This updated guideline offers best practice recommendations for the care of women with with both primary and secondary premature ovarian insufficiency (POI). POI is a clinical condition defined by the loss of ovarian function indicated by irregular menstrual cycles together with biochemical confirmation of ovarian insufficiency before the age of 40.

Women with POI have unique needs. They may not only suffer from symptoms associated with estrogen deficiency, but can also experience other issues, with a significant impact on their quality of life and later health outcomes. POI can have significant effects on fertility, bone health, cardiovascular health, sexual function, psychological health and neurological function.

The impact of POI on these different domains and the treatment options for each along with monitoring needs where relevant are all discussed in the guideline.

In addition to hormone therapy the guideline also covers non-hormonal and complementary treatments, lifestyle interventions and puberty induction.

 ESHRE Guideline on premature ovarian insufficiency - full version15.76 MB

Health Professional resources

Healthcare professional toolkit

This resource is for intended healthcare professionals (HCPs) including primary care, endocrinologists and gynaecologists. It may also be helpful for other HCPs such as psychologists, nurse practitioners and physical therapists.

This resource aims to:

• increase awareness of premature ovarian insufficiency
• facilitate recognition and prompt diagnosis of POI
• encourage shared decision making between those with POI and their HCP
• provide HCPs with tools to provide evidence-based best practice care of people with POI and reduce care variation

POI GUIDELINE_HCP Toolkit PDF6.05 MB

Content created February 2025  

There are AMS Information Sheets that will assist you in providing an explanation to your patients.

Are there natural treatments for menopausal symptoms?

• Complementary Medicines and Therapies for Hot Flushes
• NonHormonal Treatments for Menopausal Symptoms

What alternative treatments are available for menopause symptoms?

• Complementary Medicines and Therapies for Hot Flushes
• NonHormonal Treatments for Menopausal Symptoms

Is HRT (hormone replacement therapy) safe?

• Treating the Menopause – the Concept of Risk and Benefit
• Venous thrombosis/thromboembolism risk and menopausal treatment

How long does menopause last?

• What is menopause?
• Genitourinary syndrome of menopause

Does menopause cause weight gain?

• Weight management and healthy ageing

Will HRT reduce night sweats and hot flushes?

• Complementary Medicines and Therapies for Hot Flushes
• NonHormonal Treatments for Menopausal Symptoms
• Mood and the menopause

What treatments are available for menopause?

• Menopause – Combined Hormone Replacement Therapy
• Menopause – Oestrogen Only Therapy
• NonHormonal Treatments for Menopausal Symptoms

When does menopause occur?

• Diagnosing Menopause
• Glossary of Terms
• Surgical Menopause
• What is menopause?

Does menopause affect every woman?

• What is menopause?

What are the signs and symptoms of menopause? 

• Diagnosing Menopause

What is menopause? 

• Diagnosing Menopause
• Glossary of Terms
• Surgical Menopause
• What is menopause?

Now that I've begun menopause, should I be concerned about birth control?

• Contraception

Besides hormone replacement therapy, how can I treat hot flushes?

• Complementary Medicines and Therapies for Hot Flushes

Sex has become painful since menopause. What can I do?

• Genitourinary syndrome of menopause

Content updated April 2025

Heavy menstrual bleeding affects one in four Australian women of reproductive age and can have a serious impact on women’s social, emotional and physical quality of life.

The Australian Commission on Safety and Quality in Health Care (the Commission) has published a new showing a decrease in hysterectomy rates over eight years – and an increase in the less invasive option of endometrial ablation. Hysterectomy is one option for treating heavy menstrual bleeding, but there are a number of associated risks. Less invasive treatments are available, including oral medicines, the hormonal IUD and procedures like endometrial ablation. Download

