Is menopause managed well enough in general practice?

Abstract

Menopause is an important phase in the life of older women. Women’s life expectancy has increased worldwide. As women experience and perceive menopause differently depending on their personal, family and sociocultural backgrounds, perimenopausal symptoms can often go unnoticed and missed by general practitioners. General practitioners are uniquely placed in the healthcare delivery pyramid to close this gap and improve patients’ quality of life by identifying perimenopausal signs and symptoms early. This article shares knowledge about continuing medical education for general practitioners to close the existing gap. As there is great variability within each menopausal woman’s experience as well as among individual women, there is a need to individualise and render personalised care. By being able to discuss accepted and safe standards of care and by advocating for a holistic approach incorporating both non-pharmacological and pharmacological strategies, general practitioners would be able to improve the confidence of their patients for better health outcomes.

Introduction

Several community-based studies relate the onset of menopause to declining oestrogen levels as the ovaries attain senescence after 40 years of age. A bell-shaped curve is described, with menopause occurring at the mean age of 51.4 years.^1-3 The life span of women has increased worldwide, with women living longer than men by 5-6 years.⁴

Women experience and perceive menopause differently depending on their ethnicity, personal and family factors and sociocultural backgrounds.⁵ Therefore, perimenopausal symptoms can often be missed during medical consultations. General practitioners are uniquely placed in the healthcare delivery pyramid to address this gap apart from taking proactive strategies to educate and screen women for age-related disorders beyond menopause.

Menopause has been defined as the permanent cessation of ovarian function at the end of a woman’s reproductive potential.⁶ The International Menopause Society has defined natural menopause as:

• i) occurring after 12 consecutive months of amenorrhoea, for which there is no other obvious pathological or physiological cause,

• ii) occurring with the final menstrual period (FMP), which is known with certainty only in retrospect a year or more after the event, and

• iii) occurring in the absence of an adequate biological marker for the event.

The 2001 Stages of Reproductive Aging Workshop or improved STRAW+10 staging system has facilitated better understanding of the critical changes that occur in women before and after the FMP.⁷

Perimenopause is the first stage in the transition to menopause; the stage after menopause is called the postmenopausal period. Perimenopause can begin 4 to 8 years before menopause is finally attained and is clinically characterised by alterations in menstrual cycle intervals causing symptoms in some women owing to decreasing ovarian activity and fertility. Each of these phases is a gradual change that usually occurs over years.

Physiology of menopause

Menopause is not a pathological condition. It is a normal physiological transition involving the permanent cessation of menstruation for at least 12 months, during which ovarian follicles diminish in number, resulting in declining oestradiol (E2) and ovarian inhibin B levels, and serum follicular stimulating hormone (FSH) levels become elevated. Concomitant decline of anti-Mullerian hormone (AMH) production also occurs, as the number of ovarian follicles declines with age. Changes in the E2, FSH, AMH and inhibin B levels may precede or occur with irregular menstrual cycles and menopausal symptoms during the late reproductive and perimenopausal phases (Figure 1).

Figure 1. Stages of menopause (STRAW+10 staging system).⁸.

Oestrogen deficiency eventually leads to cessation of menstruation. The specific changes in the ovaries include a ‘blurring’ of the cortex and medulla, with invagination of the surface epithelium, loss of primary follicles and fibrosis in the medulla. The epithelium of the vagina atrophies, with thinning and loss of elasticity. The bone suffers during and after perimenopause, with increased osteoclastic activity because of oestrogen deficiency. The positive effect of oestrogen on the tunica intima of blood vessels declines rapidly, contributing to vasoconstriction and increased serum lipid low-density lipoprotein levels.

A fundamental change throughout the transitory perimenopausal period is the fluctuating and erratic levels of female hormones. Oestrogen levels generally decline but do so in an unpredictable manner. Sometimes, there can be relatively more oestrogen present during perimenopause than ever before. This altered proportion of oestrogen and progesterone causes problematic symptoms.^8,9 Menstrual cycles may lengthen or shorten correspondingly, and women can present with symptoms of relative oestrogen excess, oestrogen deficiency or both.

