Breast cancer

Breast cancer is the most common cancer in women and the second most common cause of cancer deaths in women in Australia.

Breast cancer occurs when cells that line either the breast ducts or lobules begin to grow abnormally. The exact cause of this abnormal cell growth is not known, but there are identified risk factors.

Capivasertib is approved for adults HR-positive, HER2-negative advanced breast cancer after disease recurrence or progression with endocrine therapies. It should be used in combination with fulvestrant.

To identify patients who may be at risk of familial breast and ovarian cancer, a comprehensive family history must be taken and regularly updated.

Download: Complementary Medicines and Therapies for Hot Flushes | Information Sheet Many women experience hot flushes and night sweats around the time of menopause. Menopausal hormone therapy (MHT) has been proven to be effective in alleviating these symptoms. 1 However, some women choose to explore complementary medicines and therapies (CM&T) for relief of symptoms. There have been many studies on CM&T; some have suggested benefits, and others have shown no benefit. It can be difficult for consumers and doctors to interpret this mixed information. 2 This information sheet provides a brief overview of the current evidence for the use of CM&T.CM&T are sometimes referred to as “natural” and may be derived from plants and other sources. Some people believe that these products are safer than prescription products. However, scientific studies of these compounds do not always support this belief.2 Extracts from plants and other so-called “natural” products may actually cause harm and interact with prescribed medicines. 3 They do not necessarily act like the hormones normally produced by women. Some over-the-counter treatments, including plant extracts, are not subject to the rigorous testing for content, safety and effectiveness that prescription treatments are subject to. Herbal products may contain heavy metals, illegal ingredients and toxic chemicals as well as naturally occurring organic toxins.Any product used for the treatment of menopausal symptoms should have clinical studies showing it to be effective. This usually requires a placebo-controlled trial or a head-to-head comparison with a known effective treatment, or both. The placebo comparison is important because there is often a temporary placebo that commonly lasts around three months. 1Unless the product is tested for more than three months, it is not possible to say it is truly effective for menopausal symptoms. This short-term placebo effect is quite different from the prolonged improvement in menopausal symptoms demonstrated by treatments such as MHT. MHT reduces hot flushes by around 90% and continues to be effective for as long as they are used.4 Prescription drugs cannot be licensed until they have been shown to be safe and effective. This is not the case for over-the-counter remedies for menopausal symptoms.The AMS advocates that all therapies, whether prescription or alternative, should not be used unless there is good research evidence for their effectiveness and safety over the short and long term.CM&T use in AustraliaIn a national representative sample of 10,011 Australian women aged 59-64 years:539% of menopausal women consulted CM&T practitioners.75% used self-prescribed CM&T.95% consulted general practitioners (GP) and 50% consulted specialists during the previous year, and 12% were current menopausal hormone therapy (MHT) users.Similarly, a cross-sectional questionnaire-based study of 2020 Australian women aged 40-65 years living independently in the community found that the prevalence of CM&T use to manage menopausal vasomotor symptoms (VMS) was 13.22%.6Specific herbal and botanical therapiesBlack cohosh (Cimicifuga racemosa or Actaea racemosa)Specific extracts of black cohosh (isopropanolic), and higher therapeutic doses may improve menopausal symptoms, including hot flushes, as shown in a recent systematic review and meta-analysis.7 It should be noted that most of the included studies were conducted over short time frames (i.e. 3-6 months) and on small numbers of patients. In addition, although many were placebo-controlled trials, no studies compared black cohosh to conventional MHT.There were originally reports of liver toxicity from the use of black cohosh.8 A review of the 69 cases of suspected black cohosh-induced liver disease concluded that data does not support a direct causal relationship, with no signal of safety concern.9 Another meta-analysis found no evidence of black cohosh adversely affecting liver function, although studies were only up to 6 months of treatment.10Phytoestrogens (including red clover, below)A wide range of products containing plant or phytoestrogens, including soy products, are available as over the counter remedies for hot flushes. The active product of these is thought to be isoflavones which bind to the oestrogen receptor.  Isoflavones have a greater affinity for ER-? than for ER-? and possess both oestrogen agonist and antagonist properties. There are study limitations and differences in the interventions and the findings are mixed. Some studies demonstrated efficacy of soy in reducing VMS or severity and others showing no benefit from soy compared to placebo.11   Efficacy of soy may be influenced by whether an individual is able to metabolize the soy isoflavone daidzein to the more potent phytoestrogen, equol. Around 20-30% of Caucasians (compared to 40-70 % of Asians) are equol producers.12 Equol supplements are not readily available in Australia. Compared to placebo, equol supplementation was found to be superior to placebo for reducing VMS frequency in 3 of the 5 trials assessed in a 2019 systematic review and meta-analysis.13Updated information by the Cancer Council of Australia, influenced by the World Cancer Research Fund (WCRF) state that the available evidence suggests that soy and other isoflavone-containing foods are unlikely to increase cancer risk, and recommend that people, including those who have been diagnosed with breast cancer, who consume soy foods, should continue to do so.14,15Red clover (Trifolium pratense)Specific extracts of red clover may be useful in reducing the daily frequency of hot flushes, particularly in post-menopausal women, if taken for a period of 12 weeks and with higher doses of isoflavones (?80 mg/day,) and when the formulations contained a higher proportion of biochanin A.16Preliminary evidence suggests there may be some benefit from use of red clover in reducing cholesterol and low-density lipoprotein (LDL).17Siberian rhubarb (Rheum rhaponticum)A systematic review and meta-analysis of the standardised extract of Rheum rhaponticum root, ERr 731® significantly reduced the Menopause Rating Scale score compared with control.18 Ffurther research is needed to establish long-term efficacy and safety.11 St John’s wort (Hypericum perforatum)Combined with black cohosh, St John’s Wort can be effective for menopausal mood symptoms. A small, randomised control-trial (n=301) compared isopropanolic black cohosh extract and ethanolic St John’s wort against a placebo. Scores on the Menopause Rating Scale decreased by 50% in the treatment group compared to 19% in the placebo group. Depression also significantly decreased compared with placebo.19It