In our ongoing series on menopause awareness, we look at the current evidence-based best practice guidelines on the management of menopause symptoms.
Menopause is being recognised as a significant public health and policy issue, shedding light on decades of neglect in addressing its challenges and impact. The widening spotlight on menopause has catalysed a movement to improve awareness, understanding and access to care.
‘Menopause isn’t a disease. It doesn’t need a formal diagnosis as such; it’s something that happens to all those born with functioning ovaries,’ said Prof Martha Hickey, a leading Australian gynaecologist with a clinical and research focus on menopause, during the 2024 Senate Inquiry on Issues relating to menopause and perimenopause. ‘It’s not necessarily helpful to take the position that menopause is a disastrous event for all women, because it isn’t. The important thing is that those who need help get help.’
More than 75 percent of Australian women experience hot flushes and night sweats; symptoms that are linked to reduced wellbeing, heightened anxiety and depressive symptoms, and diminished workplace productivity. Monash University researchers assert that despite readily available, safe hormonal and non-hormonal therapy, over 85% of women with bothersome symptoms are not receiving evidenced-based care.
But, as awareness among women grows, so too will the conversations and questions about available treatments. For aesthetic doctors, who are often a trusted source for overall wellness and wellbeing concerns, staying equipped with the latest evidence-based menopause management options is invaluable. This article explores the current treatments for menopause available in Australia, supported by current clinical guidelines and findings from the 2024 Senate Inquiry into Issues relating to menopause and perimenopause.
Understanding menopause: a brief overview
Menopause marks the cessation of ovarian function and is defined retrospectively after 12 consecutive months of amenorrhea. It typically occurs between 45 and 55 years of age but can vary depending on individual and genetic factors.
Common symptoms include vasomotor symptoms (hot flashes and night sweats), urogenital atrophy, mood changes, sleep disturbances, and increased risk of osteoporosis and cardiovascular disease.
Exploring menopausal hormone therapy (MHT)
MHT, formerly known as hormone replacement therapy (HRT), is the most effective treatment for alleviating menopausal symptoms and preventing osteoporosis.
It involves the administration of oestrogen (specifically the compound oestradiol), progesterone and, in some cases, testosterone to mitigate symptoms caused by declining endogenous hormone levels.
In the Senate Community Affairs References Committee’s final report on Issues relating to menopause and perimenopause (full review of the report here), a number of practitioners emphasised that combined MHT, which include body-identical transdermal estradiol, oral micronised progesterone and inclusion of testosterone where needed, is the best course of treatment.
In an interview with Aesthetic Medical Practitioner magazine, Dr Judy Craig, a Perth-based GP and cosmetic physician with a special focus on menopause, said: ‘The gold standard for managing symptomatic perimenopause and menopause is bioidentical estradiol in women who have had a hysterectomy, and estradiol combined with progesterone for those who haven’t had a hysterectomy.’ ‘Globally, MHT prescribing in women aged 45-64 averages only 5 percent; and in Australia, 14 percent. This is despite studies showing reductions in all-cause mortality and an increase in longevity for women on bioidentical MHT,’ she adds. ‘Once the concern over MHT increasing the risk of breast cancer is mitigated, it is hard to justify, medically, not prescribing MHT, due to the many health benefits to women.
Residual concerns surrounding the use of MHT
The senate inquiry raised the issue of continuing concerns about the Women’s Health Initiative (WHI) study in 2002. The WHI study was halted prematurely due to findings suggesting a potential increase in breast cancer risk associated with MHT use. While these results were widely publicised across the world, they were later criticised for oversimplifying the data and failing to distinguish between different types of MHT, doses and populations.
As explained by the Society of Hospital Pharmacists of Australia in their submission to the senate inquiry: ‘The release of the Women’s Health Initiative study in 2002 on the use of HRT in menopause became a catalyst for huge change in HRT use across the globe. The initial results and the proceeding media reports of increased risk of breast cancer from HRT use led to the sudden cessation of HRT in thousands of women.’
The flawed interpretation and reporting of the study led to widespread fear among both patients and clinicians, effectively stalling advancements in menopause care and discouraging the use of MHT, even for those who could benefit significantly from its use. This single study has had a lasting impact, creating a legacy of caution that persists in the management of menopause today.