Role of individualised clinical evaluation

Genetics and lifestyle can affect the age at menopause, which typically occurs from 45 to 55 years of age. The occurrence of the FMP is significantly later for non-smokers and women with better baseline health, higher levels of education, higher body mass index and prior use of oral contraceptive pills. 10 Menopausal symptoms, specifically vasomotor symptoms (VMSs), and the genitourinary syndrome affect the quality of life (QoL), with over 50% of those affected having bothersome symptoms.^11-13 However, the majority of women do not seek treatment. VMSs (i.e. hot flashes and night sweats) and the genitourinary syndrome of menopause (GSM) (i.e. vaginal dryness) are specific to oestrogen deficiency. Apart from VMSs and the GSM, the menopausal transition is often also accompanied by psychological symptoms, including stress and anxiety, which are often the earliest reasons why women visit their general practitioners during this stage. A recent mixed-method observational study of peri/menopausal women conducted in the UK revealed that women were ignored, not believed or refused menopausal hormone therapy (MHT) owing to their general practitioner’s lack of knowledge¹⁴ in managing perimenopausal symptoms.

The longitudinal nature of the landmark multi-site “Study of Women’s Health Across the Nation” or SWAN study, which examined the health of women during their middle years, including their physical, biological, psychological and social changes during the transition period, helped to distinguish some of the effects of mid-life ageing versus changes in health due to the menopausal transition.¹⁵ This study also showed that Chinese and Japanese women complained less frequently about menopausal symptoms than did Caucasian women in the USA. Similar observations have been seen among Asian women.^14,16

Older women often do not readily volunteer symptoms during consultations, and general practitioners may need to explore this with them directly, with some probing.¹⁷ As there is great variability within each menopausal woman’s experience as well as among individual women, there is a need to individualise and render personalised care.¹⁸

Not all women complain of menopausal symptoms. Early detection is crucial to ensure that every woman not only maintains her physical health but also experiences a good QoL mentally and sexually.¹⁹ Directed questions about menopausal symptoms should be integral to the interview of women aged beyond 40 years, who may consult for a range of symptoms. Applying a ‘symptom-checker’ in women in mid-life, which requires inquiring about mental/emotional symptoms and genitourinary symptoms, and physical examination, which includes mental status, memory, breast and pelvic examinations, would detect unreported problems pertinent to perimenopausal and postmenopausal women. Perimenopausal symptoms may masquerade as urinary tract infections, gastroesophageal reflux problems, anxiety or the empty-nest syndrome and therefore be missed and improperly managed by doctors as separate entities, instead of holistically. The common perimenopausal symptoms among women are shown in Table 1

Table 1. Perimenopausal symptoms and underlying causes.

OESTROGEN EXCESS
	Signs/symptoms	Underlying causes
Menstrual symptoms	Irregular cycles with heavy bleeding	Disruption of normal cyclical hormones; may be due to fibroids that occur when oestrogen levels are at their highest
General symptoms	Weight gain Mood swings Headache	Due to increased levels of oestrogen and decreased levels of progesterone
OESTROGEN DEFICIENCY
	Signs/symptoms	Underlying causes
Menstrual symptoms	Irregular cycles with absent periods	Disruption of cyclical hormones
Urogenital and sexual symptoms	Vaginal dryness causing itchiness Dyspareunia Urinary urgency and frequency Recurrent urinary infections	Oestrogen deficiency causes symptoms of the genitourinary syndrome of menopause. The primary role of oestrogen in vulvovaginal tissues is: i) to maintain the integrity of the external genitalia, vaginal epithelium and stroma; ii) to lubricate the vagina through vascularisation and iii) to maintain the integrity of the epithelium of the urethra.
Psychological symptoms	Depression Anxiety/irritability Difficulty to concentrate Decline in memory	i) Oestrogen strongly links with neurotransmitters in the brain. ii) Oestrogen encourages blood flow in the brain to keep it functioning optimally. Therefore, deficiency causes lapses in brain function, resulting in short-term memory loss.
Vasomotor symptoms	Night sweats with hot flashes Sleep disturbance	Fluctuating hormone levels affect the body’s temperature control.
General symptoms	Fatigue Muscle/joint pains or crawling sensation on the skin (‘formication’)	Due to poor sleep quality

A small proportion of women may have bothersome VMSs lasting over 10 years.²⁰

It is essential to conduct a thorough physical and pelvic examination after a comprehensive gynaecological history-taking as part of standard practice (Tables 2 and 3).

Table 2. History-taking during perimenopause.