is important to note that this therapy may interact with many prescription medicines. A lack of long-term safety data limits recommendations for its use.11Evening primrose oilVery few studies have addressed whether evening primrose oil improves hot flushes. Existing data shows no benefit in one study,20 and another small study showed a reduced frequency and severity of night sweats, but not hot flushes, compared to placebo at a dose of 1000 mg twice a day for 8 weeks (n=170).21 Evening primrose oil lowers the seizure threshold in people with epilepsy and interferes with the actions of anti-epileptic medication.3FlaxseedTwo small recent studies have shown flaxseed (also known as linseed) may be beneficial in improving hot flushes, night sweats and vaginal dryness in perimenopausal women, with the longest study conducted over 8 months.22,23 More evidence is needed before flaxseed can be recommended for use.Ashwaganda (Withania somnifera)Ashwaganda is an herbal product used in Ayurvedic medicine for its supposed adaptogenic and anti-stress properties. Only one small study, undertaken in 100 women over only 8 weeks, looked at its use for management of perimenopausal symptoms, with significant reductions in menopause symptom scores noted.24Importantly, the Therapeutic Goods Association (TGA) issued a safety advisory for Withania somnifera in 2024 due to reports of severe gastrointestinal symptoms and liver damage in patients taking the herb, several of whom required hospitalisation.25 Use of medicines or herbal supplements containing Withania somnifera should be avoided in patients with existing or previous liver pathologies.25Non-herbal medicines and therapiesVitamin ETwo very small and short-term studies have shown that Vitamin E (800 iu per day for 4 weeks) decreased the number of hot flushes by 1 per day when used by women who have had breast cancer (n=120),26 and reduced the number of hot flushes by 2 per day in other women (400 iu vitamin E daily, n= 51).27Omega-3Use of Omega-3 showed no difference in the frequency and severity of hot flushes, insomnia severity, sleep quality compared to placebo in a systematic review and meta-analysis (n=183).28Supplementation with omega-3 can improve the lipid profile of postmenopausal women,29 and the Heart Foundation of Australia recommend fish oils as part of an adult diet to help lower the risk of coronary heart disease.30Cognitive behavioural therapy, hypnosis, yoga and non-prescription medicinesThe AMS information sheet ‘Nonhormonal treatments for menopausal symptoms’ covers this.Compounded bioidentical menopausal hormone therapy (including progesterone cream)There is no evidence to support the efficacy or safety claims of compounded “bioidentical” hormones, or the superiority claims of these over conventional MHT. These products also pose the additional risks of variable purity and potency. All major national and international menopause societies have raised concerns about the safety and efficacy of these products and recommend that patients be counselled to avoid their use.31 The AMS information sheet Bioidentical hormones for menopausal symptoms has more information.Other CM&T with little or no evidence of benefit in treating menopausal symptomsWild yam creamGinseng (Panax ginseng or Panax quinquefolius)Maca (Lepidium Meyennii Walp or Lepidium peruvianum Chacon)Pine bark (Pyncogenol)Pollen extractMagnesiumCombination botanical therapiesHomeopathyAcupunctureUpdated April 2025Additional ReadingManagement of menopausal symptoms in women with a history of breast cancer | Cancer AustraliaThe 2023 Nonhormone Therapy Position Statement of The North American Menopause Society Advisory Panel: https://pubmed.ncbi.nlm.nih.gov/37252752/Memorial Sloan Kettering Cancer Center information on Integrative medicine including the “About Herbs” database. Note this is a USA website and not all of the products mentioned will be available in Australia: https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/searchReferencesMacLennan AH et al. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev 2004; 4:18.Nedrow AJ et al. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006;166(14):1453-65.Byard RW et al. What risks do herbal products pose to the Australian community? MJA 2017;206(2):86-90.MacLennan AH. Evidence-based review of therapies at the menopause. International Journal of Evidence Based Healthcare 2009;7(2):112-23.Peng et al. Complementary/alternative and conventional medicine use amongst menopausal women: results from the Australian Longitudinal Study on Women’s Health. Maturitas 2014; 79(3):340-42.Gartoulla et al. Use of complementary and alternative medicines for menopausal symptoms in Australian women aged 40-65 years. MJA 2015; 203(3):146.Castelo-Branco, C et al. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms - an update on the evidence. Climacteric 2021; 24(2): 109–119. https://doi.org/10.1080/13697137.2020.1820477Whiting PW et al. Black cohosh and other herbal remedies associated with acute hepatitis. MJA 2002;177(8):440-3.Teschke R. Black cohosh and suspected hepatotoxicity: inconsistencies, confounding variables, and prospective use of a diagnostic causality algorithm. A critical review. Menopause 2010; 17(2): 426–440. https://doi.org/10.1097/gme.0b013e3181c5159cNaser B et al. Suspected black cohosh hepatotoxicity: no evidence by meta-analysis of randomized controlled clinical trials for isopropanolic black cohosh extract. Menopause 2011;18(4):366-75.“The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society” Advisory Panel (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society.  Menopause 2023; 30(6): 573–590. https://doi.org/10.1097/GME.0000000000002200Cui C et al. Effects of soy isoflavones on cognitive function: a systematic review and meta-analysis of randomized controlled trials. Nutrition reviews 2020; 78(2), 134–144. https://doi.org/10.1093/nutrit/nuz050Daily J et al. Equol Decreases Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Journal of medicinal food 2019; 22(2):127–139. https://doi.org/10.1089/jmf.2018.4265World Cancer Research Fund / American Institute for Cancer Research. Wholegrains, vegetables and fruit and the risk of cancer [Internet]. London; 2018. Available from: https://www.wcrf.org/dietandcancer/exposures/wholegrains-veg-fruitInformation sheet: Soy & isoflavones | Cancer CouncilKanadys W et al. Evaluation of Clinical Meaningfulness of Red Clover (Trifolium pratense L.) Extract to Relieve Hot Flushes and Menopausal Symptoms in Peri- and Post-Menopausal Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2021; 13(4), 1258. https://doi.org/10.3390/nu13041258)Yigit E et al. Isoflavones obtained from red clover improve both dyslipidemia and menopausal symptoms in menopausal women: a prospective randomized placebo-controlled trial. Climacteric 2024; 1–7. Advance online publication. https://doi.org/10.1080/13697137.2024.2393121)Dubey VP et al. Efficacy evaluation of standardized Rheum rhaponticum root extract (ERr 731 ®) on symptoms of menopause: A systematic review and meta-analysis study. Journal of biomedical research 2024; 38(3):278–286. https://doi.org/10.7555/JBR.37.20230219Uebelhack et al. Black cohosh and St Johns’ wort for climacteric complaints. Obstet Gyn 2006; 107(2):247-55.Chenoy R et al. