Menopause treatment in general practice: diagnosis, HRT safety, and when not to start

Gynaecology CPD lecture

The Otter file does not state a name for the clinician who gave the menopause teaching (Speaker 2). No name is invented here. Near the end of the same recording a second person, Abby, introduces herself as obstetrics, gynaecology and fertility at Pindara / Queensland Fertility Group — that is a different talk starting, not extra HRT protocol.

Diagnosis: 12 months, FSH, and the whole hormone profile

We came from an era, she said, where people used HRT without a clear map. It is quite safe if you use it the right way. First job: know where you are. Is she menopausal, perimenopausal, or premature ovarian insufficiency?

Menopause, as she defined it for the room: no period for a good twelve months, plus a high FSH. Do a hormone profile. Do the whole thing, not just FSH. FSH can be borderline high because she is in a high-FSH phase of the cycle. If oestrogen is high as well, she is not menopausal — she is cycling. Low oestrogen plus high FSH: she is probably in menopause. If you are not sure, repeat in four to six weeks.

Bleeding, cancer, and do not start hormones blind

Irregular periods, a bit of poor sleep, a bit of body ache: is it menopause or not? You need the profile. If she has a little bleeding as well, you need to know whether this is postmenopausal bleeding. It could be cancer. She put the numbers at 2% cancer, 98% not — and you still cannot afford to miss the 2%. If she is not postmenopausal, treat it as dysfunctional bleeding: usual work-up, ultrasound, cervical screening, tick the boxes, then implement treatment.

Perimenopause, as she used the word: still bleeding, and the hormone profile does not tick menopause diagnostic criteria. You do not have to treat perimenopause with HRT. Hot flushes are less the story until the diagnosis is actually menopause — her wording in the room. The practical split later in the hour is clearer: if she is not menopausal and still bleeding, she might get pregnant, and she needs contraception, not premature HRT.

The HRT window: smallest dose, shortest time, not after 65

Golden rule: smallest dose, shortest period, up to a maximum of five years. You can be a bit more flexible on the five years now because there are safer options on the market. If she is lean, ticking the boxes, no extra risk for heart disease, liver disease, hypertension, or smoking, some people can go toward ten years. Everyone agreed: not more than ten years, and you should not start HRT more than about ten years after menopause.

Women are arriving at 75 and 78. “I didn’t have issues before, but all my friends are taking HRT.” That is beyond the benefit. There is a window of opportunity. Using or continuing HRT beyond that mark increases risks: breast cancer, stroke, clots. Use it the right way and it is useful. Use it as a morning-tea club drug and it is not.

Coming off at two years, non-hormonal options, vaginal oestrogen

When do you start talking about coming off? She starts the conversation after two years — the calmest time that hot flushes are controlled, and the time they often stop. About 15–20% continue to have hot flushes longer. Address it. You can restart if you are still inside the safety marks.

Non-hormonal options she named: SSRI, and a word Otter heard as “candy” — most likely gabapentin in this list, not invented as a brand. Decrease alcohol, caffeine, and spicy food: intensity and frequency come down. Counselling is the job. What to expect, risk, benefit.

When they stop HRT, warn them: about 50% get symptoms again. Not for as long. Not as intense. Do not panic. You can walk them through it with SSRI, gabapentin, lifestyle.

Vaginal oestrogen (pessary or cream) is quite safe long term. She uses it in a lot of women. UTI risk down about 25%. Improves dryness. Fine in breastfeeding women who are not menopausal but have lactational atrophy. Fine for any number of years. She said it does not increase cancer or clot risk. Fine after 65. Fine for 10–15 years, any age, including alongside systemic HRT. Systemic oestrogen after 65 is the thing she would not do, regardless of symptoms.

Extra systemic-HRT benefits she named: less cardiac disease and myocardial infarction, better bone density, less osteoporosis. You do not use it as a preventative in someone with no symptoms. That is not the indication.

