Menopause is a clinical diagnosis in women over 45 with typical symptoms and irregular/absent periods — hormone testing is usually unnecessary. The job at this visit is to stage where she is, map symptoms across all four domains, and check whether anything excludes or delays starting MHT.
STRAW+10 staging
Based on menstrual cycle pattern, not a blood test.
-2Early perimenopause — cycle length varies by 7+ days; FSH starts to fluctuate.
-1Late perimenopause — 60+ days amenorrhoea; vasomotor symptoms typically most intense.
+1Early postmenopause — first 1–6 years after final period; symptoms often still prominent.
+2Late postmenopause — 6+ years on; vasomotor symptoms usually settle; urogenital symptoms persist or progress.
Symptom domains — map all four
①Vasomotor: hot flushes, night sweats, palpitations.
②Psychological: low mood, anxiety, irritability, brain fog.
③Urogenital: dryness, dyspareunia, urgency, recurrent UTI.
④Musculoskeletal & sleep: joint aches, disrupted sleep independent of night sweats.
Investigations (mostly clinical)
- No routine FSH/LH or oestradiol needed over 45 with typical symptoms.
- FSH may help if under 45, hysterectomy without typical symptoms, or on combined hormonal contraception.
- FBE/TFT/ferritin if symptoms overlap with anaemia or thyroid disease.
- Baseline BP, weight, lipids & CV/fracture risk to inform — not diagnose — the MHT discussion.
MBS 695 / 19000 — health assessment — From 1 July 2025, MBS items 695 (GP) and 19000 cover a structured menopause/perimenopause health assessment of at least 20 minutes — history, focused exam, initiating relevant investigations or referrals, and a documented management plan. Temporary for an initial two-year period; confirm current item numbers and fees at mbsonline.gov.au.
When MHT needs caution or exclusion
- Current or recent hormone-sensitive breast cancer.
- Active VTE, or significant VTE risk/inherited thrombophilia.
- Active or decompensated liver disease.
- Undiagnosed vaginal bleeding — investigate before considering MHT.
Safety
- Unexplained/unscheduled bleeding is always investigated before or during MHT; prefer transdermal estradiol over oral if there's a VTE, migraine, liver or cardiometabolic risk factor.
- Labelling is shifting: in Nov 2025 the FDA began removing boxed-warning language on breast cancer/CVD/dementia risk for most MHT products — AU product information may lag; confirm current PI.
Red flags / refer
- POI under 40: endocrine and gynaecology referral; genetic counselling if familial.
- Breast cancer survivor with severe VMS: joint management with oncology — non-hormonal options first.
- Unscheduled bleeding on MHT, or complex comorbidity (active CHD, BRCA/Lynch, recent stroke, refractory VMS).
WH-05A v1.0 · Reviewed Jun 2026 · Review Jun 2027
Summary guidance only — verify staging and risk stratification against AMS guidance, the IMS 2024 White Paper and NICE NG23. See companion sheet WH-05B for prescribing & monitoring. Confirm current guidance at menopause.org.au.