The Commission has also released the updated (2024), which outlines best practice care and how healthcare practitioners can support women living with this condition. The Standard highlights key aspects of quality care for women with heavy menstrual bleeding including comprehensive assessment, ensuring they are offered appropriate treatment options, and supporting women to make informed choices about their care. This combined work aims to improve care for women with heavy menstrual bleeding. It will ensure they are offered the most appropriate and least invasive treatment for their individual situation, and can make informed choices from the range of treatments. Health service organisations, PHNs and clinicians can use the data in the Women’s Health Focus Report to view hysterectomy and endometrial ablation rates in their local area and reflect on what it means for their practice and patients. If there is substantial variation in the treatment of heavy menstrual bleeding, it is important to investigate if appropriate care is being delivered. Women with heavy menstrual bleeding that is impacting their life should be offered treatment for symptom relief from first presentation, even when waiting for investigations or access to other treatments.

A trusted practitioner can help a woman understand the range of treatments. The best treatment option will differ for each woman. It is important for clinicians to ask women about their menstrual health, as some women may not recognise their heavy bleeding is unusual and can be treated, so many do not seek help.

Resources

Find out more at

Infograhic at Heavy menstrual bleeding in Australia 2024221.69 KB

Related links

Content created June 2024

With increasing interest in the use of testosterone for women, fuelled by anecdotal reports on social media, patients may present requesting prescriptions for testosterone for a range of reasons. It is timely to reconsider the evidence base for efficacy of testosterone, and the guidelines for safe use.

The context of this discussion is for post-menopausal cis-gender women, and is separate from any consideration of gender affirming hormone therapy for trans or gender diverse people.

The closest we have to an Australian or international guideline is the endorsed by RANZCOG and the Endocrine Society of Australia. Clinicians are encouraged to read the Statement to obtain detailed information. 

Testosterone is not a routine component of menopausal hormone therapy. The only evidence-based indication for the use of testosterone in women is for the treatment of postmenopausal women who have hypoactive sexual desire disorder (HSDD).

Some points about testosterone prescribing in women include:

• There is no statistically significant association between endogenous testosterone levels and sexual function in premenopausal women and available data for postmenopausal women also show no association. Testosterone levels peak in early adulthood and decline during the reproductive years. Menopause (unless surgical) does not itself cause a sudden drop in testosterone levels.
• Libido and other elements of sexual function are multifactorial. Hormones are just one factor.
• When assessing patients, consider general physical and mental health, medications (including SSRIs and SNRIs), lifestyle, relationship issues, and previous history of trauma or abuse. Offer treatment for vaginal dryness if present.
• There are anecdotal reports that treatment with testosterone may improve mood, cognition and general well-being. However, this is not supported by RCT evidence. Testosterone has not been shown to be effective for treatment of mood disorders, ‘brain fog’ or fatigue.
• The only evidence-based indication for prescribing testosterone is for treatment of low libido, specifically hypoactive sexual desire disorder in postmenopausal women. In practice this means very low libido which distresses the woman, when other contributing factors have been considered and treated as appropriate.
• Testosterone is not currently indicated for bone or muscle health. Research is ongoing in this area.
• Transdermal testosterone has a modest beneficial effect on libido in the majority of postmenopausal women treated for this indication.
• Measurement of baseline total testosterone levels is recommended. This is usually only available by immunoassay which provides a rough estimate but not a precise level for women. Therefore, blood testing is not to diagnose ‘testosterone deficiency’, but to ensure levels are not above the upper reference range before starting therapy.
• “Free” testosterone should not be used to make a diagnosis or to monitor blood levels during treatment.
• Once on treatment, periodic measurement of testosterone levels is needed to ensure that levels stay in the physiological female reference range.
• Patients should be counselled about side effects, which are uncommon if levels remain in the normal range. Side effects include hirsutism, acne, vocal changes and clitoromegaly.
• When levels remain in the physiological reference range, testosterone appears to be safe for the breast and cardiovascular health. However, data are only available up to 48 months of follow up, and long-term safety is uncertain. Clinical trials of testosterone have generally excluded women with pre-existing cardiovascular disease or breast cancer.
• There is a TGA registered female-specific formulation available in Australia, and following TGA Guidance, this should be prescribed, not products designed for males. Products designed for males have a high potential for inadvertent application of high doses. For clinicians outside of Australia, the Consensus Statement indicates that transdermal male formulations can be used ‘off label’ judiciously, with regular monitoring of blood testosterone concentrations.