Baseline tests, contraindications, patches versus gel

Once you have the diagnosis and the hormone profile, before you start HRT:

• full blood count — do not miss low iron
• vitamin D
• thyroid, liver, kidney
• mammogram
• cervical screening
• bone density — so you know where you are standing

Contraindications she listed: do not use systemic HRT after age 65 regardless of symptoms; active severe cardiac disease; liver disease. If you give oestrogen and she has a uterus, you have to give progesterone as well. Progesterone beyond 65 has increased breast-cancer risk — another reason the window closes.

How does she choose the product? She gives a choice. She is not a fan of patches in Queensland: weather, older skin, wrinkling, irritation. She hardly writes them now. Tablets versus gel plus Prometrium at night. Transdermal is safer, especially for VTE. If she has no risk factors — lean, no smoker, no hypertension — and she prefers a tablet, that is okay. Some busy women will not rub gel in the morning. Acknowledge the VTE difference, then share the choice if it is still a safe choice.

Two pumps, Prometrium at night, follow-up

She starts with the smallest dose. For oestrogen gel she starts with two pumps (a GP in the room starts with one; she starts with two), then can increase to three or four. Teach the whole full-length pump stroke. Quick dabs are not a full dose. One pump on each arm/hand is how she usually explains it. It can go anywhere; it is not a patch, so it is not stuck on.

Prometrium: she was asked about cyclical versus continuous. She does not do cyclical HRT. One a day — the 100 milligram at night, which also helps sleep. Continuous. For a lot of women in perimenopause she is using combined pills rather than HRT anyway.

Catch-up at two months: using it, symptoms controlled, no side effects, dose right. Then six months, then one year, then yearly. When she says yearly, she still aims to stop at two years. She does not tell them on day one that they can stay five years. Guidelines allow five; some people say seven or ten; she stays on two and only rarely extends, because people get psychologically dependent.

No point starting HRT five or six years after menopause if she has no hot flushes, just because everyone at morning tea is on it.

Hot flushes that return, prolapse, incontinence, Mona Lisa

If hot flushes “come back” years later, that is very unlikely to be simple menopause returning. Check over-the-counter and compounded hormones. Check thyroid. Once hot flushes have stopped, they do not typically restart years later as the same menopause story.

Common symptoms: hot flushes, vaginal dryness, painful sex, mood swings, brain fog. Do not forget prolapse and incontinence. They get worse with lack of oestrogen. Pelvic floor muscle “just collapses,” as she put it. They will not volunteer this. They talk about flushes. Ask. It is not “just being old,” and it is not always surgery.

• pelvic floor exercise, bladder training, less alcohol and caffeine, sensible fluid — help urgency
• know urgency / urge incontinence versus stress incontinence — treatment is different
• medicines that help urge do not help stress; if she says the tablets are doing nothing, check which leak she actually has

Magnetic chair and vaginal laser (“Mona Lisa”) came up. She said Mona Lisa is not TGA-approved in Australia. Approved in Europe. Discretion of clinician and patient; they need to know that. Course as spoken: five sessions — first three four to six weeks apart, last two a year apart. Some people continue yearly. Not covered by private insurance. Benefit she quoted: about 99% improvement in dryness and painful sex; 60–70% for stress incontinence and urgency; some unquantified improvement in prolapse symptoms. Do a gynae examination. Incomplete emptying after a void is often a prolapse story.

Premature ovarian insufficiency: the 10-year rule does not apply

Everything about the ten-year safety clock does not apply to premature ovarian insufficiency. Definition as she used it: no periods, proven high FSH and a menopausal hormone profile, before age 40 (she also named 45 in the early-menopause / early-ovarian-failure conversation). Strongly recommend HRT regardless of symptoms, because they have increased cardiac mortality and morbidity. Continue until the natural age of menopause — she said 52–53 — and only then talk about the usual rules if they still need treatment. A woman who went into POI at 39 can safely, and should, be on HRT through to 52–53. That is not the same management as her 55-year-old friend.

Combined oral contraception can “do the trick” in POI, but HRT is better if she is truly POI. Sporadic ovulation is possible but very rare; pregnancy is very unlikely, not impossible.

