Menopause and Midlife Health

How to recognise perimenopause, understand treatment options and protect your long-term health

Menopause is a normal life stage, but the transition can be difficult.

Some people notice only mild changes. Others experience hot flushes, disrupted sleep, anxiety, low mood, heavy or irregular bleeding, vaginal dryness, joint pain or “brain fog” that affects work, relationships and quality of life.

These symptoms are real, and treatment is available. You do not need to simply endure them.

Midlife is also an important time to review bone health, cardiovascular risk, cancer screening, mental wellbeing and the habits that influence health in later life.

What are perimenopause and menopause?

Perimenopause is the transition leading up to the final menstrual period. During this time, ovarian production of oestrogen and progesterone becomes more variable, and periods often change.

Menopause is the final menstrual period. You know retrospectively that menopause has occurred after 12 consecutive months without a period when there is no other medical explanation.

In Australia, menopause usually occurs between ages 45 and 55, with an average age of about 51. Early menopause occurs before 45, while menopause or loss of normal ovarian function before 40 is usually described as premature ovarian insufficiency.

Postmenopause begins after those 12 months without a period.

Symptoms can begin years before the final period and may continue afterwards.

What symptoms can occur?

The menopause transition affects people differently.

Common symptoms include:

• Irregular, heavier or lighter periods
• Hot flushes and night sweats
• Difficulty sleeping
• Fatigue
• Mood changes, irritability or anxiety
• Low mood
• Difficulty concentrating or “brain fog”
• Headaches
• Joint and muscle pain
• Vaginal dryness or irritation
• Pain during sex
• Reduced sexual desire
• Bladder urgency or recurrent urinary infections
• Changes in body-fat distribution

Not every new symptom in midlife is caused by menopause. Thyroid disease, anaemia, depression, sleep apnoea, pregnancy, medicine effects and other health conditions can produce overlapping symptoms.

Period changes during perimenopause

Periods commonly become less predictable.

They may occur closer together, farther apart, become heavier or lighter, or occasionally be missed. Ovulation can still occur, so pregnancy remains possible until menopause is confirmed.

Abnormal bleeding should not automatically be blamed on hormones.

Speak with your GP if you experience:

• Very heavy bleeding
• Bleeding between periods
• Bleeding after sex
• Bleeding that is persistently more frequent
• New bleeding while using menopause hormone therapy
• Any vaginal bleeding after menopause

Bleeding after 12 months without periods always requires medical assessment.

Do you need a blood test?

Usually not.

For most people aged over 45 with typical symptoms and changing periods, perimenopause and menopause are diagnosed from the history rather than hormone testing.

Hormone levels fluctuate considerably during perimenopause, so one “normal” follicle-stimulating hormone result does not rule it out, and one high result does not necessarily confirm that the transition is complete.

Blood tests may be helpful when:

• Symptoms begin before age 45
• Premature ovarian insufficiency is suspected
• Periods cannot be assessed after hysterectomy
• Another medical condition needs to be excluded
• Symptoms are unusual or the diagnosis is unclear

Commercial hormone panels and repeated testing are rarely needed for routine diagnosis.

Managing hot flushes and night sweats

Hot flushes involve a sudden feeling of heat, often with sweating, facial flushing, palpitations or chills afterwards.

Useful practical measures include:

• Dressing in removable layers
• Keeping the bedroom cool
• Using a fan
• Reducing triggers such as excess alcohol or very hot drinks
• Maintaining regular sleep and exercise
• Practising cognitive behavioural strategies

Lifestyle changes may improve general wellbeing, but they are not always sufficient for troublesome symptoms.

Menopause hormone therapy is the most effective treatment for hot flushes and night sweats. Non-hormonal prescription treatments are also available when hormone therapy is unsuitable or not preferred.

Menopause hormone therapy

Menopause hormone therapy, or MHT, is also commonly called hormone replacement therapy.

It replaces some of the oestrogen that declines during menopause and may improve:

• Hot flushes
• Night sweats
• Sleep disrupted by these symptoms
• Vaginal and urinary symptoms
• Quality of life

It also maintains bone density and reduces fracture risk while it is being used.

MHT is available as:

• Tablets
• Skin patches
• Gels
• Vaginal tablets, creams or pessaries
• Combination preparations

Treatment should be individualised according to symptoms, age, health history, preferences and whether the uterus is present.