Clinicians considering offering testosterone to their patients are advised to read the Global Consensus Position Statement. Other resources include the AMS webinar featuring Prof Susan Davis, and a  presented by Jean Hailes.  

Clinicians should also be aware of the Council of Australian Therapeutic Advisory Groups position on off -label prescribing:

1. If therapeutic alternatives are available to treat a particular condition, evidence about comparative clinical effectiveness, safety and cost-effectiveness between the off-label medicine and TGA-approved alternatives should be sought. The medicine with a demonstrated advantage in clinical effectiveness and/or safety and/or cost-effectiveness (in the relevant population and for the intended use) should be chosen.

2. When a medicine is prescribed off-label, this should be made explicit, along with expansion of the associated uncertainties. Patients should be advised when there is a TGA approved alternative available and why the off-label use is being recommended. Discussion of financial cost implications and access issues is necessary and should occur prior to initiation of therapy. In addition, the level and quality of evidence available to support the use of a medicine off-label plays a role in the decision about the nature and documentation of the informed consent process.

Content created March 2024

AMS agrees that we need to empower women to manage their menopause transition, their post-menopausal health and well-being, and indeed has been promoting this for decades (see the AMS tagline – “Empowering menopausal women”). However, over 25% of women will have moderate to severe symptoms that impact on their quality of life. Menopausal hormone therapy remains an evidence-based, first line treatment option for women with symptoms.

AMS and IMS Past-Presidents, Professors Susan Davis AO and Rod Baber AM have kindly shared a response to the series.

Response

Four papers published pertaining to menopause in the Lancet are not about new research findings but offer opinions as to how menopause might be viewed and how the experience of menopause might be optimised.

It is disappointing that the lead article states that “the principles of health empowerment have not been applied to menopause” when empowerment of women to best navigate their menopause, through the provision of credible health information to support informed and shared decision-making, has been the focus of national and international organisations (such as the Australasian and International Menopause Societies and Jean Hailes for Women’s Health) for many years.

The papers raise the important concern of potential misattribution of an array of psychological symptoms to menopause. While this is also not a new concept, it is consistent with other recently published reviews and highlighting this concern reinforces the message to women and clinicians not to blame every symptom on menopause.

The authors stress that most women will not experience debilitating menopausal symptoms. Nevertheless, they acknowledge that 60-80% of women will have menopausal flushes and sweats that can last, on average, about 7 years, and that for 1 in 3 women these can be quite severe.

The authors caution against “over-medicalisation” of the menopause but the messaging regarding therapy is mixed and potentially confusing. For example, it is stated that “The North American Menopause Society recommends specific MHT, gabapentin and oxybutynin which have mild to moderate efficacy and reduce hot flushes by 1-2 per day with no significant improvement in menopause-related quality of life”. But, further on it is stated that MHT is effective (reduces flushes by 2-4/day) and improves health related quality of life. Of concern is the promotion of gabapentin and oxybutynin, neither of which are approved in any country for the treatment of menopausal flushes/sweats (vasomotor symptoms) and data for oxybutynin is notably scant. In contrast fezolinetant, which has been approved in the UK, EU, Australia and the US specifically for vasomotor symptoms, has been downplayed to being only modestly effective despite robust evidence which is lacking for these other nonhormonal therapies.

The importance of bone loss at menopause is also recognised together with the effectiveness of MHT for fracture prevention, but other long-term effects of menopause on health are called to question. This conflicts with other highly regarded expert opinions^1,2 and this in turn demonstrates that this Lancet series needs to be seen as only one interpretation of the published research.

The authors seem determined to minimise the important role of MHT in helping many women as they reach menopause. They ignore other published systematic reviews which all agree that MHT is the most effective treatment for vasomotor symptoms, is as effective as other bone-specific therapies (antiresorptive agents) in reducing postmenopausal osteoporosis and associated fractures and, unlike some antiresorptives, is not associated with an increased risk of fracture upon stopping treatment.