Perimenopause: contraception, Nextstellis, Slinda, age 35

If she is not truly POI — irregular periods, profile not menopausal — combined oral contraception is the first long trip, up to 50. The only combined pill she named as approved in Australia to age 50 is Nextstellis, and it is on the PBS now. Slinda (drospirenone-only) is also in that conversation. Progestogen-only options remain. A GP asked if GPs can prescribe that combined option; she said the Australian / TGA line is that it is approved to 50. The room was talking perimenopause management, not using it as postmenopausal HRT.

Proven menopause: go HRT. Not menopausal yet, still bleeding here and there, profile not fulfilled: she might get pregnant. She needs contraception.

A 47-year-old with a high symptom score and a normal hormone profile: give the pill. It takes the edge off flushes. Do not start HRT early. When she really needs HRT she will already be approaching the safety margin, because VTE risk and progesterone–breast-cancer risk come with longer use and older age. Save it.

Age 35 on combined pills is a relative contraindication on its own. Age 35 or above plus high BMI, smoking, a bit of hypertension, diabetes, or heart issues becomes absolute. Transdermal oestrogen bypasses the liver and is a different instrument from the usual combined pill. Or go progestogen-only.

Migraine with aura: theoretically Nextstellis has a very small VTE story, but still follow the guideline — if migraine with aura, choose something else. Migraine without aura: okay in her telling. Slinda or any progestogen. Progesterone can take the edge off hot flushes maybe 40–50%, like other non-oestrogen options. They will not get 100% symptom control. She put it bluntly: there is no point having good quality of life if you do not have a life.

Mirena: some women go through menopause without noticing. You cannot test FSH while she is on hormonal contraception — negative feedback. Take the system into account before you call the number.

Combined pill after 35: the main extra risk is VTE and stroke. Age alone is relative; add BMI, smoking, cardiac events, or hypertension and it becomes a hard no.

What the recording does after the HRT teaching

After the questions trail off, a new speaker — Abby — introduces herself: obstetrics, gynaecology and fertility at Pindara, Queensland Fertility Group. She brought a laptop for cases. That is the start of a different session, not more menopause protocol, so it is not folded into the HRT advice above.

Take-home messages for clinic

1. Menopause = 12 months amenorrhoea plus high FSH on a full hormone profile. High FSH plus high oestrogen is a cycle, not menopause. Unsure: repeat in 4–6 weeks.
2. Do not start HRT or a pill until you know where you are. A little bleeding in someone who might be postmenopausal is PMB until you have thought about cancer (she said ~2%, and you cannot miss it).
3. Smallest dose, shortest time. Her counselling: two years, then revisit. Guidelines allow five; some people ten. Not more than ten. Do not start systemic HRT more than about ten years after menopause, and not after 65.
4. Vaginal oestrogen is a different drug — long-term, after 65, breastfeeding dryness, with or without systemic HRT. UTI risk down ~25% as she quoted. No clot/cancer story in her telling.
5. Baseline before systemic HRT: FBC, iron, vitamin D, thyroid, liver, kidney, mammogram, CST, bone density. Uterus in situ: add progesterone.
6. Transdermal safer for VTE. She rarely uses patches in Queensland weather. Gel two pumps to start, full pump stroke, Prometrium 100 mg at night continuous. Review at two months.
7. Fifty percent get some symptoms back when they stop — shorter, less intense. SSRI, gabapentin, lifestyle. Hot flushes years later: look for thyroid and compounded hormones, not “menopause came back.”
8. Ask about prolapse and leaks. Urge and stress are different treatments. Mona Lisa is not TGA-approved in Australia; quote that if you discuss it.
9. POI: ignore the 10-year clock. Replace until 52–53, symptoms or not. Cardiac risk is the reason.
10. Perimenopause needs contraception. Nextstellis was the combined option she named as approved to 50 and PBS-listed. A 47-year-old with symptoms and a normal profile gets the pill, not early HRT. Combined pill: age 35 is relative; 35 plus BMI/smoking/BP/diabetes/heart is absolute. Do not interpret FSH on a Mirena or a pill.

Dr Kotha · Gold Coast · menopause.drkotha.com