Do you need progesterone?

If you still have a uterus and use systemic oestrogen, you generally also need a progestogen.

Oestrogen by itself can stimulate the uterine lining and increase the risk of endometrial cancer. Progestogen protects the lining.

After a hysterectomy, oestrogen-only treatment is usually sufficient, although some surgical histories require specialist advice.

In perimenopause, treatment may be arranged so that progestogen is taken for part of each month, producing a planned withdrawal bleed. After menopause, some people use continuous combined treatment intended to avoid regular bleeding.

MHT is not contraception.

Is MHT safe?

For most healthy people with troublesome symptoms who begin MHT before age 60 or within about 10 years of menopause, the benefits generally outweigh the risks.

Risk varies according to:

• Age
• Time since menopause
• Medical history
• Type of oestrogen and progestogen
• Dose
• Tablet versus skin preparation
• Duration of treatment

Transdermal oestrogen, given through a patch or gel, is associated with a lower risk of venous blood clots than oral oestrogen and may be preferred when clot risk, migraine, liver disease or other factors are relevant.

Combined oestrogen–progestogen therapy may slightly increase breast-cancer risk with longer use. Oestrogen-only therapy after hysterectomy has a different and generally lower breast-risk profile. The absolute risk for an individual depends on baseline risk and treatment duration.

MHT should not be prescribed solely to prevent heart disease or dementia.

When might systemic MHT be unsuitable?

Systemic MHT may not be appropriate, or may require specialist advice, if you have:

• Current or previous hormone-sensitive breast cancer
• Unexplained vaginal bleeding
• Previous blood clots or a high clotting risk
• Previous stroke or heart attack
• Significant liver disease
• Certain endometrial cancers
• Other important contraindications

This does not mean symptoms cannot be treated. Non-hormonal medicines, vaginal treatments and behavioural therapies may still help.

The decision should be based on individual risk rather than a blanket rule that MHT is either universally safe or universally dangerous.

Vaginal and urinary symptoms

Declining oestrogen can cause changes collectively known as the genitourinary syndrome of menopause.

Symptoms may include:

• Vaginal dryness
• Burning or irritation
• Pain during sex
• Reduced elasticity
• Urinary urgency
• Pain with urination
• Recurrent urinary infections

Unlike hot flushes, these symptoms often persist or worsen without treatment.

Options include:

• Vaginal moisturisers used regularly
• Lubricants during sexual activity
• Low-dose vaginal oestrogen
• Pelvic-floor physiotherapy when relevant

Low-dose vaginal oestrogen has minimal absorption into the bloodstream, does not usually require additional progestogen and can also reduce recurrent urinary infections. It may be used alongside systemic MHT when local symptoms persist.

People with a history of breast cancer should discuss vaginal hormone treatment with their treating team.

Non-hormonal treatment options

Hormone treatment is not the only option.

Depending on the symptom, a GP may consider medicines such as:

• Certain antidepressants
• Gabapentin
• Clonidine
• Other approved or evidence-based non-hormonal treatments

These medicines may reduce hot flushes but have their own adverse effects and do not provide the bone benefits of systemic oestrogen.

Cognitive behavioural therapy can reduce how disruptive hot flushes feel and may improve sleep and emotional wellbeing.

What about “bioidentical” hormones?

The term bioidentical is often used in marketing.

Some regulated Australian MHT products contain hormones chemically identical to those produced by the body, including oestradiol and micronised progesterone.

These should not be confused with custom-compounded hormone mixtures.

Compounded products may have inconsistent dosing, limited quality control and less reliable safety evidence. When an approved regulated product is available, it is generally preferred.

Saliva and urine hormone testing used to customise compounded hormones is not reliable for routine menopause management.

Complementary medicines and supplements

Products such as black cohosh, red clover, phytoestrogens and herbal mixtures are widely promoted.

Evidence for consistent benefit is limited, and “natural” does not mean harmless. Supplements can cause adverse effects, interact with medicines or vary substantially in quality.

Discuss regular supplements with your GP or pharmacist, particularly if you have liver disease, cancer history or take prescription medicines.