Current guidance from international and national menopause societies, including Australia and New Zealand all speak to empowerment of every woman at this pivotal stage of her life. They also stress the importance of an evidence-based approach and, importantly, offering each woman the care, support and, where required, treatment she seeks to help her on her journey.

Nonetheless, in general these papers align with, and support the latest internationally and nationally endorsed best practice guidance for menopause published in 2023, Practitioner Toolkit for Managing Menopause³, with open online access for women and clinicians to facilitate health empowerment, as recommended by these papers.

1. Mehta JM, Manson JE. The menopausal transition period and cardiovascular risk. Nat Rev Cardiol 2024; 21(3): 203-11.
2. Gersh F, O'Keefe JH, Elagizi A, Lavie CJ, Laukkanen JA. Estrogen and cardiovascular disease. Prog Cardiovasc Dis 2024.
3. Davis SR, Taylor S, Hemachandra C, et al. The 2023 Practitioner's Toolkit for Managing Menopause. Climacteric 2023; 26(6): 517-36.

Professor Susan Davis AO MBBS, FRACP, PhD, FAHMS
NHMRC Investigator
Professor and Director, Women's Health Research Program
Department of Epidemiology and Preventive Medicine
School of Public Health and Preventive Medicine

Professor Rodney Baber AM B Pharm. MB BS FRCOG FRANZCOG 
Professor of Obstetrics and Gynaecology
Faculty of Medicine and Health
The University of Sydney.
Past President IMS
Chair, Scientific Programme Committee
19th IMS World Congress on Menopause.

Disclosures:

Professors Davis and Baber are both past Presidents of the International Menopause Society and ��ݮ��Ƶ. Prof Davis is an NHMRC Leadership 3 Investigator. 

SRD has prepared and delivered educational presentations for Besins Healthcare, Abbott, Mayne Pharma, has been on Advisory Boards for Theramex, Astellas, Abbott Laboratories, Mayne Pharma and Gedeon Richter and has received institutional grant funding for Que Oncology and Ovoca Bio research. RJB has prepared and delivered educational presentations for Besins Healthcare, Abbott, Viatris, and Pfizer Australia and has served on medical advisory boards for Theramex, Mayne Pharma, Astellas and Besins Healthcare

Content created 6 March 2024

Understanding risk

Cancer Australia has a dedicated website  that provides comprehensive information concerning risk.

"As a woman, over the course of your lifetime there are many factors that can influence your risk of breast cancer.

While some of the most important of these risk factors, such as being a woman, getting older or having a strong family history cannot be changed, you can still aim to reduce risk of breast cancer through making healthy lifestyle choices and other risk-reducing strategies.

You can also improve your chance of better outcomes by being breast aware and knowing what to do about finding breast cancer early."

Risk Calculator 

 iPrevent

This web-based tool  is available to help women understand their personal breast cancer risk and then act on it. It is designed to be used collaboratively by women and their doctors. Women can use it at home, print the output, and bring it to a consultation for discussion.

Content created Februay 2024

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.

The article is available free online from the Australian Prescriber, Issue 3 October 2023

Article Summary

During perimenopause and after menopause, women may experience diverse symptoms.

All women require a comprehensive assessment of their current health and risks for future disease, appropriate screening, and promotion of a healthy lifestyle.

Menopausal hormone therapy is the most effective treatment for menopausal symptoms. It can be offered to symptomatic patients with no contraindications following an individualised discussion about the risk of harms versus benefits.

Menopausal hormone therapy is recommended for women with premature ovarian insufficiency (menopause occurring before 40 years of age) regardless of symptoms, unless contraindicated.

Nonhormonal medications may improve symptoms for women who have contraindications to, or do not wish to take, menopausal hormone therapy.

See article

Download

Reference

Magraith K, Jang C. Management of menopause. Aust Prescr 2023;46:48–53.

