin, an osteocyte-derived protein that inhibits bone formation. Inhibition of sclerostin leads to an increase in bone formation and a reduction in bone resorption. A meta-analysis of the studies examining the effect of Romozumab in post-menopausal women found a reduction in the rate of both vertebral and non-vertebral fractures (14). Like teriparatide, Romosozumab must be prescribed by a specialist.Romosozumab is administered as two injections each month for a total of 12 months. The PBS indications for Romosozumab are also similar to teriparatide. Where can I get more information?healthybonesaustralia.org.au  Healthy Bones Australia (02) 9518 8140bones.org.nzjeanhailes.org.aubonehealth.org.aumenopause.org.au References:Johnell O et al. Osteoporosis Int. 2006: 17;(12):1726-1733Cheng XG et al. Bone. 1997;20(3):213-213Greendale GA et al. J Bone Mineral Res. 2012; 27:111-118)Kanis JA et al. Osteoporosis Int. 2005;16(2):155-162Trevisan C et al. J Clin Densitom. 2020;23(3):381-389Emaus N et al. J Bone Miner Res. 2014;29(9):2080-2089Kanis JA et al. Osteoporosis Int 2005 Jul;16(7):737-42Tosteson ANA et al. Osteoporosis 2008; 19(4); 437-447Cummings SR et al. NEJM 2008; 359:697-708Ettinger B et al. JAMA 1999;282(7):637-645Khan AA et al. J Bone Miner Res 2015;30:3Eastell R. JCEM: 2019; 104(5):1595–1622Qaseem A. et al. Ann Intern Med. 2017; 166(11):818–839Sing S et al. Osteoporosis Int. 2022; Jan;33(1):1-1

Download: Diagnosing Menopause | Information Sheet Key PointsMenopause is the final period in a woman’s life.Perimenopause is usually diagnosed clinically on the basis of new onset vasomotor or other symptoms and a change in the pattern of menstrual bleeding. Menopause is diagnosed 12 months after the final menstrual period.The average age of menopause is 51. Early menopause is defined as menopause occurring between 40-45years and premature ovarian insufficiency (POI) prior to age 40.Measuring oestradiol or FSH is generally not indicated because of marked daily fluctuations.A symptom score sheet can be helpful in measuring the severity and impact of symptoms and assessing response to any intervention.DON’TMeasure FSH, LH, AMH (anti-Müllerian hormone), oestradiol or testosterone, inhibin A or B (which inhibit FSH production) levels and antral count or ovarian volume in a woman with symptoms at the normal age for menopause (over 45 years) because these results are unlikely to change your management. The indications for intervention are clinical.BUT for premature menopauseWhich is defined as occurring before the age of 40 and is designated as ‘Premature Ovarian Insufficiency’ (POI).Measurement of FSH is indicated in women under 40 and 40-45 with menopausal symptoms. Premature menopause is diagnosed by elevated FSH levels on two occasions, 4-6 weeks apart.DO take a historyMenopausal symptoms – the multiplicity of which are identified in the Greene scale below is a useful standardised symptom measurement system.Vasomotor symptoms cause sleep disturbance. Ask about severity and number.Sleep disturbance is a major factor affecting quality of life. Identify the impact of sleep disturbance.Record personal medical history and risk factors for breast cancer, cardiovascular disease, thromboembolic disease and osteoporosis.Ask about absolute or relative contraindications to MHT: uncontrolled hypertension, undiagnosed abnormal bleeding, previous breast or endometrial cancer and personal history or high inherited risk of thrombo-embolic diseaseEnsure that screening (breast, cervical) is up to dateIntroductionFrequently, the woman herself has already made the diagnosis of menopause. She attends her doctor with symptoms such as hot flushes or night sweats interrupting her sleep, together with changes in her menstrual cycle. Not all women with menopausal symptoms will need treatment. Most women will be glad of information about menopause and about the safe and effective treatment options available. The questions we should be asking her are "Why did you come to see me", and "What do you hope to get out of this consultation?"Common questions are:How long does menopause last?When will I be through it?What are the pros and cons of taking menopause hormone therapy (MHT) for me?Can I treat my symptoms naturally?If I do decide to take MHT, for how long should I take it?When am I no longer fertile and when should I stop using contraception?There is a lot of information to give, and even if a menopause information sheet is given, a long appointment will be required to give all the information required and answer questions. Menopausal women often have multiple health issues that need addressing and they may be anxious and tired due to sleep disturbance. Allowing adequate time for the consultation allows her to discuss the issues she is concerned about without feeling rushed.Perimenopause, Menopause or Postmenopause?Perimenopause refers to the time from the onset of menopausal symptoms (some or all of symptoms such as irregular periods, hot flushes, night sweats or sleep disturbance) to 12 months after the last menstrual period1. This can last on average 4 to 8 years. Menopause is the last menstrual period. One year after the last menstrual period the woman is considered "postmenopausal". Peri-menopausal symptoms can occur when periods are still regular, but typically the symptoms worsen in the premenstrual days. The symptoms experienced during the perimenopause are often the most distressing. Menstrual changes are common and it is normal to have periods that are less frequent or irregular. More frequent periods or those that are very heavy may not be normal and suggest that there may be pelvic or systemic pathology.Women older than 40 years with more