Detailed history-taking
1.	Personal history
2.	Menstrual and sexual histories
3.	Obstetric and gynaecological histories
4.	Specific menopausal symptoms (VMSs and vaginal dryness)
5.	Mood and psychological problems
6.	Skeletal and mobility problems
7.	Cognitive performance
8.	Medical history (liver disease, breast and endometrial cancers, DVT, thyroid problem, diabetes mellitus, osteoporosis or recurrent UTI), including medications (hormones) and surgery (oophorectomy or hysterectomy)
9.	Social history (smoking, alcohol drinking or sedentary lifestyle)

Table 3. Comprehensive physical examination during perimenopause.

Detailed history-taking
1.	Body weight and body mass index evaluation
2.	Blood pressure and cardiovascular examination
3.	Breast examination
4.	Abdominal and gynaecological examination
5.	Transvaginal ultrasound
6.	PHQ-9 Depression Test Questionnaire and Mini Mental State Examination
Legend: VMS - vasomotor symptoms DVT - deep vein thrombosis UTI – urinary tract infection PHQ – patient health questionnaire

Key investigations for menopause management

Once a clinical diagnosis of menopause is made (12-month history of amenorrhoea with signs and symptoms), other causes of amenorrhoea (especially in younger women) and fatigue must be excluded.

In younger women who are suspected to have premature menopause (<40 years), the FSH and oestradiol levels (E2) are checked. The AMH level is the first parameter to decline as women approach menopause. A clinical diagnosis of menopause is typically made on the basis of a woman’s medical history and reported symptoms, and hormonal tests are typically not necessary for diagnosing menopause in older women who are experiencing symptoms. Instead, standard investigations that are routinely performed for all women in mid-life (Table 4) focusing on screening for age-related disorders are conducted.

Table 4. Investigations conducted during perimenopause.

1.	Urine pregnancy test
2.	Serum prolactin level assessment (in the presence of galactorrhoea)	To determine the cause of amenorrhoea
3.	Thyroid function test (hyperthyroidism)
4.	Full blood count	To determine the cause of fatigue
5.	Thyroid function test (hypothyroidism)
6.	Fasting blood sugar and HbAlc level assessment	If there are central obesity and signs of insulin resistance
7.	Fasting lipid profile
8.	Serum calcium and vitamin D level assessment	Indicated cases
9.	Serum B12 level assessment	Indicated cases
10.	Liver and renal profiles	Baseline
11.	Fasting blood glucose level assessment	To exclude diabetes mellitus
12.	Electrocardiogram	In the presence of chest discomfort or hot flashes
13-	Papanicolaou smear test	Performed thrice yearly until 65 years of age
14.	Mammogram	>50 years; twice or thrice yearly (low risk)
15-	Pelvic ultrasonography	To assess uterine size, endometrial thickness or adnexal masses

The transition from a normal menstrual cycle (pre-menopausal) to the perimenopausal and postmenopausal phases of life (without the need for blood investigations) can be established using the algorithm described by Jane and Davis.²¹

As a woman passes 40 years of age, a multitude of symptoms (Table 1) raises concern in the development of chronic disorders, including osteoporosis and cardiometabolic disorders, especially when the patient is overweight and has diabetes mellitus. Sleep disorders, mood changes and various degrees of depression warrant further exploration apart from the specific investigations shown in Table 4, as some of these conditions may be associated with the menopausal transition.

Oestrogen deficiency together with poor lifestyle habits can also cause cardiometabolic effects such as central abdominal fat deposition and insulin resistance with an increased risk of age-related chronic diseases, including type 2 diabetes mellitus, hyperlipidaemia and hypertension; this mandates the need to screen for such diseases in perimenopausal women (Table 4).

QoL in the perimenopausal state

The increased life expectancy of women indicates that they will spend about 20—30 years after the onset of menopause. The menopausal transition is a disruptive process. As this transition affects the QoL, primary care physicians play a greater role in helping women cope with menopausal symptoms and adapt to life after menopause.²² The physical, psychological, social and sexual changes during the transition have impacted the QoL of 96% of women. VMSs have been reported in 49 different ways in clinical research.²³

Treatment options

Symptoms stemming from perimenopause, menopause or postmenopause are subjective. Some women may sail through menopause without any symptoms, as more substantial changes take place within their bodies. For other women, the transition may be a challenging phase in their life, especially when their roles in their family are changing.

Several safe strategies are available to help alleviate symptoms caused by fluctuating or declining levels of or deficiency of oestradiol, depending on the woman’s stage in the menopausal transition. However, there is no complete cure. There is no specific hormonal formulation designed for women in the perimenopausal period, wherein the goals of hormonal treatment are to regulate the menstrual cycle, provide safe contraception and offer relief from distressing symptoms.

