GP Menopause Consultation Template

Menopause and Perimenopause Health Assessment (MBS Item 695)

History

• Menopausal status: Perimenopause, spontaneous transition, uterus intact.
• Symptoms discussed: Hot flushes, night sweats, sleep maintenance insomnia, irritability, brain fog, vaginal dryness, decreased libido.
• Menstrual history: Irregular cycles (q40–60d) over past 12 months, lighter flow, LMP 12/02/2026, nil prior gynaecological surgery.
• Medical history:
  • Mild hypertension (diet-controlled)
  • Migraine without aura
  • G2P2 (both NVD)
• Family history:
  • Mother: Osteoporosis (sustained NOF fracture aged 78)
  • Father: T2DM, IHD
  • Nil FHx of breast, ovarian, or endometrial malignancy, nil FHx of VTE
• Contraindications to treatment considered:
  • Nil personal history of breast or endometrial cancer
  • Nil personal history of VTE or thrombophilia
  • Nil unexplained vaginal bleeding
  • Nil active liver disease
• Psychosocial wellbeing: The patient reports feeling overwhelmed at work due to persistent sleep deprivation and cognitive fatigue. Her mood is labile with increased irritability, though she denies anhedonia or suicidal ideation. She has a supportive partner at home who is understanding of her symptoms.

Examination

• Well-looking, alert, cardiovascular and respiratory exams NAD, breast examination normal bilaterally with no palpable masses or skin changes.
• Blood pressure: 128/82 mmHg
• Height: 165 cm
• Weight: 72 kg
• BMI: 26.4 kg/m²

Investigations and Referrals

• Cervical screening
• Mammography
• Bone densitometry (DEXA)
• Additional pathology as indicated: FBE, UEC, LFT, fasting lipids, Hba1c, TSH, ferritin, vitamin D.
• Referrals initiated: Pelvic floor physiotherapist, BreastScreen Victoria.

Management

• Non-pharmacological options discussed:
  • Sleep hygiene measures
  • Layered breathable clothing and cooling bedroom environment
  • Vaginal moisturisers and olive oil/water-based lubricants for GSM
  • CBT for vasomotor symptoms and mood support
• Pharmacological options discussed:
  • estradiol (Estrogel®) 0.06% gel 1.25 g (1 pump) transdermal daily
  • progesterone (Prometrium®) 200 mg PO nocte for 12 days per calendar month (sequential regimen)
  • estriol (Ovestin®) 0.1% vaginal cream 0.5 mg PV nocte for 2 weeks, then twice weekly
• Risks and benefits explored with patient
• Shared decision-making documented
• Symptom-focused management plan implemented

Preventative Health Care Advice

• Physical activity
• Alcohol use
• Nutrition and calcium/vitamin D intake
• Weight management
• Educational resources provided as appropriate

Team Involvement

• Assistance provided under GP supervision by Practice Nurse Sarah Jenkins (RN), who completed baseline anthropometrics, blood pressure, and preventative screening history.
• Allied health and other providers involved:
• Jane Doe (Pelvic Floor Physiotherapist)
• BreastScreen Victoria
• Coordination of care and communication arranged as required

Review

• Follow-up planned for 3 months to review symptom response to MHT, check side effects, and discuss outstanding screening and pathology results.