frequent or heavy bleeding, or intermenstrual bleeding require investigation by their doctor. Hormone levels may fluctuate during this time and measurement of sex steroids is rarely clinically helpful once the diagnosis has been made2. At this time of hormone fluctuation, oestradiol can actually briefly be higher than normal, giving symptoms of excess oestrogen, such as breast tenderness. Explaining to women that, at a time when their body is running out of oestrogen, they may get brief periods of high oestrogen symptoms is useful. (Some women are told that because of these brief periods of high oestrogen they need progesterone treatment but there is no evidence that this is needed). Eventually, symptoms of oestrogen deficiency predominate.Menopause is said to have occurred when there has been no menstruation for one year. If a woman has taken MHT since she was peri-menopausal, it may not be possible to assess the exact age at which she became menopausal. This may also impact on the advice provided about perimenopausal contraception (see AMS information sheet Contraception) If a woman has required peri-menopausal MHT for symptoms, it is a reasonable guess to expect her to be post-menopausal after 4-5 years.PostmenopauseThis starts one year after the last menstrual period. There is no reliable way of predicting how long menopausal symptoms will continue. For many women they resolve within 2-5 years. Ten to 20% of women will have symptoms for up to 12 years. Vaginal dryness and urinary frequency may start during the peri-menopause and tend not to resolve naturally with time. Some women only experience vaginal dryness during sexual activity and others are aware of uncomfortable vaginal symptoms at other times.For those symptomatic women who elect to use MHT, we advise that they be reviewed annually to evaluate ongoing care and the need to continue MHT.Premature menopausePremature menopause is considered to have occurred if a woman is younger than 40 when she becomes menopausal. About 1% of women experience a spontaneous premature menopause (POI or premature ovarian insufficiency) and around another 6% have premature menopause due to surgery, chemotherapy or radiation. There has been relatively little research on symptoms in these women, but it seems that their menopausal symptoms may be more severe than in older women, particularly when menopause occurs due to surgery or chemotherapy. There are also distinct personal, sexual, social and psychological issues for younger women, particularly for those women who wish to have children but have not yet started or completed their families. These women need extra counselling, and time to come to terms with their situation. This is the one time that measuring and finding a high FSH and a low oestradiol is helpful to differentiate between menopause and other causes of secondary amenorrhoea.POI is a pathological condition associated with an increased risk of osteoporosis and fracture, an increased risk of cardiovascular disease, possible cognitive impairment, Parkinson’s disease and reduced life expectancy. It is conventional to treat with MHT at least until the average age of the menopause.There are 3 main identifiable causes of POI: genetic, autoimmune and iatrogenic3Genetic conditions include a strong maternal family history, 45,X, 46,XX and46,XY POI.POI is associated with galactosemia and FMR premutations (e.g., Fragile X)Women with an autoimmune predisposition may develop autoimmune POI, with or without other autoimmune diseases (diabetes mellitus, Addison's, thyroid).Women with iatrogenic menopause includes women with benign disease and those having treatment for cancer (hormonal, chemotherapy and/or radiotherapy) which has brought about an early menopause. In most women the cause of an early menopause is unknown.Early menopause affects 3.7% of African-American women, 2.9% of white women, 2.2% of Chinese women and 0.8% of Japanese women4. About 1 in 1000 women are affected under the age of 305.Lower socioeconomic status has been associated with POI.The measurement of FSH and oestradiol should be repeated at least once (See AMS information sheets Early Menopause Due to Chemotherapy and Spontaneous Premature Ovarian Insufficiency).Symptom assessment and diagnosis at Perimenopause and MenopauseThe time when most women are trying to understand what is happening to them is during the peri- menopause. During this time of hormonal fluctuation women may experience some, but not all of the symptoms listed in the table. For instance, she may come with severe joint aches and tiredness, which may be suggestive of a rheumatological disease. Checking a symptom score will often reveal many more unreported menopausal symptoms.In most cases, recording a symptom score helps to make the diagnosis, at the same time educates the woman and is a basis for assessing efficacy of treatment. Checking FSH or AMH levels or serum oestradiol and progesterone are unnecessary tests in diagnosing menopause for most women.  