MHT and antidepressants have both been used for menopause-related VMSs with good results. Although MHT is considered the gold standard treatment for VMSs and the GSM, it is known to be linked to an increased risk of oestrogen-dependent pathologies, such as breast and endometrial cancers, cardiovascular disease and thromboembolism. Therefore, clinicians must first assess patient-specific risks and benefits, which must be discussed with every patient on an individual basis. Women who are experiencing hot flashes but are unable to take hormone replacement therapy (MHT) or prefer alternative options often turn to non-hormonal therapies to manage the frequency and severity of VMSs. These non-hormonal therapies may include both non-pharmaceutical and pharmaceutical options.

i) Non-hormonal therapy may be instituted when MHT is contraindicated. Serotonin receptor inhibitors such as SSRI or selective norepinephrine receptor inhibitor, gabapentin and pregabalin have yielded improvements of VMSs by up to 50%-60%.

ii) Pelvic floor physical therapy and bladder training are useful adjuvant measures for urinary incontinence.

iii) Nutrition, exercise and other lifestyle measures

In an 8-year prospective study conducted on Finnish women, the role of physical activity on the QoL among menopausal women was studied.^24,25 Although the menopausal transition was not significantly correlated with changes in the global QoL, the study highlighted the importance of increased physical activity and supported the hypothesis that menopause may provide a ‘window of opportunity’ for counselling by v) general practitioners to induce lifestyle modification. General practitioners should take cognisance and proactively work with preventive and lifestyle measures, such as a balanced diet, exercise regime, smoking and alcohol drinking cessation and relaxation therapy, rather than expect women’s condition to improve spontaneously when symptoms resolve.

iv) Cognitive behavioural therapy (CBT) for women with low mood

CBT has been used as a useful tool for a range of health-related problems in the perimenopausal period, including hot flashes, depressed mood, sleep problems and stress. Relaxation and paced breathing are employed to calm the body’s physical and emotional reactions. Yoga, breathing exercises and meditation have effectively reduced physical and psychosocial symptoms. Life stresses, the empty-nest syndrome, disability or death of a spouse are additional stresses that compound menopausal symptoms, leading to anxiety—depressive illness and difficulty in coping with day-to-day living.

A comprehensive and holistic approach is necessary to effectively manage these issues. Loss of sleep, excessive consumption of caffeine, nocturia, age-related pelvic organ prolapse and urinary incontinence need careful evaluation and cause-focused therapy. Stress, caffeine consumption and smoking can worsen mastalgia.²⁶ Many women mistake these symptoms as part of serious diseases and waste much time, energy and money pursuing ineffective remedies, with work impairment and unnecessary healthcare utilisation.²⁷ In cases of sexual dysfunction, marital and sexual therapies and counselling can be implemented. Promoting healthy lifestyle and addressing negative attitudes about the menopausal transition through educational interventions should be strongly encouraged. Good nutrition, physical activity such as brisk walking for a minimum of 150 minutes per week, cessation of smoking and reduction of alcohol intake should also be highlighted, as these would benefit women of all ages.

v) MHT

In the menopausal transition, cyclical hormone therapy can be prescribed if regular menstrual bleeding is desired. Treatment should be individualised on the basis of patient and risk factors, and a non-oral oestrogen is often preferred. Oestrogen—progestogen therapy (EPT) in the form of oral contraceptives and combination therapy with intrauterine levonorgestrel and oral/percutaneous oestrogen (LNG-IUS plus oral/ percutaneous oestrogen) have been commonly used. Ten to fourteen days of progestogen therapy can be added to MHT if the patient has not undergone hysterectomy. The shortest duration of therapy is typically prescribed, aiming to discontinue MHT within 3—5 years. A tailing-off period of 6 months is advised when MHT is to be terminated.

MHT is the most effective treatment for VMSs associated with menopause. Its benefits outweigh the risks for symptomatic women, provided it is administered within 10 years after the diagnosis of menopause and within 60 years of age. The use of MHT in symptomatic women during this ‘window of opportunity’ significantly counteracts the ageing process at many target organs.²⁸ MHT is contraindicated in patients with breast cancer. Oral oestrogen is associated with an increased risk of venous thromboembolism (VTE). Transdermal oestrogen and vaginal rings are preferrable for women who have an increased risk of VTE (i.e. smokers or obese women). Selective serotonin receptor inhibitors, selective norepinephrine inhibitors, gabapentin and pregabalin are alternatives when MHT is contraindicated.