Mood, anxiety and cognition

Hormone fluctuations, sleep disruption and major midlife pressures may all affect mental wellbeing.

Some people experience:

• Irritability
• Anxiety
• Low mood
• Reduced confidence
• Difficulty concentrating
• Problems retrieving words
• Feeling mentally slower

MHT may improve mood when symptoms are closely linked to the menopause transition, particularly when poor sleep and hot flushes are contributing. It is not a complete treatment for major depression or a significant anxiety disorder.

Seek assessment if symptoms are persistent, severe or affecting safety and function.

Call 000 for immediate danger. Lifeline provides 24-hour crisis support on 13 11 14.

Sexual health

Sexual wellbeing can be affected by dryness, pain, low desire, relationship changes, sleep problems, stress, medicines and other health conditions.

Helpful approaches may include:

• Vaginal moisturisers
• Lubricants
• Local vaginal oestrogen
• Reviewing medicines
• Pelvic-floor physiotherapy
• Addressing relationship or psychological factors
• Treating pain before repeatedly attempting intercourse

Testosterone treatment may be considered for selected postmenopausal women with persistent low sexual desire causing distress after other contributors have been assessed. It is not a general treatment for fatigue, weight gain or “brain fog” and requires careful prescribing and monitoring.

Weight and body composition

Many people notice weight or waist changes during midlife.

Ageing, reduced activity, sleep disruption and declining muscle mass are major contributors. Hormonal changes can also shift fat distribution towards the abdomen.

MHT is not a weight-loss treatment, but evidence does not support the common belief that appropriately prescribed MHT itself causes weight gain.

The priorities are:

• Preserving muscle with resistance exercise
• Eating adequate protein
• Maintaining regular aerobic activity
• Improving sleep
• Reducing excessive alcohol
• Choosing a sustainable eating pattern

Protect bone and cardiovascular health

Lower oestrogen after menopause accelerates bone loss.

Midlife is a useful time to review:

• Calcium and vitamin D intake
• Weight-bearing and resistance exercise
• Smoking
• Alcohol
• Falls risk
• Family history of osteoporosis
• Need for bone-density testing

Cardiovascular risk also increases with age. Review:

• Blood pressure
• Cholesterol
• Blood glucose
• Smoking
• Physical activity
• Body composition
• Family history

Menopause is not itself a disease, but the transition provides an opportunity for preventive healthcare.

Early menopause and premature ovarian insufficiency

Menopause before 45—and particularly loss of ovarian function before 40—deserves specific assessment.

Earlier oestrogen loss is associated with increased risks to bone, cardiovascular health and fertility.

Unless contraindicated, hormone therapy is usually recommended until approximately the usual age of natural menopause, even when symptoms are not severe.

People may also need support regarding fertility, sexual health, grief and emotional wellbeing.

When to see your GP

Book an appointment if:

• Symptoms are affecting daily life
• Periods become very heavy or abnormal
• Symptoms begin before age 45
• You have vaginal bleeding after menopause
• Vaginal or urinary symptoms are persistent
• Sleep, mood or concentration are significantly affected
• You want to discuss MHT or non-hormonal treatment
• You have a cancer, clotting or cardiovascular history
• Treatment is not working or causing adverse effects

A menopause consultation should include your symptoms, bleeding history, contraception needs, health risks, medicines, screening and personal treatment preferences.

Start with one change

Choose one useful action:

• Record your symptoms and period pattern
• Book a longer GP appointment
• Begin regular resistance exercise
• Use a vaginal moisturiser for persistent dryness
• Reduce evening alcohol if night sweats are worse
• Check your blood pressure and screening history
• Ask for an individual discussion about MHT

You do not need to decide on every treatment before seeking advice.

The bottom line

Perimenopause and menopause can affect periods, temperature regulation, sleep, mood, cognition, joints, sexual comfort and bladder health.

Diagnosis is usually based on age, symptoms and menstrual history rather than routine hormone testing.

MHT is the most effective treatment for hot flushes and night sweats and is suitable for many symptomatic people when prescribed after an individual risk assessment. Non-hormonal medicines, vaginal treatments, behavioural strategies and lifestyle support are also available.

You do not need to push through symptoms that are affecting your life. Midlife is an opportunity to obtain effective treatment and invest in your long-term bone, heart and mental health.