According to the senate report, several submitters explained that healthcare providers, especially GPs, have a lack of confidence in prescribing, recommending and managing MHT as a form of therapy due to the WHI study findings and associated concerns about the purported increased risk of breast cancer, heart disease and stroke.
The WHI study has since been found to have significant limitations in its design and conclusions. Notably, it utilised a synthetic progestin which is not extrapolatable to the body-identical hormone treatments currently available.
Indications for MHT
- Moderate to severe vasomotor symptoms
- Prevention of postmenopausal osteoporosis in women at high risk
- Premature or early menopause (before 45 years)
Gold standard MHT available in Australia
- Oestrogen-only therapy: Oestrogen-only therapy is suitable for women who have undergone a hysterectomy and is usually utilised for treating vasomotor symptoms such as hot flushes and night sweats. It also has protective factors in preventing bone loss. It is available as tablets, skin patches and gels. Vaginal oestrogen in creams, pessaries or tablets is available for vaginal dryness or dyspareunia.
- Combined oestrogen- progestogen therapy: For women who have not had a hysterectomy, a progestogen should be used alongside oestrogen to counteract the risk of endometrial cancer from the oestrogen by itself. Progestogens are most often taken orally, and micronised progesterone capsules are a form of body-identical progesterone. Women who have had a hysterectomy do not require use of a progestogen. Cyclic or continuous regimens are available.
- Testosterone: Testosterone is sometimes added to MHT and may improve libido and energy in some women.
‘IT IS HARD TO JUSTIFY, MEDICALLY, NOT PRESCRIBING MHT, DUE TO THE MANY HEALTH BENEFITS TO WOMEN.’
Contra-indications to MHT
For women with the following disease or conditions, non- hormonal strategies are preferred, and decisions should involve multidisciplinary input.
- Hormone-dependent cancers, including breast and endometrial
- Undiagnosed vaginal bleeding
- Acute cardiovascular event
- Acute venous thromboembolism (NB2)
- Porphyria cutanea tarda
- Severe liver disease.
Risks and benefits of MHT
According to the Australian Menopause Society:
- MHT is the most effective treatment for hot flashes and night sweats. It also effectively treats vaginal dryness.
- MHT reduces the risk of postmenopausal bone fracture, including hip fracture.
- MHT use is not associated with weight gain.
- The risks are small in most women within 10 years of their final menstrual period. The risk of breast cancer attributable to combined MHT (oestrogen/ progestogen therapy) is small and decreases after treatment is stopped. Oestrogen alone has not been shown to increase breast cancer risk in high-quality randomised controlled trials.
- Non-oral routes of administration have fewer risks than oral preparations. Oral MHT increases the risk of stroke and the risk increases with age. Stroke risk is not significantly altered in women younger than 60 years with normal blood pressure. The risk may be less with the use of oestrogen gel or skin patches.
- Cessation of MHT is associated with increased cardiovascular and cerebrovascular events and increased risk of fracture.
A 2022 study published in The BMJ provided a comprehensive analysis of how different types of hormone therapy affect breast cancer outcomes. This large observational study reviewed data from over 600,000 women and found that, in line with other evidence, the risks of HRT are generally low.
Oestrogen-only HRT increased breast cancer risk only marginally and this extra risk disappeared after treatment stopped. This type of MHT can only be taken by women who have had a hysterectomy; the majority of women took combined HRT (oestrogen and progestogen), which was linked to a small increase in risk of breast cancer.
The study found the risk associated with combined MHT increased with the duration of treatment. There was no increase in risk of breast cancer for HRT taken for less than a year; for short-term use (less than 5 years), the increase in risk was minimal; for long-term use (beyond 5 years), the risk became more pronounced.
Age also contributed, with women in their 50s at lower risk than those in their 60s and 70s. The type of progestogen in combined HRT also made a difference: norethisterone was linked to the highest increases in risk of breast cancer, and dydrogesterone to the lowest risk.