Unless treated, urogenital atrophy persists after menopause. The GSM, previously known as atrophic vaginitis or vulvovaginal atrophy, is caused by low levels of oestrogen. It affects more than 50% of postmenopausal women, mostly causing urinary problems and sexual dysfunction. Low-dose over-the-counter vaginal oestrogen cream is safe and effective. It is the mainstay treatment when symptoms are limited to vaginal dryness, discomfort or dyspareunia.²⁹ However, this should be avoided in survivors of hormone-sensitive cancers.

Although MHT prevents bone loss and fractures, it is not specifically prescribed for the prevention of osteoporosis.

Women should be prescribed MHT after informed consent is obtained, and evaluation is performed for its suitability. Doctors must document patients’ deliberated reasons for considering MHT (ET/EPT) (e.g. QoL or severity of symptoms) as well as consideration of risks and benefits of short-term ET/ EPT use. Once started, the regimen should be reviewed annually to justify safe continuation of MHT to within 10 years after menopause. In most instances, MHT should be prescribed for 2-3 years and reviewed for extension of use to up to 5 years. Long-term use needs thorough review of risk factors.

vi) Progesterone-only regimen

Although the levonorgestrel-releasing intrauterine device (LNG-IUD) can suppress the endometrium while providing contraception, it is particularly helpful for managing cases of heavy bleeding. Although initial breakthrough bleeding may occur, 80% of women become amenorrhoeic after 1 year. The LNG-IUD can be combined with oral or transdermal oestrogen and left in situ for 5 years. However, the LNG-IUD alone will not stop vulvar and vaginal changes or VMSs. When oestrogen is not tolerated, oral medroxyprogesterone 10 mg daily can be administered to alleviate VMSs.³⁰

The Women’s Health Initiative Study employed treatment with medroxyprogesterone 2.5 mg daily and showed an excess risk of coronary heart disease and breast cancer. Micronised progesterone taken at bedtime reduces sleep disturbance and is safer for the cardiovascular system. If hysterectomy has been conducted, progestogen is not prescribed. There are controversies that the progestogen component in MHT increases the incidence of breast cancer. The selection of cases and duration of therapy with newer micronised progestins have been successful with the safe use of this hormone.³¹

vii) Combined oral contraceptive pills (COCPs)

COCPs not only provide contraception and menstrual cycle control but also offer relief from VMSs and other symptoms. Low-dose ethinyloestradiol OCP (20 pg) or oestradiol-containing OCP is preferred. However, each woman’s risks in using COCPs must be assessed individually. Detailed history-taking must exclude risks such as smoking, coexisting high blood pressure or cholesterol level, liver disease, migraine with aura, history of thrombosis, epilepsy and family history of breast cancer. Third-generation oral contraceptives are recommended for smokers and women aged above 35 years if there are no other risk factors for thrombotic arterial disease.³² VMSs in the pill-free week can be managed by discarding the placebo tablets or adding a low dose of oestrogen. When contraception is no longer needed, the woman can transition from COCP therapy to MHT.

Continuous COCP therapy is required when menopausal symptoms are experienced during pill-free days when low-dose oestrogen-containing COCPs are prescribed. This therapy may be prescribed after good case selection and case screening.

viii) Selective oestrogen receptor modulators (SERMs) and vaginal dehydroepiandrosterone

SERMs and vaginal dehydroepiandrosterone are newer treatment options that can also be considered. The combination of bazedoxifene with conjugated oestrogen has been shown to be effective for treating VMSs in women who cannot tolerate the side effects of progestogen (e.g. bloating and breast tenderness). However, similar to other SERMs, bazedoxifene is associated with an increased risk of deep vein thrombosis.

ix) Tibolone

Tibolone is a synthetic steroid that is not as effective as oestrogen in reducing VMSs. Nevertheless, it has beneficial effects on bone mineral density and sexual dysfunction. Recurrence of breast cancer and stroke (>60 years) are its known complications.

Conclusion

Menopause provides an opportunity to initiate preventive and screening strategies. It should not be approached as if it is only a transition from the reproductive age. As women live for 2—3 decades after menopause, screening and definitive management of biopsychosocial aspects of chronic cardiometabolic diseases should be considered apart from addressing the disabling symptoms of menopause if present.