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ 1994;308(6927):501-3.Kazemi F et al. The Effect of Evening Primrose Oil Capsule on Hot Flashes and Night Sweats in Postmenopausal Women: A Single-Blind Randomized Controlled Trial. Journal of menopausal medicine 2021; 27(1), 8–14. https://doi.org/10.6118/jmm.20033Dizaye K et al. Effects of flaxseed (Linum usitatissimum) on climacteric symptoms and clinical parameters in post-menopausal women: Flaxseed effects on menopause associated symptoms and biochemical parameters. Iraqi Journal of Pharmaceutical Sciences 2023; 32:257-265.Shrivastava R et al. Effects of Flaxseed on Perimenopausal Symptoms: Findings From a Single-Blind, Randomized, Placebo-Controlled Study. Cureus 2024; 16(9): e68534. https://doi.org/10.7759/cureus.68534Gopal S et al. Effect of an ashwagandha (Withania Somnifera) root extract on climacteric symptoms in women during perimenopause: A randomized, double-blind, placebo-controlled study. The Journal of Obstetrics and Gynaecology Research 2021; 47(12): 4414–4425. https://doi.org/10.1111/jog.15030https://www.tga.gov.au/news/safety-alerts/medicines-containing-withania-somnifera-withania-ashwagandhaBarton DL et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 1998; 16(2): 495–500. https://doi.org/10.1200/JCO.1998.16.2.495Ziaei S et al. The effect of vitamin E on hot flashes in menopausal women. Gynecologic and obstetric investigation 2007; 64(4): 204–207. https://doi.org/10.1159/000106491Mohammady M et al. Effect of omega-3 supplements on vasomotor symptoms in menopausal women: A systematic review and meta-analysis. European journal of obstetrics, gynecology, and reproductive biology. 2018; 228:295–302. https://doi.org/10.1016/j.ejogrb.2018.07.008Wang J et al. Does Omega-3 Fatty Acid Supplementation Have Favorable Effects on the Lipid Profile in Postmenopausal Women? A Systematic Review and Dose-response Meta-analysis of Randomized Controlled Trials. Clinical therapeutics 2023; 45(1): e74–e87. https://doi.org/10.1016/j.clinthera.2022.12.009https://assets.contentstack.io/v3/assets/blt8a393bb3b76c0ede/blt30294411bd96bdd3/65ea8b022b979deb55896f8b/Summary_Evidence_FISH_FISH-OILS_FINAL.pdf“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794. doi: 10.1097/GME.0000000000002028. PMID: 35797481.

Access to this information sheet is reserved for members.  Log into view or Join Herefor instant access to member-only resources.   Key PointsSERMS are selective oestrogen receptor modulators - chemicals that have differing agonist or antagonist effects at the oestrogen receptor in different tissuesdifferent SERMS have different clinical applications, such as ovulation induction, treatment of osteoporosis, reduction in breast cancer risk or recurrence, treatment of vaginal atrophy and dyspareunianot all SERMS are available in all countries

Download: Surgical Menopause | Information Sheet Key pointsRemoval of both ovaries (bilateral oophorectomy) before a woman has gone through her natural menopause is referred to as “surgical menopause”Bilateral oophorectomy may be performed at the time of hysterectomy for benign disease or gynaecological cancers, or as part of risk reduction treatment in women with an inherited increased cancer riskNegative effects of surgical menopause include a sudden onset of severe menopause symptoms, loss of fertility, and increased risks of osteoporosis, cardiovascular disease, sexual dysfunction, mood disorders and cognitive issuesMenopausal hormone therapy (MHT) is advised for all women who undergo surgical menopause before the age of natural menopause, provided they do not have contraindications to MHT use.What is surgical menopause?Menopause refers to the final menstrual period. The average age of menopause in Australia is around 51 years, but most women start to experience perimenopausal symptoms due to decreasing ovarian oestrogen levels from their mid-40s, starting with a change to their menstrual cycles (1). Surgical removal of both ovaries (bilateral oophorectomy) before the average age of natural menopause is referred to as surgical menopause. Earlier menopause may also occur due to other gynaecological procedures, such as uterine artery embolisation, hysterectomy with ovarian conservation, or ovarian cystectomy, presumably due to compromised ovarian blood supply (2,3).Indications for bilateral oophorectomyBilateral oophorectomy (usually with bilateral salpingectomy) is uncommonly performed at the time of hysterectomy for benign disease in premenopausal women, e.g. for management of heavy menstrual bleeding (4).A more common indication for this procedure is to reduce the risk of ovarian cancer; this is especially relevant and beneficial to women who carry an inherited increased risk of developing cancer due to gene mutations in BRCA or HNPCC (Lynch Syndrome), for example (5). In general, bilateral oophorectomy is not recommended for premenopausal women who are concerned about ovarian cancer risk but have no inherited increased risk, as the disadvantages of removing normal, healthy ovaries prior to the average age of menopause far outweigh the very small risk of ovarian cancer (6).Some premenopausal women may elect to have their ovaries removed for other indications, such as endometriosis, persistent pelvic pain, and premenstrual dysphoric disorder. Their healthcare provider may suggest a trial of medically-induced menopause prior to surgery for these women, both to test how surgical menopause may affect their underlying symptoms, and also to allow a trial of MHT to test for patient tolerance to the hormone therapy (7).Positive effects of surgical menopauseReduced risk of ovarian cancer in women who are at an increased risk due to inherited genetic mutationsReduced anxiety around developing ovarian cancer in this populationReduced symptoms of persistent pelvic pain, particularly in women with endometriosis or pelvic adhesions who have ovarian involvementReduced symptoms of premenstrual dysphoric disorderNegative effects of surgical menopauseSudden and severe onset of vasomotor symptoms (VMS) and genitourinary syndrome of the menopause (GSM)Loss of bone density and increased risk of osteoporosis and possibly fractures (8)Increased risk of cardiovascular disease and an associated increase in mortality risk (9,10)Increased risk of cognitive impairment, including dementia (11,12)Impaired sexual function due to GSM symptoms, and hypoactive sexual desire disorder (HSDD) due to loss of ovarian testosterone production (13)Increased long-term risk of depression and anxiety (14)Loss of fertility potentialManagement of surgical menopauseIdeally, a menopause specialist should review premenopausal women prior to them undergoing bilateral oophorectomy, to explain the potential adverse consequences of surgical menopause and to plan for symptom management and long-term health optimisation (2).Lifestyle management and ongoing monitoringEvidence-based lifestyle management strategies for reducing cardiovascular and cognitive risk, and for maintaining bone density, should be discussed. These may include advice around diet, exercise, smoking and alcohol, and ensuring adequate sleep and dietary calcium and vitamin D intake. Cardiovascular risk factors should be assessed annually. In Australia, women who are under the age of 45 who have been hypogonadal for 6 months or more are entitled to Medicare bone density scans, which should be performed