Checking an androgen profile as a routine on all peri-menopausal women is also unnecessary and costly. Many women come to the consultation expecting a blood test to diagnose menopause, and it is important to explain to them why we use the symptom score rather than a blood test in establishing a diagnosis. It is important to explain to women that the blood tests of FSH/oestradiol can fluctuate on a daily basis and therefore are not useful or necessary. It is especially unhelpful to do hormone blood tests while women are on MHT/OCP – symptoms, not blood levels, guide therapy. Treat the symptoms, not the biochemistry.Symptom score sheetThe Modified Greene Scale6 (see below) can be completed together with the woman, or she can do it herself in the waiting room. The woman judges the severity of her own symptoms and records the score - 1 for mild, 2 for moderate, 3 for severe and 0 if she does not have that particular symptom. A score of 15 or over usually indicates oestrogen deficiency that is intrusive enough to require treatment, but this is only a guide. Women are very variable in their tolerance of discomfort, often tolerating quite severe symptoms before they will even consider taking MHT. Scores of 20-50 are common in symptomatic women, and with adequate treatment tailored to the individual, the score will reduce to 10 or under in 3-6 months.Using the symptom score sheet at subsequent follow-up visits is a useful method of judging whether adequate oestrogen is being taken to alleviate symptoms. Generally, there is a halving of the symptom score after 2-3 months on MHT and if the woman is still experiencing a lot of symptoms, she may require a dose increase. If symptoms still persist, changing from the oral route to transdermal may help if the problem is oestrogen malabsorption.If it's not menopause, what is it?Depression, anaemia and thyroid disorders are the most common conditions that may occur concurrently. Unstable diabetes and hyperthyroidism may cause hot flushes. Medication, such as the SSRI family of anti-depressants, may also cause hot flushes.Doing a blood count, ferritin and/or a TSH level will usually establish the diagnosis. However, if a woman presents with low mood or anxiety, there is a need to evaluate whether this is a primary anxiety/depression or one aggravated by the lack of oestrogen. A previous history of depression or an elevated FSH may help to differentiate between the two. Hair loss may be a sign of iron deficiency or hypothyroidism rather than menopause.Need more information?Diagnosing menopause is something that most GPs are skilled at doing and helping women at this difficult stage of their life can be very rewarding. If you are reading this information sheet because you have inadequate knowledge on how to counsel menopausal women, then consider joining the Australasian Menopause Society and receiving its monthly newsletter, called eChanges. Attend one of our annual meetings, which aim to be of interest to a wide range of doctors, nurses, psychologists and physiotherapists.ReferencesMcKinlay SM et al. The normal menopause transition. Maturitas 1992;14:103.Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause Int 2011;17:153.?ükür, Y[anuz]. E., K?vançl?, ?. B., & Özmen, B. Ovarian aging and premature ovarian failure. Journal of the Turkish German Gynecological Association, 2014;15(3):190.Green R et al. Menopausal Symptoms and Ethnicity: the Study of Women’s Health across the Nation. Womens Health (Lond). 2009;5(2):127-33Coulam CB et al. Incidence of Premature Ovarian Failure. Obstet Gynecol 1986;67(4):604-606Greene JG. Constructing a standard climacteric standard. Maturitas 1998;29:25-31 Symptom Score (Modified Greene Scale)

Download: What is menopause? | Information Sheet  Key PointsThe term "menopause" refers to the final menstrual period. The average age of menopause in Australian women is 51 years (normal range 45-55).Surgical menopause refers to menopause as a result of bilateral oophorectomy.Natural menopause occurs due to loss of ovarian follicles, follicular development and thus hormone production. The resulting oestrogen withdrawal leads to varying clinical effects.The perimenopause (time period preceding the menopause to one year after the menopause) is characterised by hormonal fluctuation, anovulatory cycles and onset of cycle irregularity and menopausal symptoms.Common symptoms of menopause include vasomotor symptoms (hot flushes and night sweats) and urogenital symptoms. However, multiple other symptoms may be experienced.Menopause is associated with adverse metabolic and bone changes leading to an increased risk of cardiovascular disease and osteoporosis.The diagnosis of the menopause is usually a clinical diagnosis in women over 45 who have not had a hysterectomy.Management requires a comprehensive assessment to formulate an individualised treatment plan.Definition of menopauseThe word menopause refers to the last or final menstrual period. When a woman has had no periods for 12 consecutive months, she is considered to be postmenopausal. At menopause, loss of ovarian follicles, follicular development and ovulation results in cessation of cyclical oestrogen and progesterone production.Most women become menopausal naturally between the ages of 45 and 55 years, with the average age of onset at around 51 years. Surgical menopause refers to menopause as a result of bilateral oophorectomy. Premature menopause or premature ovarian insufficiency may occur before the age of 40 due to natural ovarian function ceasing, following surgery to remove the ovaries, or as a result of chemo/ radiotherapy. Menopause is considered “early” when it occurs between 40 and 45 years. See AMS information sheets Early menopause due to chemotherapy and radiotherapy, Spontaneous Premature Ovarian Insufficiency and Surgical Menopause.Now that women live around one third of their lives after menopause, optimising physical and mental health during this period is becoming more important.What is perimenopause (the menopausal transition)?The perimenopause is the time period preceding the menopause to one year after the menopause, and is characterised by hormonal fluctuation, anovulatory cycles and onset of cycle irregularity and symptoms. The menopause transition is the time period leading up to the final menstrual period1. Hallmarks of the perimenopause are changes in a woman’s