How to manage perimenopause in women's health

Perimenopause is one of the most common women’s health presentations encountered in primary care, and general practitioners are often the first clinicians consulted regarding menopausal symptoms and treatment.

Perimenopause is defined as the phase leading up to a woman’s final period and the following 12 months, typically starting during the 40s and lasting for four to six years. Menopause is identified retrospectively when there has been at least 12 months without menstruation and usually occurs between the ages of 45 and 55.

Three-quarters of women will experience at least mild symptoms during perimenopause, so it remains a common reason for attending the general practitioner.

Women may present with vasomotor symptoms, sleep disturbance, mood or cognitive changes, genitourinary symptoms, or changes in libido. Menstrual cycle changes are characteristic, including variable cycle length and changes in bleeding. Abnormal bleeding, such as menorrhagia, post‑coital, or intermenstrual bleeding, should be investigated as usual, for example with examination, imaging and testing for sexually transmitted infections where appropriate.

Alternative explanations for symptoms, including pregnancy, thyroid dysfunction, anaemia and depression, should also be considered. Physical examination may not be required and is guided by presentation; when indicated, it may include blood pressure, BMI, and vulvovaginal examination. These consultations also provide an excellent opportunity to address cardiovascular and bone health and ensure routine screening is up to date.

Perimenopause may be diagnosed clinically when the woman is 45 or older with typical vasomotor symptoms and changes to their menstrual cycle, and routine hormone testing is not generally indicated. FSH testing may be considered in women aged 40–45 with suggestive symptoms and menstrual changes. For women taking hormonal contraception, diagnosis of perimenopause may be more difficult; however, it should remain symptom-focused.

Pregnancy remains possible during perimenopause despite irregular periods, and hormone replacement therapy (HRT) is not contraceptive. Women using non-hormonal contraception should continue it for two years after their final menstrual period if aged under 50, or one year if aged 50 or over. Contraception can generally be stopped at age 55, although the method used should be reviewed as women approach menopause.

Education and reassurance may be sufficient initial management for women with mild symptoms. Healthy eating, regular physical activity, smoking cessation, and reduced alcohol intake support overall health and may improve menopause symptoms. Practical cooling strategies, avoiding individual triggers and good sleep hygiene may also help women manage symptoms.

HRT can be considered in eligible women with troublesome symptoms. HRT should be tailored to the woman’s age, medical history, comorbidities, and personal preferences. Women with a uterus require adequate progestogen alongside systemic oestrogen for endometrial protection, usually through a sequential regimen during perimenopause. Low-dose vaginal oestrogen can treat genitourinary symptoms, either alone or alongside systemic HRT.

Menopause-specific cognitive behavioural therapy (CBT) can help with vasomotor symptoms, sleep and mood. Non-hormonal medicines may be considered when HRT is unsuitable, with selection guided by symptoms, comorbidities and adverse effects. Treatment should be reviewed after three months and at least annually thereafter, assessing benefit, adverse effects and ongoing contraceptive needs.

Referral is indicated where the diagnosis is uncertain, symptoms remain troublesome despite treatment, or management is complicated by significant comorbidity.

As perimenopause affects most women and commonly presents in primary care, GPs play a key role in recognising symptoms, excluding alternative diagnoses, providing evidence-based treatment options, and supporting women’s long-term health.

- Dr Samantha Miller, MBChB

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References

1. Australian Government: Department of Health, Disability and Ageing. https://www.health.gov.au/perimenopause/understanding/perimenopause
2. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of vasomotor and genitourinary symptoms of menopause (2026). https://ranzcog.edu.au/wp-content/uploads/Managing-Menopausal-Symptoms.pdf
3. National Institute for Health and Care Excellence (NICE)(2026). Clinical Knowledge Summary: Menopause. https://cks.nice.org.uk/topics/menopause/
4. National Institute for Health and Care Excellence (NICE) (2015, updated 2026). Menopause: identification and management. NICE guideline NG23. https://www.nice.org.uk/guidance/ng23
5. National Institute for Health and Care Excellence (NICE)(2017). Quality Standard 143: Menopause. https://www.nice.org.uk/guidance/qs143
6. Spencer, R., & Newman, A. (2026). The menopause consultation. Australian Journal of General Practice, 55(4). https://doi.org/10.31128/AJGP-09-25-7834
7. Australasian Menopause Society. The perimenopause or menopausal transition. Information sheet. https://www.menopause.org.au/images/stories/infosheets/docs/Perimenopause_Information_Sheet.pdf
8. Department of Health, State Government of Victoria, Australia. Better Health Channel: Menopause. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menopause