every 2 years.Symptom managementCurrent international guidelines recommend the use of MHT for all women who undergo early menopause, even if they have minimal menopausal symptoms, provided that they do not have any contraindications to use (3, 15, 16). MHT should be commenced as soon as possible post-operatively, reviewed within 6-12 weeks for symptom response, and continued at least until the average age of menopause. MHT is highly effective at treating VMS and GSM in this population, although higher oestrogen doses may be required in younger women than that used at the average age of menopause, to achieve physiological doses of oestradiol (3, 15). MHT can be commenced at a standard dose and titrated up according to response and side-effects. MHT can be prescribed to women who have had a bilateral oophorectomy performed for cancer risk reduction, and who have no contraindications to its use, without increasing their risk of breast cancer (17). Most guidelines recommend changing these patients to non-hormonal treatments for VMS if they are still required beyond the age of natural menopause, although there is minimal evidence for this recommendation (16, 18).A progestogen needs to be used in women who retain their uterus and should be considered for women with a history of endometriosis, even if she has had a hysterectomy, due to concerns about disease and symptom recurrence (19). Tibolone may also be considered as MHT for women with a history of endometriosis (2). Given that higher oestrogen doses may be required for symptom management in younger women, correspondingly higher doses of a progestogen may also be necessary (3).Prevention of morbidity and mortalityWhile a lack of longitudinal outcome data currently exists for this population, MHT has been shown in observational studies to reduce risks of osteoporosis and fracture, cardiovascular morbidity and mortality, and cognitive issues (16). Observational data show a probable “window of opportunity” for MHT initiation early after surgical menopause, especially to mitigate cardiovascular and cognitive risk (3).Management of sexual dysfunction and psychosocial risksThe sexual and psychological dysfunction arising after surgical menopause is complex and is likely to arise not only due to hormonal changes but also due to potential early ageing, self-esteem and body-image issues, emerging mood disorders and concerns around loss of fertility (3). As such, a biopsychosocial model is often required for the management of both sexual and psychological concerns after surgical menopause.MHT may improve some aspects of sexual dysfunction and vaginal oestrogen or dehydroepiandrosterone can be added to systemic MHT to further improve GSM symptoms (15). In addition, for women with HSDD despite MHT use, testosterone therapy can be considered, but women need to be advised that long-term efficacy and safety are unknown (16, 20). Note that currently there is conflicting evidence for use of testosterone for other indications in patients with early menopause, specifically for neurological function, bone health and cardiovascular health (16).With regards to the increased long-term risk of a diagnosis of depression and/or anxiety following surgical menopause, given that these risks have only been identified in observational studies, it is unclear whether or not MHT use mitigates these risks (14).Further informationA Practitioner’s Toolkit for Managing MenopauseAMS guide to MHT/HRT doses – AustraliaAMS guide to MHT/HRT doses - New ZealandPremature ovarian insufficiency: International Menopause Society White Paper:Surgical menopause: a toolkit for healthcare professionals (British Menopause Society)ReferencesHarlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ; STRAW 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. Menopause 2012; 19(4): 387-95.Hamoda H, Sharma A. Premature ovarian insufficiency, early menopause, and induced menopause. Best Practice & Research Clinical Endocrinology & Metabolism 2024; 38: 101823.Panay N, Anderson RA, Nappi RE, Vincent AJ, Vujovic S, Webber L, Wolfman W. Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric 2020; 23(5): 426-46.Hickey M, Ambekar M, Hammond I. Should the ovaries be removed or retained at the time of hysterectomy for benign disease? Human Reproduction Update 2009; 16(2):131-41.Rebbeck TR, Kauff ND, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo-oophorectomy in BRCA1 or BRCA2 mutation carriers. Journal of the National Cancer Institute 2009; 101(2):80-87.Parker WH, Shoupe D, Border MS, Liu Z, Farquhar C, Berek JS. Elective oophorectomy in the gynaecological patient: when is it desirable? Current Opinion in Obstetrics and Gynecology 2007; 19(4):350-54.Green LJ, O'Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. British Journal of Obstetrics and Gynaecology 2017; 124: e73–e105.Gallagher JC. Effect of early menopause on bone mineral density and fractures. Menopause 2007; 14:567-71.Honigberg MC, Zekavat SM, Aragam K, Finneran P, Klarin D, Bhatt DL, Januzzi Jr JL, Scott NS, Natarajan P. Association of premature natural and surgical menopause with incident cardiovascular disease. Journal of the American Medical Association 2019; 322(24):2411-21.Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton LJ 3rd. Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncology 2006; 7(10):821-8.Bove R, Secor E, Chibnik LB, Barnes LL, Schneider JA, Bennett DA, De Jager PL. Age at surgical menopause influences cognitive decline and Alzheimer pathology in older women. Neurology 2014;82(3):222-9.Rocca WA, Bower JH, Maraganore DM, Ahlskog JE, Grossardt BR, de Andrade M, Melton LJ 3rd. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology 2007;69(11):1074-83.Nappi RE, Cucinella L, Martini E, Rossi M, Tiranini L, Martella S, Bosoni D, Cassani C. Sexuality in premature ovarian insufficiency. Climacteric 2019;22(3):289-295.Rocca WA, Grossardt BR, Geda YE, et al. Long-term risks of depressive and anxiety symptoms after early bilateral oophorectomy. Menopause 2018; 25:1275-85.Hamoda H in collaboration with the medical advisory council of the British Menopause Society. Premature ovarian insufficiency (Consensus Statement). Reviewed 2024. Premature ovarian insufficiency - British Menopause Society (thebms.org.uk)The ESHRE Guideline Group on POI, Panay N, Vincent AJ et al. ESHRE Guideline: management of women with premature ovarian insufficiency, 2024. https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Premature-ovarian-insufficiencyGordhandas S, Norquist BM, Pennington KP, Yung RL, Laya MB, Swisher EM. Hormone replacement therapy after risk reducing salpingo-oophorectomy in patients with BRCA1 or BRCA2 mutations; a systematic review of risks and benefits. Gynecologic Oncology 2019;153:192-200.Gard A, Robinson L in collaboration with the medical advisory council of the British Menopause Society. Surgical menopause: a toolkit for healthcare professionals. Reviewed 2024. https://thebms.org.uk/wp-content/uploads/2021/06/13-BMS-TfC-Surgical-Menopause-JUNE202102B.pdfSecosan C, Balulescu L, Brasoveanu S, Balint O, Pirtea P, Dorin G, Pirtea L. Endometriosis in Menopause-Renewed Attention on a Controversial Disease. Diagnostics (Basel) 2020;10(3):134.Davis SR, Baber R, Panay N, Bitzer J, Cerdas Perez S, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Climacteric 2019;22(5):429-434.