menstrual periods such as, irregular periods or changes in flow. Cycles can be shorter or longer in length. Symptoms may also include hot flushes and night sweats, aches and pains, fatigue or irritability, as well as premenstrual symptoms such as sore breasts. Although women may be experiencing irregular menstrual cycles and anovulation, pregnancy can occur and contraception is required. Some women can experience menopausal symptoms for 5-10 years before their final menstrual period. Age at which a woman’s menopausal symptoms will start or how long they will last, is not able to be predicted2. See AMS information sheets Perimenopause or Menopausal Transition and Contraception.Physical symptoms and changes of menopauseCessation of physiological production of oestrogen at the menopause may result in sequelae ranging or ‘raging’ from unpleasant to pathological. Only 20% of women report no menopausal symptoms. Typical symptoms commonly reported by peri- and postmenopausal women include hot flushes, night sweats and sleeping difficulties, bodily aches and pains, dry skin, vaginal dryness, loss of libido, urinary frequency, and mood and memory changes. Some women may have unwanted hair growth, itchiness of the scalp, thinning of scalp and pubic hair and skin changes3. Multiple biopsychosocial factors impact menopausal symptoms including cause of menopause, woman’s age, psychological and physical health, attitude to menopause, ethnicity and education levels.Vasomotor symptoms (hot flushes and sweats)Hot flushes and night sweats are the hallmarks of menopause, occurring in approximately 75% of postmenopausal women, with 25% of these being severely affected. The percentage of women reporting hot flushes varies across countries and ethnic backgrounds. Symptoms may resolve in 2–5 years but the median duration is 7 years.A hot flush is a subjective sensation of extreme heat associated with objective signs of cutaneous vasodilation and a subsequent drop in core body temperature. Women with oestrogen deficiency have a narrower thermoneutral zone. They have sensations of extreme heat despite a small increase in core body temperature. Peripheral vasodilation and sweating help to dissipate heat. Recent literature describes the hypertrophy of KNDY neurons in the hypothalamus in postmenopausal women. These neurons express Neurokinin B which appears to induce hot flushes4.Vasomotor instability in the menopause is a major contributing factor to disturbed sleep at menopause, adversely affecting quality of life, relationships, careers, and wellbeing. Vasomotor symptoms may also be a marker of cardiovascular disease with greater severity and earlier onset of vasomotor symptoms being of greater relevance5. See AMS information sheet Menopause and Sleep.Genitourinary Syndrome of the MenopauseUrogenital symptoms associated with menopause, referred to as genitourinary syndrome of menopause or vulvovaginal atrophy are common but often “suffered in silence” as women may be reluctant to disclose these symptoms. Symptoms include vaginal dryness, burning, irritation, decreased lubrication with sexual activity, dyspareunia and an increased risk for urinary tract infections. Thinning of pubic hair, loss of the labial fat pad, thinning and resorption of the labia minora, reduced vaginal calibre and changes in the vaginal mucosa all occur as a result of oestrogen depletion in the menopause. These symptoms frequently persist in older women after vasomotor symptoms have resolved. See AMS information sheets Genitourinary Syndrome of Menopause and Sexual difficulties in the menopause.Psychological and cognitive symptoms of menopauseHormonal changes, vasomotor symptoms and sleep deprivation can contribute to mood changes, anxiety, irritability, forgetfulness, and trouble concentrating or making decisions. Women often complain of “brain fog” or brain fade6. There is a 50% decrease in serotonin (a chemical that regulates mood, emotions and sleep) after the menopause with declining oestrogen levels. Depression is not more common at menopause than at other stages of life, but a past history of depression, particularly post-natal depression, and stress during the peri-menopause may make a woman more likely to succumb to mood problems. See AMS information sheets Mood and the menopause and Oestrogen and cognition in the perimenopause and menopause.Skin ChangesOestrogen increases production of glycosaminoglycans, promote sebum production, increase water retention and improve barrier function of the stratum corneum and menopause is therefore associated with dry skin. Degradation of elastin and a reduction in the microvasculature and thinning of the epidermis also occurs. There is a reduction in axillary and pubic hair. Some women complain of pruritis (itching) while others have a feeling of ants crawling on their skin (formication).Muscle and boneAgeing and menopause contribute to decline in muscle mass and strength in postmenopausal women. The menopausal transition is associated with a decline in oestrogen, growth hormone, IGF-1, and DHEA, a decrease in muscle protein synthesis, and an increase in inflammation. However, low physical activity, protein intake (<0.8 g/kg/day) and elevated oxidative stress are the greatest contributors of sarcopenia in postmenopausal women.Osteoporosis is a systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue leading to enhanced bone fragility, and a consequence increase in fracture risk7. Oestrogen prevents bone loss and may restore lost bone and limits excess osteoclastic resorption. Thus, the risk of osteoporosis is increased in postmenopausal women, where one in three women after the age of 50 experience a fragility fracture. Fragility