Importantly, the risks declined once the HRT was stopped. Five years after stopping, there was no increase in breast cancer risk for women who had taken combined HRT for less than five years. Even for women who took combined HRT long-term (more than 5 years), risks reduced after therapy was stopped. For women in their 50s, there was no extra risk of breast cancer with combined HRT that was stopped more than 5 years previously. There was little extra risk among women in their 60s and 70s.
The researchers stressed that some women who had never taken HRT would still get breast cancer. For example, if a group of 10,000 women in their 50s had never taken HRT, 26 women would still get breast cancer in a year. If all 10,000 women had recently taken combined HRT for less than 5 years, 35 would get breast cancer. So, in this large group of women, the HRT is linked to 9 extra cases of breast cancer in a year. That is less than one in a thousand women.
Non-hormonal pharmacological treatments
For women unable or unwilling to use MHT, non-hormonal options to counter the effects of symptoms include specific antidepressants (SNRI and SSRI), epilepsy drugs (gabapentin) and clonidine, a medication for high blood pressure that can help with mild menopausal symptoms.
Fezolinetant (Veoza), a neurokinin 3 receptor antagonist, is a newly TGA-approved non-hormonal therapy for moderate to severe menopause-related vasomotor symptoms (VMS). Results have demonstrated rapid and substantial reduction in the frequency and severity of VMS. In patients taking fezolinetant, liver function should be monitored during treatment.
Laser, RF and other energy-based vaginal therapies
There are currently no energy- based devices included in the Australian Register of Therapeutic Goods that are approved for use for vaginal rejuvenation. This follows a post-market review by the TGA of such devices used for vaginal rejuvenation, published in November 2024. The review found there was insufficient clinical evidence to support the therapeutic use and long-term safety of these devices.
Complementary and alternative medicines
Research from Monash University has shown Australian GPs and specialists lack skills and confidence in managing menopause, and often recommend unproven and ineffective complementary and alternative medicines (CAMs) before prescribing MHT or effective non- hormonal therapy.
‘The use of unproven and ineffective CAMs, fuelled by misinformation on social media and the lack of counter-balancing accessible evidence-based information leads to a major waste of money for women and delays use of effective treatments,’ the Monash Centre for Health Research and Implementation said in their senate inquiry submission.
The Australian Medical Association submitted that some over the counter alternative treatments ‘… are not subject to the rigorous testing for content, safety and effectiveness that prescription treatments are subject to. Despite no clinical trial evidence, natural therapies are easily purchased and tend to be very expensive. The associated marketing is sophisticated and typically use celebrity endorsement.’
However, some alternative therapies may provide some relief, including cognitive behavioural therapy, yoga and acupuncture, dietary and herbal supplements, and, to a lesser extent, exercise and reflexology.
Studies have shown mixed results for lifestyle changes. However, since maintaining a healthy weight, regular exercise and reducing alcohol consumption contribute to overall health and wellbeing, addressing these lifestyle factors should be part of an integrated approach to menopause management.
‘By improving awareness, increasing research funding and fostering open dialogue, we can begin to address the gaps in menopause care and support,’ says Dr Craig. ‘This shift is crucial, not only for improving the quality of life for women but also acknowledging and addressing the broader economic and social costs associated with menopause.’ AMP
‘RESEARCH SHOWS AUSTRALIAN GPS AND SPECIALISTS LACK SKILLS AND CONFIDENCE IN MANAGING MENOPAUSE, AND OFTEN RECOMMEND UNPROVEN ALTERNATIVE MEDICINES BEFORE PRESCRIBING MHT OR NON-HORMONAL THERAPY.’
Practitioner resources
- The Practitioner’s Toolkit for Managing Menopause, developed by the Women’s Health Research Program in the Monash University School of Public Health and Preventive Medicine. Access at www.menopause.org.au/images/ pics/ptmm/a-practitioners-toolkit-for-managing-menopause.pdf
- In development: MenoPROMPT, Monash University’s co-designed, comprehensive evidence-based program – a simple assessment and decision-making tool, targeting menopause, integrated into practitioner software so that key information is immediately accessible.
- For continuing professional development (CPD) activities, including congress meetings, e-learning courses and webinars, as well as resources and practice support tools, visit menopause.org.au/hp and jeanhailes.org.au/ health/professionals.