Download: Diagnosing Menopause | Information Sheet Key PointsMenopause is the final period in a woman’s life.Perimenopause is usually diagnosed clinically on the basis of new onset vasomotor or other symptoms and a change in the pattern of menstrual bleeding. Menopause is diagnosed 12 months after the final menstrual period.The average age of menopause is 51. Early menopause is defined as menopause occurring between 40-45years and premature ovarian insufficiency (POI) prior to age 40.Measuring oestradiol or FSH is generally not indicated because of marked daily fluctuations.A symptom score sheet can be helpful in measuring the severity and impact of symptoms and assessing response to any intervention.DON’TMeasure FSH, LH, AMH (anti-Müllerian hormone), oestradiol or testosterone, inhibin A or B (which inhibit FSH production) levels and antral count or ovarian volume in a woman with symptoms at the normal age for menopause (over 45 years) because these results are unlikely to change your management. The indications for intervention are clinical.BUT for premature menopauseWhich is defined as occurring before the age of 40 and is designated as ‘Premature Ovarian Insufficiency’ (POI).Measurement of FSH is indicated in women under 40 and 40-45 with menopausal symptoms. Premature menopause is diagnosed by elevated FSH levels on two occasions, 4-6 weeks apart.DO take a historyMenopausal symptoms – the multiplicity of which are identified in the Greene scale below is a useful standardised symptom measurement system.Vasomotor symptoms cause sleep disturbance. Ask about severity and number.Sleep disturbance is a major factor affecting quality of life. Identify the impact of sleep disturbance.Record personal medical history and risk factors for breast cancer, cardiovascular disease, thromboembolic disease and osteoporosis.Ask about absolute or relative contraindications to MHT: uncontrolled hypertension, undiagnosed abnormal bleeding, previous breast or endometrial cancer and personal history or high inherited risk of thrombo-embolic diseaseEnsure that screening (breast, cervical) is up to dateIntroductionFrequently, the woman herself has already made the diagnosis of menopause. She attends her doctor with symptoms such as hot flushes or night sweats interrupting her sleep, together with changes in her menstrual cycle. Not all women with menopausal symptoms will need treatment. Most women will be glad of information about menopause and about the safe and effective treatment options available. The questions we should be asking her are "Why did you come to see me", and "What do you hope to get out of this consultation?"Common questions are:How long does menopause last?When will I be through it?What are the pros and cons of taking menopause hormone therapy (MHT) for me?Can I treat my symptoms naturally?If I do decide to take MHT, for how long should I take it?When am I no longer fertile and when should I stop using contraception?There is a lot of information to give, and even if a menopause information sheet is given, a long appointment will be required to give all the information required and answer questions. Menopausal women often have multiple health issues that need addressing and they may be anxious and tired due to sleep disturbance. Allowing adequate time for the consultation allows her to discuss the issues she is concerned about without feeling rushed.Perimenopause, Menopause or Postmenopause?Perimenopause refers to the time from the onset of menopausal symptoms (some or all of symptoms such as irregular periods, hot flushes, night sweats or sleep disturbance) to 12 months after the last menstrual period1. This can last on average 4 to 8 years. Menopause is the last menstrual period. One year after the last menstrual period the woman is considered "postmenopausal". Peri-menopausal symptoms can occur when periods are still regular, but typically the symptoms worsen in the premenstrual days. The symptoms experienced during the perimenopause are often the most distressing. Menstrual changes are common and it is normal to have periods that are less frequent or irregular. More frequent periods or those that are very heavy may not be normal and suggest that there may be pelvic or systemic pathology.Women older than 40 years with more frequent or heavy bleeding, or intermenstrual bleeding require investigation by their doctor. Hormone levels may fluctuate during this time and measurement of sex steroids is rarely clinically helpful once the diagnosis has been made2. At this time of hormone fluctuation, oestradiol can actually briefly be higher than normal, giving symptoms of excess oestrogen, such as breast tenderness. Explaining to women that, at a time when their body is running out of oestrogen, they may get brief periods of high oestrogen symptoms is useful. (Some women are told that because of these brief periods of high oestrogen they need progesterone treatment but there is no evidence that this is needed). Eventually, symptoms of oestrogen deficiency predominate.Menopause is said to have occurred when there has been no menstruation for one year. If a woman has taken MHT since she was peri-menopausal, it may not be possible to assess the exact age at which she became menopausal. This may also impact on the advice provided about perimenopausal contraception (see AMS information sheet Contraception) If a woman has required peri-menopausal MHT for symptoms, it is a reasonable guess to expect her to be post-menopausal after 4-5 years.PostmenopauseThis starts one year after the last menstrual period. There is no reliable way of predicting how long menopausal symptoms will continue. For many women they resolve within 2-5 years. Ten to 20% of women will have symptoms for up to 12 years. Vaginal dryness and urinary frequency may start during the peri-menopause and tend not to resolve naturally with time. Some women only experience vaginal dryness during sexual activity and others are aware of uncomfortable vaginal symptoms at other times.For those symptomatic women who elect to use MHT, we advise that they be reviewed annually to evaluate ongoing care and the need to continue MHT.Premature menopausePremature menopause is considered to have occurred if a woman is younger than 40 when she becomes menopausal. About 1% of women experience a spontaneous premature menopause (POI or premature ovarian insufficiency) and around another 6% have premature menopause due to surgery, chemotherapy or radiation. There has been relatively little research on symptoms in these women, but it seems that their menopausal symptoms may be more severe than in older women, particularly when menopause occurs due to surgery or