Menopause - clinical fact sheet and MCQ

Menopause is defined as the permanent cessation of menstruation due to loss of ovarian follicular function. It is characterised by hypoestrogenism and increased gonadotropins, resulting in systemic symptoms.

Perimenopause is the time from onset of cycle irregularity to 12 months after the final period.

Epidemiology

In Australia:

• the average age of menopause is 51.5 years (range is 45 to 55 years) 

• up to 10% experience early menopause (<45 years)

• about 1% experience premature ovarian insufficiency (POI) (before age 40)

Aetiology/risk factors

The primary cause of menopause is age-related ovarian follicle depletion. Other factors which may contribute to earlier timing of menopause include:

• genetic factors (eg familial POI)

• iatrogenic causes (eg chemotherapy, oophorectomy) 

• autoimmune disease

• smoking (advances menopause onset by 1–2 years)

• lower body mass index

• lower socioeconomic status

Clinical features of menopause

Typical symptoms include:

• vasomotor symptoms (VMS) (hot flushes, night sweats)

• urogenital symptoms (vaginal dryness, irritation, dyspareunia, urinary urgency)

• psychological (mood disturbance, anxiety, irritability)

• sleep disturbance

• decreased libido

• cognitive symptoms

Red flags

• Bleeding post-menopause

• Unexplained weight loss

• Severe depression or suicidality

• Age <45 (consider possibility of POI)

Differential diagnoses

• Thyroid dysfunction: symptoms overlap with vasomotor and mood changes

• Depression/ anxiety: may occur independently

• Drug-induced symptoms: eg from tamoxifen, SSRIs

Investigations

For women ≥45 years, diagnosis is clinical.

Consider investigations if:

• aged <45 with symptoms (FSH, estradiol on two occasions, four weeks apart)

• differential diagnosis is uncertain (TSH, Hb, ferritin, blood glucose)

1. Initial management

• Educate about the normal menopausal transition

• Discuss expectations, quality of life, and treatment goals

• Encourage lifestyle modification: smoking cessation, reduced alcohol, healthy weight, regular exercise
  
  

2. Pharmacological treatment

Menopausal hormone therapy (MHT)

MHT is the most effective treatment for vasomotor symptoms and urogenital atrophy. It also helps prevent bone loss and may improve sleep, mood, and joint pain in some women.

Non-hormonal treatments

• Neurokinin-3 receptor antagonists (eg fezolinetant) are a class of non-hormonal medications that modulate thermoregulatory pathways in the hypothalamus to reduce moderate to severe VMS and have recently been approved by the TGA for use in menopause

• Other non-hormonal medications which, although they have evidence to support their use for VMS, are prescribed off label, include SSRIs/SNRIs (eg, venlafaxine, paroxetine), gabapentin, pregabalin, and oxybutynin

3. Complementary and lifestyle therapies

• CBT can help both menopausal symptoms and mood

• Limited evidence for herbal remedies (eg, black cohosh, soy)

• Yoga and hypnosis show benefit in small trials

4. Monitoring and follow-up

• Annual review of symptom control and therapy risks

• Monitor BP, weight, breast health, and discuss screening adherence

Indications for referral

• Diagnostic uncertainty (eg atypical presentation, persistent symptoms)

• Suspected POI or early menopause

• Failure of primary care management

• History of hormone-sensitive cancer or complex medical background

Prognosis and follow-up

Symptoms typically last 4–7 years; 10% experience symptoms beyond 10 years. Untreated urogenital symptoms often persist. MHT improves quality of life and bone health but must be used judiciously. Patients may need to consider a trial of gradual reduction of their medication to assess whether their symptoms persist in the absence of treatment.

References

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Managing menopausal symptoms. 2020. (last accessed June 2025). 

Australasian Menopause Society. Non-hormonal Treatments for Menopausal Symptoms. 2024. (last accessed June 2025). 

S. R. Davis, S. Taylor, C. Hemachandra, K. Magraith, P. R. Ebeling, F. Jane &
R. M. Islam (2023) The 2023 Practitioner’s Toolkit for Managing Menopause. Climacteric.2023; 26(6):517-536.

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