Menopause and Perimenopause Assessment

Menopausal Status and Relevant History

Menopausal Stage

Peri-menopause

Medical and Gynecological History

The patient is a 49-year-old G2P2 female presenting with a 10-month history of oligomenorrhoea, with cycles currently occurring every 45 to 60 days. Her last menstrual period was on 12/02/2025. She has an intact uterus and no history of intermenstrual or post-coital bleeding. Her past medical history is significant for mild asthma and a previous laparoscopic cholecystectomy in 2018. Her last cervical screening test in 2022 was negative for HPV, and her most recent mammogram in 2024 was normal (BI-RADS 1).

Symptoms and Concerns

• Frequent vasomotor symptoms, including 5 to 6 hot flushes daily and drenching night sweats.
• Sleep maintenance insomnia secondary to nocturnal vasomotor symptoms.
• Increased irritability, low mood, and daytime fatigue.
• Mild vulvovaginal dryness and superficial dyspareunia.

Wellbeing Assessment

The patient reports feeling emotionally exhausted due to chronic sleep disruption, which is negatively impacting her concentration at work. She notes decreased libido and avoids intimacy due to vaginal discomfort, though her partner remains supportive. She denies any pervasive anhedonia or suicidal ideation, and her PHQ-9 score is 6, indicating mild depressive symptoms likely secondary to peri-menopause.

Contraindications

• No personal or family history of breast, endometrial, or ovarian cancer.
• No personal or family history of venous thromboembolism (VTE) or thrombophilia.
• No history of stroke, ischaemic heart disease, Migraine with aura, or active liver disease.

Physical Examination Findings

Blood Pressure

124/78 mmHg

Height and Weight

165 cm, 68 kg

BMI

25.0 kg/m²

Other Findings

Cardiovascular and respiratory examinations were unremarkable. Breast examination revealed no palpable masses, skin tetherings, or nipple discharge, and there was no axillary lymphadenopathy. Speculum examination was deferred today as per patient preference, given her up-to-date cervical screening and absence of abnormal bleeding.

Investigations and Referrals

Planned Investigations

• Fasting lipid profile and HbA1c
• Thyroid-stimulating hormone (TSH)
• Full blood count (FBC) and serum ferritin
• Serum 25-hydroxyvitamin D

Screening Referrals

• Advised to continue routine two-yearly mammography through BreastScreen Victoria (next due 2026).
• Advised to complete her next routine Cervical Screening Test in 2027.

Specialist Referrals

• Referral to a pelvic floor physiotherapist was discussed for management of dyspareunia, which the patient will consider if topical measures are insufficient.

Discussion of Management Options

Non-Pharmacological Strategies

• Dressing in layers, using a bedside fan, and maintaining a cool bedroom environment.
• Regular use of non-hormonal vaginal moisturisers and water-based or silicone-based lubricants during intercourse.
• Sleep hygiene optimisation and cognitive behavioural therapy (CBT) strategies for vasomotor symptoms and insomnia.

Pharmacological Options

• Combined menopausal hormone therapy (MHT) utilising transdermal estradiol and oral micronised progesterone.
• Non-hormonal pharmacological alternatives, including low-dose SSRIs/SNRIs (e.g., escitalopram or venlafaxine) or gabapentin.
• Topical low-dose vaginal estriol for genitourinary syndrome of menopause (GSM).

Risks and Benefits

The benefits of MHT were discussed, specifically its high efficacy in reducing vasomotor symptoms, improving sleep quality, and preserving bone mineral density. The baseline risks and small absolute increases in the risk of breast cancer and VTE with combined MHT were explained. It was emphasised that transdermal estradiol carries a lower VTE risk compared to oral formulations, and micronised progesterone has a more favourable breast safety profile compared to synthetic progestins. The patient was also counselled on expected side effects, such as transient breast tenderness and irregular breakthrough bleeding during the first 3 to 6 months of therapy.

Management Plan

Symptom Management

• Commence estradiol (Estrogel®) 0.06% transdermal gel 1.5 mg (2 pumps) applied topically OD.
• Commence micronised progesterone (Prometrium®) 100 mg PO nocte continuously (or 200 mg PO nocte for 14 days per calendar month if cyclical regimen preferred; patient elected to start with cyclical 200 mg PO nocte for 12–14 days/month given recent periods).
• Commence daily non-hormonal vaginal moisturiser (Replens®) and use silicone lubricant PRN for intercourse.

Follow-up

The patient will return for a review in 3 months to assess symptom resolution, treatment tolerability, bleeding patterns, and blood pressure, or earlier if she experiences any heavy or persistent abnormal uterine bleeding.

Preventative Health Advice

Physical Activity

The patient was advised to engage in at least 150 minutes of moderate-intensity aerobic activity per week, alongside progressive resistance training twice weekly to support bone density and cardiovascular health.

Alcohol

The patient was counselled to limit alcohol intake to fewer than 10 standard drinks per week and no more than 4 standard drinks on any single occasion, noting that alcohol frequently triggers hot flushes and disrupts sleep architecture.

Nutrition

Dietary counselling was provided, focusing on a Mediterranean-style diet rich in whole grains, lean proteins, and phytoestrogens, while ensuring an adequate dietary calcium intake of 1,000 to 1,300 mg daily.

Weight Management

Strategies to prevent midlife weight gain and visceral adiposity were discussed, focusing on portion control, reducing refined carbohydrates, and maintaining regular physical activity.

Consent and Documentation

Shared Decision-Making

The patient actively participated in shared decision-making regarding her assessment and management plan, expressing a clear preference to trial transdermal MHT after weighing the individualised risks and benefits.

Resources Provided

Written fact sheets from the Australasian Menopause Society (AMS) regarding perimenopause, MHT, and non-hormonal management options were provided to the patient.

Documentation

This comprehensive menopause assessment, discussion of risks and benefits, and agreed management plan have been documented in the patient's electronic medical record.