chemotherapy. There are also distinct personal, sexual, social and psychological issues for younger women, particularly for those women who wish to have children but have not yet started or completed their families. These women need extra counselling, and time to come to terms with their situation. This is the one time that measuring and finding a high FSH and a low oestradiol is helpful to differentiate between menopause and other causes of secondary amenorrhoea.POI is a pathological condition associated with an increased risk of osteoporosis and fracture, an increased risk of cardiovascular disease, possible cognitive impairment, Parkinson’s disease and reduced life expectancy. It is conventional to treat with MHT at least until the average age of the menopause.There are 3 main identifiable causes of POI: genetic, autoimmune and iatrogenic3Genetic conditions include a strong maternal family history, 45,X, 46,XX and46,XY POI.POI is associated with galactosemia and FMR premutations (e.g., Fragile X)Women with an autoimmune predisposition may develop autoimmune POI, with or without other autoimmune diseases (diabetes mellitus, Addison's, thyroid).Women with iatrogenic menopause includes women with benign disease and those having treatment for cancer (hormonal, chemotherapy and/or radiotherapy) which has brought about an early menopause. In most women the cause of an early menopause is unknown.Early menopause affects 3.7% of African-American women, 2.9% of white women, 2.2% of Chinese women and 0.8% of Japanese women4. About 1 in 1000 women are affected under the age of 305.Lower socioeconomic status has been associated with POI.The measurement of FSH and oestradiol should be repeated at least once (See AMS information sheets Early Menopause Due to Chemotherapy and Spontaneous Premature Ovarian Insufficiency).Symptom assessment and diagnosis at Perimenopause and MenopauseThe time when most women are trying to understand what is happening to them is during the peri- menopause. During this time of hormonal fluctuation women may experience some, but not all of the symptoms listed in the table. For instance, she may come with severe joint aches and tiredness, which may be suggestive of a rheumatological disease. Checking a symptom score will often reveal many more unreported menopausal symptoms.In most cases, recording a symptom score helps to make the diagnosis, at the same time educates the woman and is a basis for assessing efficacy of treatment. Checking FSH or AMH levels or serum oestradiol and progesterone are unnecessary tests in diagnosing menopause for most women.  Checking an androgen profile as a routine on all peri-menopausal women is also unnecessary and costly. Many women come to the consultation expecting a blood test to diagnose menopause, and it is important to explain to them why we use the symptom score rather than a blood test in establishing a diagnosis. It is important to explain to women that the blood tests of FSH/oestradiol can fluctuate on a daily basis and therefore are not useful or necessary. It is especially unhelpful to do hormone blood tests while women are on MHT/OCP – symptoms, not blood levels, guide therapy. Treat the symptoms, not the biochemistry.Symptom score sheetThe Modified Greene Scale6 (see below) can be completed together with the woman, or she can do it herself in the waiting room. The woman judges the severity of her own symptoms and records the score - 1 for mild, 2 for moderate, 3 for severe and 0 if she does not have that particular symptom. A score of 15 or over usually indicates oestrogen deficiency that is intrusive enough to require treatment, but this is only a guide. Women are very variable in their tolerance of discomfort, often tolerating quite severe symptoms before they will even consider taking MHT. Scores of 20-50 are common in symptomatic women, and with adequate treatment tailored to the individual, the score will reduce to 10 or under in 3-6 months.Using the symptom score sheet at subsequent follow-up visits is a useful method of judging whether adequate oestrogen is being taken to alleviate symptoms. Generally, there is a halving of the symptom score after 2-3 months on MHT and if the woman is still experiencing a lot of symptoms, she may require a dose increase. If symptoms still persist, changing from the oral route to transdermal may help if the problem is oestrogen malabsorption.If it's not menopause, what is it?Depression, anaemia and thyroid disorders are the most common conditions that may occur concurrently. Unstable diabetes and hyperthyroidism may cause hot flushes. Medication, such as the SSRI family of anti-depressants, may also cause hot flushes.Doing a blood count, ferritin and/or a TSH level will usually establish the diagnosis. However, if a woman presents with low mood or anxiety, there is a need to evaluate whether this is a primary anxiety/depression or one aggravated by the lack of oestrogen. A previous history of depression or an elevated FSH may help to differentiate between the two. Hair loss may be a sign of iron deficiency or hypothyroidism rather than menopause.Need more information?Diagnosing menopause is something that most GPs are skilled at doing and helping women at this difficult stage of their life can be very rewarding. If you are reading this information sheet because you have inadequate knowledge on how to counsel menopausal women, then consider joining the Australasian Menopause Society and receiving its monthly newsletter, called eChanges. Attend one of our annual meetings, which aim to be of interest to a wide range of doctors, nurses, psychologists and physiotherapists.ReferencesMcKinlay SM et al. The normal menopause transition. Maturitas 1992;14:103.Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause Int 2011;17:153.?ükür, Y[anuz]. E., K?vançl?, ?. B., & Özmen, B. Ovarian aging and premature ovarian failure. Journal of the Turkish German Gynecological Association, 2014;15(3):190.Green R et al. Menopausal Symptoms and Ethnicity: the Study of Women’s Health across the Nation. Womens Health (Lond). 2009;5(2):127-33Coulam CB et al. Incidence of Premature Ovarian Failure. Obstet Gynecol 1986;67(4):604-606Greene JG. Constructing a standard climacteric standard. Maturitas 1998;29:25-31 Symptom Score (Modified Greene Scale)