fractures are the fourth leading cause of chronic disease and morbidity. Mortality rates of up to 25% occur in the first year after a hip fracture. All postmenopausal women should have a clinical osteoporosis risk assessment8,9. See AMS information sheets Osteoporosis and Prevention of falls and fractures.Metabolic changesDecline in oestrogen levels with menopause, combined with ageing, leads to metabolic changes which increase the risk of cardiovascular disease, the leading cause of death in women5,10,11. Increased visceral fat, adverse changes in lipids and blood vessels, endothelial dysfunction, increased insulin resistance, increased blood pressure and activation of the renin-angiotensin pathway contribute to atherosclerosis10.How is menopause diagnosed?The diagnosis of the menopause is a clinical diagnosis in women over 45 years based on a woman’s symptoms and changes in menstruation. The diagnosis is obvious where a woman has had her ovaries removed surgically.A symptom score sheet can be a useful way to determine what symptoms a woman is experiencing and whether any treatment is indicated (See AMS Symptom Score Card).Measurement of FSH to diagnose perimenopause or menopause is not usually indicated. A single hormone test, such as a measurement of elevated follicle-stimulating hormone (FSH) is not a reliable indicator of the perimenopause, as women’s hormone levels may fluctuate from day to day. However, investigations may be required in certain cases including: (i) if the woman has had a hysterectomy; (ii) concern that symptoms may be due to illness (e.g., thyroid disorder rather than natural ageing); or (iii) if woman is under 45 years of age. See AMS information sheet Diagnosing menopause).How can symptoms be handled?Managing menopause requires a comprehensive assessment including symptoms, risk of chronic disease, lifestyle and appropriate screening and development of an individualised plan incorporating the woman’s treatment goals and risk: benefit analysis. Management options include: lifestyle measures, non-pharmacological, contraception, non-hormonal and menopausal hormone therapies13. The AMS Symptom Score Card can assist in assessing response to treatment. AMS information sheets are available describing these options in detail (see AMS Information sheets:Lifestyle and behaviour modifications for menopausal symptomsWeight management and healthy ageingCombined menopausal hormone therapyOestrogen only menopausal hormone therapyRisks and benefits of MHT/HRTVenous thrombosis/thromboembolism risk and menopausal treatmentsNonhormonal treatments for menopausal symptomsComplementary Medicines and Therapies for Hot FlushesBioidentical custom compounded hormone therapy is not recommended (see AMS information sheet Bioidentical custom compounded hormone therapy).Feeling positive about the menopauseWomen may experience physical and emotional changes during menopause but that doesn’t mean life has taken a turn for the worse! Many women are prompted at this time to ‘take stock’ of their lives and set new goals. The menopause occurs at a time when many women may be juggling roles as mothers of teenagers, as carers of elderly parents, and as members of the workforce. Experts suggest that creating some ‘me time’ is important to maintain life balance. Menopause can be seen as a new beginning: it’s a good time to assess lifestyle, health and to make a commitment to strive for continuing wellbeing in the mature years.ReferencesMcKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas 1992;14:103.Greene JG. Constructing a standard climacteric standard. Maturitas 1998; 29:25-31Avis NE, Crawford SL, Greendale G et al. Study of Women’s Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-9Rance NE, Krajewski SJ, Smith MA et al. Neurokinin B and the hypothalamic regulation of reproduction. Brain Res. 2010;1364:116-128.Zhu D, Chung HF, Dobson AJ, Pandeya N, Giles GG, Bruinsma F, Brunner EJ, Kuh D, Hardy R, Avis NE, et al. Age at natural menopause and risk of incident cardiovascular disease: a pooled analysis of individual patient data. Lancet Public Health. 2019;4(11):e553–64.Freeman, E.W. Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population. Womens Midlife Health 1, 2 (2015). https://womensmidlifehealthjournal.biomedcentral.com/articles/10.1186/s40695-015-0002-yWorld Health Organization. Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis Assessment of fracture risk and its application for postmenopausal osteoporosis: report of a WHO study group. WHO Technical Report Series 843Langer RD, Hodie Mn, Lobo RA & Allison MA. Hormone Replacement Therapy – Where Are We Now? Climacteric 2021 24:1, 3-10. DOI:10.1080/13697137.2020.1851183Stuckey B, Magraith K, Opie N et al. Fracture risk prediction and the decision to treat low bone density. AJGP 2021: 50,3: 165-170.Patterson R, McNamara E, Tainio M et al. Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality and incident of type 2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol. 2018;33:811-829. Doi:10.107/s10654-018-0380-1Boardman HM, Hartley L Eisinga EA et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev. 2015CD002229. doi:10.1002/14651858.CD002229Khoudary SR, Aggarwai B, Beckie TM et al. Menopause Transition and cardiovascular disease risk: Implications for timing of early prevention: A scientific statement from the American Heart Association. Circulation 142:26;506-532.Daan NM, Fauser BC. Menopause prediction and potential implications. Maturitas. 2015;82(3):257–65

Menopausal hormone therapy is the most effective treatment for menopausal symptoms and, for most women, the benefits of symptom control outweigh the potential harms of therapy.

