Perimenopause - clinical fact sheet and MCQ

Overview

Perimenopause is the transitional phase leading up to and including menopause, during which a woman’s ovaries gradually produce less estrogen. It is defined as the time from onset of cycle irregularity to 12 months after the final period.  

Perimenopause is characterised by fluctuations in ovarian function and hormone levels. During this time, a woman may experience a range of physical and psychological symptoms. 

Menopause refers to the final menstrual period. It is a retrospective diagnosis made after 12 months of amenorrhoea. 

Stages of Menopause

Image reference Menopause—Biology, consequences, supportive care, and therapeutic options: Cell

Epidemiology 

In Australia: 

• the average age of menopause is 51 years, and most reach menopause between 45 to 55 years

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

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

Clinical features of peri/menopause 

Menopausal symptoms affect around 75% of women and are moderate to severe in 28%. They may begin during perimenopause and last 7-10 years on average. 

Typical symptoms include:

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

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

• psychological symptoms (mood disturbance, anxiety, irritability)

• sleep disturbance

• decreased libido

• cognitive symptoms 

The AMS symptom score card can be used to document symptoms and monitor response to treatments.
 

Investigations 

Perimenopause is usually diagnosed clinically on the basis of new onset vasomotor or other symptoms and a change in the pattern of menstrual bleeding. 

Consider investigations if:

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

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

Initial management

• Educate about the normal menopausal transition

• Discuss expectations, quality of life, and treatment goals

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

Pharmacological treatment 

Menopausal hormone therapy (MHT) 

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

MHT can also improve bone density and reduce fracture risk and is associated with a reduction in the risk of heart disease and type 2 diabetes in some women.  

Indications: 

• management of menopausal symptoms, including vasomotor and genitourinary symptoms , sleep disturbance

• prevention/management of low bone density and osteoporosis 

• treatment of POI (continue until at least age 50)

• MHT is also generally recommended for women aged 40-45 years with early menopause 

Contraindications to systemic MHT:  

• history of hormone-sensitive cancer (eg, breast, endometrial)

• unexplained vaginal bleeding

• active VTE disease/thrombophilia

• untreated/uncontrolled cardiovascular disease

• severe active liver disease 

Formulations and route 

This clinical guide outlines MHT prescribing principles.  

• Combined MHT (estrogen + progestogen): for women with an intact uterus to reduce endometrial hyperplasia risk

• Estrogen-only MHT: for women post-hysterectomy (unless history of moderate to severe endometriosis) 

• Estrogen can be delivered orally or transdermally (patch, gel)

  • Transdermal is preferred for women at higher risk of thromboembolic events or with metabolic/liver disorders

  • Patients with history of migraine may also benefit from transdermal delivery as it maintains a more stable supply of estrogen, avoiding the fluctuating serum oestradiol levels, which can be a migraine trigger in the perimenopausal years

• Progesterone can be delivered either via an intrauterine device (Mirena), orally, or as a transdermal patch

• Perimenopausal women experiencing intermittent menses or those very recently postmenopausal benefit from cyclical oral progesterone (14 days on, 14 days off) to prevent breakthrough bleeding 

• For women who are postmenopausal, continuous progesterone is appropriate

• Breakthrough bleeding may occur in the first three to six months of any MHT regimen, but any unscheduled bleeding after that should be investigated

• It is important to advise women that MHT does not provide contraception due to the lower doses of estrogen and progesterone (the exception would be women who are using a Mirena device for endometrial protection)

• For women <50 who are still having periods, a low-dose combined oral contraceptive pill (COCP) may be an appropriate option to both manage their symptoms and provide adequate contraceptive cover  

See the AMS Guide to MHT/HRT Doses - Australia | Information Sheet | Australasian Menopause Society Hub for a list of MHT products available in Australia. 

Dosing principles

• Start low and titrate to symptom relief

• No standard duration; use the lowest effective dose for the shortest period consistent with treatment goals

• Annual review is essential to reassess risks, benefits, and treatment goals 
  

Breast cancer and thromboembolism risk 

• Combined MHT is associated with a very small increase in breast cancer risk, increasing with age at initiation and duration of use

• Estrogen-only MHT may have a lower breast cancer risk compared to combined MHT

• Oral MHT carries a higher risk of thromboembolism; transdermal preferred in higher-risk women

• For most women, the benefits of MHT outweigh the risks, with the lowest risk when started before the age of 60, or within 10 years of menopause; annual review should occur to determine need for ongoing use  

Monitoring 

Once treatment has been established, annual review is recommended to establish the indications and ongoing need for treatment along with individual risks and benefits. This should include: 

• review of efficacy and tolerability 

• review of blood pressure, BMI, and other CV risk factors

• mammography and cervical screening per national screening guidelines

• a trial of lower dose MHT or cessation can occur if the need for treatment is uncertain 

There is no specific recommended duration for MHT. Continuation should be based on consideration of benefits and harms at each yearly review.   

Special considerations 

• Women with early or surgical menopause are generally advised to take MHT until at least the age of 50 years for symptom control and long-term health protection

• Testosterone transdermal cream is commonly promoted as an option to improve mood or energy levels; however, the only evidence-based indication is for the treatment of hypoactive sexual desire dysfunction (HSDD) in postmenopausal women  

Management of genitourinary syndrome of menopause (GSM) 

• Vaginal estrogen therapy effectively treats GSM (vaginal dryness, dyspareunia, urinary frequency and urgency, and recurrent UTIs) but does not treat vasomotor symptoms

• Vaginal estrogen can be used alongside systemic MHT when GSM persists despite systemic treatment

• Vaginal estrogen is considered safe for most women, including those with a history of breast cancer (in consultation with oncology)

• Prasterone (vaginal DHEA) has weak estrogenic and androgenic effects; there are no head-to-head trials with vaginal estrogen and safety data in women with a history of breast cancer is limited

• Non-hormonal vaginal moisturisers and lubricants are useful for vaginal dryness

Non-hormonal treatments for vasomotor symptoms 

• Fezolinetant: 

  • neurokinin-3 receptor antagonist 

  • modulates thermoregulatory pathways in the hypothalamus 

  • TGA-listed for moderate to severe VMS

  • requires LFT monitoring monthly for the first 3 months, then at 6 and 9 months 

• Other non-hormonal medications include SSRIs/SNRIs (eg venlafaxine, paroxetine), gabapentin, pregabalin, and oxybutynin; there is limited evidence to support their use for VMS and use is off-label  
  

Complementary and lifestyle therapies 

• Cognitive behavioural therapy can help both menopausal symptoms and mood

• Yoga and hypnosis show benefit in small trials

• Limited evidence for herbal remedies (see AMS factsheet) 

Indications for specialist 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 

References 

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Managing menopausal symptoms. 2020. Available at: https://ranzcog.edu.au/wp-content/uploads/Managing-Menopausal-Symptoms.pdf. (last accessed June 2025).  

Australasian Menopause Society. Non-hormonal Treatments for Menopausal Symptoms. 2024. Available at: https://www.menopause.org.au/images/stories/infosheets/docs/AMS_Nonhormonal_Treatments_for_Menopausal_Symptoms.pdf. (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.

Therapeutic Guidelines. Overview of menopause. Therapeutic Guidelines. 2025. Available from: https://app-tg-org-au.ap1.proxy.openathens.net. (last accessed Jul 2026).

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