About the authors

Dr Karen Magraith BMBS FRACGP

Past-President AMS

Karen Magraith graduated from Flinders University and spent 6 years in Darwin before returning to Adelaide, where she worked until 2007. She currently works in general practice in Hobart, where she is involved in registrar training. She has had a longstanding interest in women's health and has been a member of AMS since 2004.

Karen recognises that most menopause medicine occurs in general practice, where the GP is in a unique position to manage the medical, gynaecological and psychosocial issues in an integrated way.

Karen is keen to promote the role of the AMS in educating and supporting a wide variety of GPs, to enable them to provide high quality health care to women.   

Dr Christina Jang MBBS MD FRACP

President-Elect AMS

Dr Christina Jang graduated MBBS from Monash University in 1994. She undertook advanced training in Endocrinology in Melbourne and received her FRACP in 2004. She received an NHMRC Scholarship to carry out studies towards her Doctor of Medicine which was conferred in 2008.   

She has undertaken research in the area of women’s health and won the Young Investigator Award at the Australasian Menopause Foundation in 2003. 

She is a consultant endocrinologist at The Mater Hospital Brisbane and Greenslopes Private Hospital, and honorary Senior Lecturer at the University of Queensland.  She has a clinical interest in female reproductive endocrinology.

Content created October 2023

The primary milestones discussed relate to menstrual cyclicity, adverse pregnancy outcomes, breast cancer treatments, and menopause. Each of these categories has a number of permutations that have been shown in observational studies to be associated with increased cardiovascular risks. In current clinical care, recognition of these reproductive milestones has been encouraged so patients can be informed and motivated to engage in primary prevention of cardiovascular disease early in their life course rather than retrospectively later in life.

Options for specifically targeted care with specialist teams are designed to enhance success with risk identification, screening and possible detection of CVD, and optimally, primary or secondary prevention of CVD. Promoting cardiovascular health of women has far reaching effects for themselves, their families, and their progeny. It’s time to make women’s cardiovascular health a priority

See a PDF of the full paper here

The paper is also available via Climacteric.

Content created October 2023

Key Points

• Menopause 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.

Diagnosing_menopause.pdf147.55 KB

�ٰ���’T

• Measure 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 menopause

• Which 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 history

• Menopausal 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 disease
• Ensure that screening (breast, cervical) is up to date

Introduction

Frequently, 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 ) 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.

Postmenopause

This 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 menopause

Premature 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 iatrogenic³
• Genetic 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 Menopause

The 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 sheet

The 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 ��ݮ��Ƶ 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.

References

1. McKinlay SM et al. The normal menopause transition. Maturitas 1992;14:103.
2. Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause Int 2011;17:153.
3. Şükür, Y[anuz]. E., Kıvançlı, İ. B., & Özmen, B. Ovarian aging and premature ovarian failure. Journal of the Turkish German Gynecological Association, 2014;15(3):190.
4. Green R et al. Menopausal Symptoms and Ethnicity: the Study of Women’s Health across the Nation. Womens Health (Lond). 2009;5(2):127-33
5. Coulam CB et al. Incidence of Premature Ovarian Failure. Obstet Gynecol 1986;67(4):604-606
6. Greene JG. Constructing a standard climacteric standard. Maturitas 1998;29:25-31

Symptom Score (Modified Greene Scale)

AMS Diagnosing Menopause Symptom score sheet91.45 KB  

Note: Medical and scientific information provided and endorsed by the ��ݮ��Ƶ might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider. This Information Sheet contains copyright or otherwise protected material. Reproduction of this Information Sheet by ��ݮ��Ƶ Members and other health professionals for clinical practice is permissible.

No other reproduction or transmission is permitted in any form or by any information storage and retrieval systems except as permitted under the Copyright Act 1968 or with prior written permission from the copyright owner.

Content created May 2022

AMS Template for Menopause Consult107.54 KB 

 Note: Medical and scientific information provided and endorsed by the ��ݮ��Ƶ might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider. This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by ��ݮ��Ƶ Members and other health professionals for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the ��ݮ��Ƶ.

Content created 16 March 2022