Download: Surgical Menopause | Information Sheet Key pointsRemoval of both ovaries (bilateral oophorectomy) before a woman has gone through her natural menopause is referred to as “surgical menopause”Bilateral oophorectomy may be performed at the time of hysterectomy for benign disease or gynaecological cancers, or as part of risk reduction treatment in women with an inherited increased cancer riskNegative effects of surgical menopause include a sudden onset of severe menopause symptoms, loss of fertility, and increased risks of osteoporosis, cardiovascular disease, sexual dysfunction, mood disorders and cognitive issuesMenopausal hormone therapy (MHT) is advised for all women who undergo surgical menopause before the age of natural menopause, provided they do not have contraindications to MHT use.What is surgical menopause?Menopause refers to the final menstrual period. The average age of menopause in Australia is around 51 years, but most women start to experience perimenopausal symptoms due to decreasing ovarian oestrogen levels from their mid-40s, starting with a change to their menstrual cycles (1). Surgical removal of both ovaries (bilateral oophorectomy) before the average age of natural menopause is referred to as surgical menopause. Earlier menopause may also occur due to other gynaecological procedures, such as uterine artery embolisation, hysterectomy with ovarian conservation, or ovarian cystectomy, presumably due to compromised ovarian blood supply (2,3).Indications for bilateral oophorectomyBilateral oophorectomy (usually with bilateral salpingectomy) is uncommonly performed at the time of hysterectomy for benign disease in premenopausal women, e.g. for management of heavy menstrual bleeding (4).A more common indication for this procedure is to reduce the risk of ovarian cancer; this is especially relevant and beneficial to women who carry an inherited increased risk of developing cancer due to gene mutations in BRCA or HNPCC (Lynch Syndrome), for example (5). In general, bilateral oophorectomy is not recommended for premenopausal women who are concerned about ovarian cancer risk but have no inherited increased risk, as the disadvantages of removing normal, healthy ovaries prior to the average age of menopause far outweigh the very small risk of ovarian cancer (6).Some premenopausal women may elect to have their ovaries removed for other indications, such as endometriosis, persistent pelvic pain, and premenstrual dysphoric disorder. Their healthcare provider may suggest a trial of medically-induced menopause prior to surgery for these women, both to test how surgical menopause may affect their underlying symptoms, and also to allow a trial of MHT to test for patient tolerance to the hormone therapy (7).Positive effects of surgical menopauseReduced risk of ovarian cancer in women who are at an increased risk due to inherited genetic mutationsReduced anxiety around developing ovarian cancer in this populationReduced symptoms of persistent pelvic pain, particularly in women with endometriosis or pelvic adhesions who have ovarian involvementReduced symptoms of premenstrual dysphoric disorderNegative effects of surgical menopauseSudden and severe onset of vasomotor symptoms (VMS) and genitourinary syndrome of the menopause (GSM)Loss of bone density and increased risk of osteoporosis and possibly fractures (8)Increased risk of cardiovascular disease and an associated increase in mortality risk (9,10)Increased risk of cognitive impairment, including dementia (11,12)Impaired sexual function due to GSM symptoms, and hypoactive sexual desire disorder (HSDD) due to loss of ovarian testosterone production (13)Increased long-term risk of depression and anxiety (14)Loss of fertility potentialManagement of surgical menopauseIdeally, a menopause specialist should review premenopausal women prior to them undergoing bilateral oophorectomy, to explain the potential adverse consequences of surgical menopause and to plan for symptom management and long-term health optimisation (2).Lifestyle management and ongoing monitoringEvidence-based lifestyle management strategies for reducing cardiovascular and cognitive risk, and for maintaining bone density, should be discussed. These may include advice around diet, exercise, smoking and alcohol, and ensuring adequate sleep and dietary calcium and vitamin D intake. Cardiovascular risk factors should be assessed annually. In Australia, women who are under the age of 45 who have been hypogonadal for 6 months or more are entitled to Medicare bone density scans, which should be performed every 2 years.Symptom managementCurrent international guidelines recommend the use of MHT for all women who undergo early menopause, even if they have minimal menopausal symptoms, provided that they do not have any contraindications to use (3, 15, 16). MHT should be