It would be prudent to offer non-pharmacological therapies first and hormonal therapy for moderate-to-severe symptoms last. The recommendations for good practice are to use the lowest dose possible for the shortest duration, and a non-oral route for oestrogen is preferred. Non-pharmacological lifestyle and psychological approaches, including health literacy, may contribute to effective relief of symptoms and are often better accepted by patients. There is a widespread underuse of safer non-pharmacological therapies, such as psychotherapy, relaxation therapy, occupational therapy and nutritional therapy, in the treatment of menopausal symptoms. While possibly not effective as stand-alone treatments for distressing symptoms, the combination of non-pharmacological and pharmacological approaches may improve management outcomes and minimise the side effects of MHT.

Cases that require specialist care are those considered complex and those that do not respond to first-line MHT. Cancer survivors would require referral to a cancer specialist. Osteoporosis may be managed with bone-enhancing medication and supportive/ supplemental care. Some examples of cases that are better referred are as follows:

• Early menopause (before 40 years of age) or premature ovarian insufficiency,

• History of breast cancer or other hormonesensitive cancers (endometrial cancer),

• Pelvic endometriosis (after total hysterectomy and bilateral salpingo-oophorectomy),

• Significant menopausal symptoms that do not respond to first-line treatment options (e.g. hormone therapy),

• Complex medical histories or multiple chronic health conditions,

• Consideration of or plan for surgical menopause and

• Concerns about the long-term health risks associated with menopause, such as osteoporosis and cardiovascular disease.

As the global population continues to age, the proportion of women aged 50 years and above is increasing. In 2021, this age group accounted for 26% of all women worldwide, up from 22% a decade earlier.³³ With more women expected to live into very old age, ageing is likely to become an increasingly important ‘sex issue’. General practitioners who are well placed at the first-contact level can help to close the gap and improve patients’ QoL by recognising perimenopausal signs and symptoms early. By being able to discuss accepted and safe standards of care with their patients and by advocating for and individualising a holistic approach incorporating both non-pharmacological and pharmacological strategies, general practitioners would be able to promote active ageing, enhance the QoL of women in mid-life and close the existing gap.

It is therefore important that women have access to appropriate menopause-related health information and services in their communities to support healthy ageing and good QoL before, during and after menopause. Unfortunately, in Malaysia, there are currently no health policies or financing programmes to ensure the inclusion of menopause-related services to routine healthcare delivery for women.

Menopause is often not discussed within families, communities, workplaces or healthcare settings. Therefore, this short review is aimed at general practitioners to take a more considered and proactive view in the management of menopause wherein the mainstay management is a holistic, biopsychosocial patient-centred strategy that includes lifestyle measures aimed at promoting and maintaining good health in women in mid-life and wherein hormone therapy is reserved only for eligible moderate and severe cases of VMSs and the GSM.

Key learning points

1. The influences of and dynamic changes during menopause extend beyond reproductive tissues.

2. Early detection of the menopausal transition in women beyond 40 years old is critical in optimising health outcomes.

3. Perimenopausal symptoms masquerading as other conditions are often treated as separate entities and missed.

4. Non-pharmacological therapies are offered first and hormone therapies, last.

5. MHT is reserved for the following:

   • a. moderate-to-severe VMSs,

   • b. severe vulvar and vaginal atrophies and

   • c. prevention of osteoporosis in postmenopausal women at a high risk of fractures who are younger than 60 years or within 10 years of menopause.

Author Contributions

Both the named authors have read the manuscript and approved its submission. The contributions from each author are:

1. Dr Chandramani Thuraisingham: article conception, drafting and revising of article and abstract and final approval of version

2. Dr Sivalingam Nalliah: revising of article and final approval of version

Conflicts of interest

None.

Funding

Nil.

How does this paper make a difference in general practice?

• Menopause is an important phase in the life of older women who often do not readily volunteer symptoms.

• As the conservative nature of some cultures pose as a help-seeking barrier, general practitioners need to explore perimenopausal symptoms with older women directly, with some probing.

• Hormone therapy should be only part of a holistic biopsychosocial management strategy that also includes lifestyle measures aimed at promoting and maintaining good health.

• By sharing knowledge through continuing medical education and by providing a framework that could be applied as a symptom-checker, it is hoped that general practitioners will be able to close this gap.