Contraception | Information Sheet  Download: Contraception | Information Sheet Key PointsContraception is required for 12 months after the final menstrual period (FMP) if the FMP occurs after the age of 50. If the FMP occurs before the age of 50, 24 months of contraception is required.Oestrogen - based methods are not recommended over the age of 50 due to cardiovascular risks.The Levonorgestrel IUD (Mirena®) provides effective management of heavy menstrual bleeding as well as contraception and can also be used as part of an MHT regimenWomen in a new relationship should be advised about the use of condoms to prevent sexually transmitted infections.Women should be informed about the availability of the Emergency Contraceptive Pill without a prescription at pharmacies.Fertility declines with age and available data suggest that spontaneous conception for women over age 50 is very rare (1). Pregnancy at the age of 45-49 results in a live birth rate of less than 2 per 1000, while over the age of 50 it is less than 1 per 2000. Despite the low risk in this age group, women should be counselled about the possibility of unintended pregnancy and advised about appropriate contraception.Contraception is required for 12 months after the final menstrual period (FMP) if the FMP occurs after the age of 50 (2). If the FMP occurs before the age of 50, 24 months contraception is required.Amenorrhea is common in perimenopausal women using progesterone-only contraception making it difficult to determine the date of her FMP. In this situation, for women age 50 or older, a single FSH measurement ?30mI U/L will indicate that contraception will be required for a further 12 months, and can then be ceased. If the FSH is ?30mIU/L, contraception should be continued for the next 12 months and FSH to be repeated to check if ?30 at that time (3).The choice of contraception is determined by several factors including the woman’s age, medical eligibility criteria (4), comorbid medical conditions, affordability, and personal choice. Oestrogen-containing methods are not recommended for women over the age of 50. Women of any age with contraindications to oestrogen, such as a history of breast cancer, thromboembolic disorders, complex migraines and heavy smokers should be offered non-hormonal or progestogen-only methods.1.  LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS (LARC)(a) Levonorgestrel Intrauterine System (hormonal IUS)(i) The Mirena IUD® is inserted into the uterus. It releases levonorgestrel (LNG) 52mg over 5 years (with extended use for contraception up to 10 years if inserted after age 45) (3). It works primarily by thinning the endometrium and thickening of the cervical mucus. It is a highly effective form of contraception (>99% efficacy) (4) and suitable for women with contraindications to oestrogen–containing methods.Women should be warned of possible spotting and bleeding for the first few months. Some women experience progestogen side effects such as acne and mood changes.The Mirena IUD is an excellent option for women around the perimenopause particularly if they are experiencing irregular heavy periods. It also provides endometrial protection for women using MHT; use should not be extended beyond 5 years at any age for this indication.(ii) The Kyleena IUD® is similar to the Mirena® but releases a smaller dose of LNG (19.5mg) over 5 years. The IUD device itself is smaller than the Mirena and is most suitable for nulliparous women who don’t mind having a regular lighter period. Importantly it does NOT provide adequate endometrial protection for women on MHT and is not suitable for women experiencing heavy menstrual bleeding around the time of menopause.In New Zealand, Jaydess® is the lower dose IUS, releasing 13.5mg of levonorgestrel over its use in 3 years.(b) The Contraceptive ImplantThe Implanon NXT® is available in Australia and is a 4cm single rod inserted under the skin of the inner non-dominant arm under local anaesthetic. It releases the progestogen etonorgestrel over a three-year period but can be removed earlier if required. It inhibits ovulation, thickens the cervical mucus and thins the endometrium. The Implanon is available on PBS in Australia.In New Zealand the Jadelle® implant is fully funded. It consists of 2 small flexible silicon rods, each containing levonorgestrel 75mg.The contraceptive implants provide highly >99% effective (5) and are cost-effective. Side effects can include irregular bleeding along with common progestogenic side effects (6). Contraceptive implants should not be used for endometrial protection in an MHT regimen.(c) Copper-bearing IUDThe copper IUD is >99% effective. It is toxic to sperm and can prevent implantation of the fertilized egg. In Australia, three types of Copper IUD are available, Load375® and Copper TT380 Short® which last for 5 years and Copper TT380 Standard®, which is effective for 10 years. As there are no hormones, it is suitable for women concerned about hormone side effects or those with contraindications to hormonal methods.The Copper IUD can cause heavier, longer and more painful periods. In Australia Copper IUDs are not PBS listed with a higher upfront cost that the hormonal IUDs. In New Zealand, Copper IUDs are subsidised and less expensive than the hormonal IUD.2.  MEDIUM ACTING CONTRACEPTION(a) Depomedroxyprogesterone acetate (DMPA) injectionsDMPA injections (Depo-Provera® and Depo-Ralovera®) are progestogen-only injections administered every 3 months into the gluteal or deltoid muscle. It prevents ovulation and is 99.8% (5) effective when used correctly. Most women are amenorrhoeic so it may be helpful for women with heavy menstrual bleeding. As it also suppresses oestrogen production, long term use may result in low bone density or osteoporosis (7). For this reason, it is also less preferred in women over age 45 (7, 8).(b) The Vaginal RingThe vaginal ring (NuvaRing®) is a soft silastic ring containing ethinyl oestradiol and etonorgestrel. It is inserted by the woman herself and left in place for 3 weeks, then removed for a week before a new ring is inserted. Women must remember to remove and replace the ring for it to be effective.The vaginal ring works in a similar principle to the oral contraceptive pill but obviates the need for daily tablet taking.  In perfect use the risk of pregnancy is <1% per year (5). The vaginal rings can be used ‘back-to-back’ for 3 months at a time, to prevent withdrawal bleeding. It can also provide better regulation of the menstrual cycle for women who experience breakthrough bleeding with combined oral contraceptive pill (COCP).The vaginal ring has the same contraindications as COCP (see below). It is not PBS listed so the cost may be a deterrent for some women. 3.  