commenced as soon as possible post-operatively, reviewed within 6-12 weeks for symptom response, and continued at least until the average age of menopause. MHT is highly effective at treating VMS and GSM in this population, although higher oestrogen doses may be required in younger women than that used at the average age of menopause, to achieve physiological doses of oestradiol (3, 15). MHT can be commenced at a standard dose and titrated up according to response and side-effects. MHT can be prescribed to women who have had a bilateral oophorectomy performed for cancer risk reduction, and who have no contraindications to its use, without increasing their risk of breast cancer (17). Most guidelines recommend changing these patients to non-hormonal treatments for VMS if they are still required beyond the age of natural menopause, although there is minimal evidence for this recommendation (16, 18).A progestogen needs to be used in women who retain their uterus and should be considered for women with a history of endometriosis, even if she has had a hysterectomy, due to concerns about disease and symptom recurrence (19). Tibolone may also be considered as MHT for women with a history of endometriosis (2). Given that higher oestrogen doses may be required for symptom management in younger women, correspondingly higher doses of a progestogen may also be necessary (3).Prevention of morbidity and mortalityWhile a lack of longitudinal outcome data currently exists for this population, MHT has been shown in observational studies to reduce risks of osteoporosis and fracture, cardiovascular morbidity and mortality, and cognitive issues (16). Observational data show a probable “window of opportunity” for MHT initiation early after surgical menopause, especially to mitigate cardiovascular and cognitive risk (3).Management of sexual dysfunction and psychosocial risksThe sexual and psychological dysfunction arising after surgical menopause is complex and is likely to arise not only due to hormonal changes but also due to potential early ageing, self-esteem and body-image issues, emerging mood disorders and concerns around loss of fertility (3). As such, a biopsychosocial model is often required for the management of both sexual and psychological concerns after surgical menopause.MHT may improve some aspects of sexual dysfunction and vaginal oestrogen or dehydroepiandrosterone can be added to systemic MHT to further improve GSM symptoms (15). In addition, for women with HSDD despite MHT use, testosterone therapy can be considered, but women need to be advised that long-term efficacy and safety are unknown (16, 20). Note that currently there is conflicting evidence for use of testosterone for other indications in patients with early menopause, specifically for neurological function, bone health and cardiovascular health (16).With regards to the increased long-term risk of a diagnosis of depression and/or anxiety following surgical menopause, given that these risks have only been identified in observational studies, it is unclear whether or not MHT use mitigates these risks (14).Further informationA Practitioner’s Toolkit for Managing MenopauseAMS guide to MHT/HRT doses – AustraliaAMS guide to MHT/HRT doses - New ZealandPremature ovarian insufficiency: International Menopause Society White Paper:Surgical menopause: a toolkit for healthcare professionals (British Menopause Society)ReferencesHarlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ; STRAW 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. Menopause 2012; 19(4): 387-95.Hamoda H, Sharma A. Premature ovarian insufficiency, early menopause, and induced menopause. Best Practice & Research Clinical Endocrinology & Metabolism 2024; 38: 101823.Panay N, Anderson RA, Nappi RE, Vincent AJ, Vujovic S, Webber L, Wolfman W. Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric 2020; 23(5): 426-46.Hickey M, Ambekar M, Hammond I. Should the ovaries be removed or retained at the time of hysterectomy for benign disease? Human Reproduction Update 2009; 16(2):131-41.Rebbeck TR, Kauff ND, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo-oophorectomy in BRCA1 or BRCA2 mutation carriers. Journal of the National Cancer Institute 2009; 101(2):80-87.Parker WH, Shoupe D, Border MS, Liu Z, Farquhar C, Berek JS. Elective oophorectomy in the gynaecological patient: when is it desirable? Current Opinion in Obstetrics and Gynecology 2007; 19(4):350-54.Green LJ, O'Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. British Journal of Obstetrics and Gynaecology 2017; 124: e73–e105.Gallagher JC. Effect of early menopause on bone mineral density and fractures. Menopause 2007; 14:567-71.Honigberg MC, Zekavat SM, Aragam K, Finneran P, Klarin D, Bhatt DL, Januzzi Jr JL, Scott NS, Natarajan P. Association of premature natural and surgical menopause with incident cardiovascular disease. Journal of the American Medical Association 2019; 322(24):2411-21.Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton LJ 3rd. Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncology 2006; 7(10):821-8.Bove R, Secor E, Chibnik LB, Barnes LL, Schneider JA, Bennett DA, De Jager PL. Age at surgical menopause influences cognitive decline and Alzheimer pathology in older women. Neurology 2014;82(3):222-9.Rocca WA, Bower JH, Maraganore DM, Ahlskog JE, Grossardt BR, de Andrade M, Melton LJ 3rd. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology 2007;69(11):1074-83.Nappi RE, Cucinella L, Martini E, Rossi M, Tiranini L, Martella S, Bosoni D, Cassani C. Sexuality in premature ovarian insufficiency. Climacteric 2019;22(3):289-295.Rocca WA, Grossardt BR, Geda YE, et al. Long-term risks of depressive and anxiety symptoms after early bilateral oophorectomy. Menopause 2018; 25:1275-85.Hamoda H in collaboration with the medical advisory council of the British Menopause Society. Premature ovarian insufficiency (Consensus Statement). Reviewed 2024. Premature ovarian insufficiency - British Menopause Society (thebms.org.uk)The ESHRE Guideline Group on POI, Panay N, Vincent AJ et al. ESHRE Guideline: management of women with premature ovarian insufficiency, 2024. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Premature-ovarian-insufficiencyGordhandas S, Norquist BM, Pennington KP, Yung RL, Laya MB, Swisher EM. Hormone replacement therapy after risk reducing salpingo-oophorectomy in patients with BRCA1 or BRCA2 mutations; a systematic review of risks and benefits. Gynecologic Oncology 2019;153:192-200.Gard A, Robinson L in collaboration with the medical advisory council of the British Menopause Society. Surgical menopause: a toolkit for healthcare professionals. Reviewed 2024. https://thebms.org.uk/wp-content/uploads/2021/06/13-BMS-TfC-Surgical-Menopause-JUNE202102B.pdfSecosan C, Balulescu L, Brasoveanu S, Balint O, Pirtea P, Dorin G, Pirtea L. Endometriosis in Menopause-Renewed Attention on a Controversial Disease. Diagnostics (Basel) 2020;10(3):134.Davis SR, Baber R, Panay N, Bitzer J, Cerdas Perez S, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Climacteric 2019;22(5):429-434.

Download: Practitioner’s Toolkit for the Management of the Menopause Developed by the Women’s Health Research Program in the Monash University School of Public Health and Preventive Medicine, in 2023 and updated in 2025.The supporting notes for the Practitioner’s Toolkit for Managing Menopause are published, with free access, in Climacteric, the journal of the International Menopause SocietyDownload the algorithms hereFrom the Women's Health Research Program which is part of the School of Public Health and Preventive Medicine Monash University.AbstractObjective: The Practitioner’s Toolkit for Managing the Menopause, developed in 2014, provided an accessible desk-top tool for health-care practitioners caring for women at midlife. To ensure the Toolkit algorithms and supporting information reflect current best practice, the Toolkit has been revised in accordance with the published literature.Methods: A systematic search for guidelines, position and consensus statements pertaining to the menopause and published after 2014 was undertaken, and key recommendations extracted from the Clinical Practice Guidelines determined to be the most robust by formal evaluation. The peer-reviewed literature was further searched for identified information gaps.Results: The revised Toolkit provides algorithms that guide the clinical assessment and care of women relevant to menopause. Included are the reasons why women present, information that should be ascertained, issues that may influence shared decision-making and algorithms that assist with determination of menopausal status, menopause hormone therapy (MHT) and non-hormonal treatment options for symptom relief. As clear guidelines regarding when MHT might be indicated to prevent bone loss and subsequent osteoporosis in asymptomatic women were found to be lacking, the Toolkit has been expanded to support shared decision-making regarding bone health.Conclusions: The 2023 Toolkit and supporting document provide accessible desk-top information to support health-care providers caring for women at midlife.The Toolkit has been endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean Hailes for Women’s Health

Access to this information sheet is reserved for members.  Log into view or Join Herefor instant access to member-only resources.   KEY POINTSMigraine is not a contraindication to using menopausal hormone therapyMigraine without aura is more sensitive to hormonal flux than migraine with auraFalling oestrogen commonly triggers the onset of a hormonally sensitive migraineMaintaining stable oestrogen levels is important and transdermal delivery is preferable