SHORT ACTING CONTRACEPTION(a) The Combined Oral Contraceptive Pill (COCP)The COCP contains both oestrogen and progestogen hormones. It works primarily by inhibiting ovulation but also thickens cervical mucus and thins the endometrium with >99% efficacy with perfect use (93% in typical use) (5). Active hormone pills can be taken continuously for up to 12 months to reduce menstrual blood loss. There is some data that suggest a reduction in the risk of ovarian and endometrial cancer with COCP use.The COCP should not be used in women with contraindications to oestrogen (e.g. women with a history of breast cancer, VTE, migraine with aura and smokers over the age of 35 year). The COCP is associated with an increased risk of VTE by approximately 2-fold (8) (although the absolute risk for most women is very low). The COCP is not recommended for women over the age of 50 because of increased cardiovascular risk. For women with additional risk factors such an elevated BMI, a history of diabetes or hypertension, consideration should be given to cease the use of COCP at an earlier age.(b) The progestogen-only pill (POP) or “minipill”The progestogen-only pill contains a small dose of progestogen and primarily works by thickening cervical mucus. It can be used by women with contraindications to the use of oestrogen who prefer an oral method. There is no increased risk of thromboembolic events.Most POPs must be taken within a three-hour time frame each day for it to be effective, although the newer Drospirenone-containing Mini-Pill (Slinda®) has a 24-hour window (10).In New Zealand, Cerazette® is the only POP available and has a 12-hour window of use.Similar to contraceptive implants, POPs should not be used for endometrial protection in an MHT regimen.4.  COITALLY DEPENDENT BARRIER METHODSThe barrier methods require ‘action’ with every act of sexual intercourse, which results in lower effectiveness in typical use than other contraceptive methods. Condoms, both male and female (now also referred to “external” and “internal” condoms respectively), are the only method of contraception that can prevent STIs.(a) Contraceptive DiaphragmThe diaphragm Caya® is a barrier method which the woman inserts herself, to cover the cervix to prevent sperm reaching the uterus. It must be left in place for a minimum of 6 hours after intercourse to allow sperm to be killed off by the vaginal acidity. The single size diaphragm has a lifespan of two years; the manufacturer recommends the use of a lactic acid buffer gel with the diaphragm (note that spermicide is not available in Australia).The diaphragm may be associated with urethal irritation and a risk of urinary tract infection (10). Some women find it difficult to insert and there is a risk of incorrect placement.(b) Male CondomThe male condom is a fine latex or polyurethane sheath, worn on the erect penis. It can be used with a water-based lubricant which may be useful for women experiencing perimenopausal vaginal dryness.  Condoms have a relatively high failure rate in typical use (especially in ‘new users’) due to the need for consistent use and the risk of breakage, slippage or leakage (98% effective in perfect use and 88% in typical use) (4). Some men and some women believe they interfere with sexual pleasure.(c) Female CondomThe female condom is a polyurethane sheath inserted into the vagina prior to intercourse. It is less commonly used than other forms of contraception. They are more expensive than male condoms and have a slightly higher failure rate. They can be purchased online at family planning clinics and also at some pharmacies. More information here: here5.  EMERGENCY CONTRACEPTIONEmergency contraception (previously known as “the morning after pill”) is used to prevent pregnancy after unprotected intercourse or contraceptive failure.(a) Single 1.5mg levonorgestrel emergency contraceptive (LNG-ECP) tabletThe LNG-ECP contains 1.5mg levonorgestrel and is recommended for use up to 72 hours after unprotected intercourse; it has some effectiveness if taken up to 120 hours after unprotected intercourse.   It is available over the counter without a prescription. It acts by preventing or delaying ovulation.  It can be used by breastfeeding women and can be used multiple times in a cycle if needed.(b) Single 30mg ulipristal acetate (UPA) tabletUlipristal acetate is a selective progesterone receptor modulator (SPRM) which works to prevent or delay ovulation even when the LH surge has begun.   It can be used up to 120 hours after unprotected intercourse with superior efficacy to LNG-EC. Breastfeeding women are advised to express and discard breastmilk for one week after taking UPA. Women using progestogen containing contraception should seek medical advice on when to start or re-start the method after taking UPA as UPA can reduce the effectiveness of hormonal contraception.(c) Copper IUDIf inserted within five days of unprotected intercourse, the copper IUD provides highly effective ongoing long-term contraception. However, it can be difficult to access within the appropriate time frame.6.  PERMANENT(a) Tubal ligation or Salpingectomy (female sterilization)Tubal ligation or salpingectomy are carried out under general anaesthetic either laparoscopically or during laparotomy.  It may be appropriate for women undergoing laparoscopy for other reasons or at the time of a Caesarian Section.  It may be appealing for women concerned about side effects of other contraceptive methods.  (b)Vasectomy (male sterilization)Vasectomy is a surgical procedure, usually performed under local anaesthetic, during which the vas deferens is cut so that no sperm will enter the ejaculate. It allows the male partner to take responsibility for contraception. Couples should be advised ongoing contraception is required for 3 months after the procedure, at which time a follow-up semen analysis is performed to confirm azoospermia. There is a small risk of haematoma, infection, sperm granuloma and rarely post-vasectomy pain syndrome.ReferencesTrussell J et al. Sterility in a population with natural fertility. Population Studies 2010;39(2):269–86Sauer MV. Reproduction at a advanced maternal age. Fertility Sterility. 2015; 103(5):1136-43Faculty or Sexual and Reproductive Healthcare. FSRH Guideline for women aged over 40 years. Contraception for Women aged over 40 years. FSRH Clinical Effectiveness Unit; 2017(Amended 2019). https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/Pearson S et al. Long Acting Reversible Contraceptives. AJGP 2022;51(4)Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. FSRH, 2019.Sexual and Reproductive Health Experts Group. In: Therapeutic Guidelines.  Melbourne: Therapeutic Guidelines Limited;2020.   Available online at:https://tgldcdp.tg.org.au/guideLine?guidelinePage=Sexual+and+Reproductive+Health&frompage=etgcomplete (subscription required) (accessed March 2022)Rocca ML et al. Safety and Benefits of Contraceptive Implants: A Systematic Review Pharmaceuticals (Basel). 2021; 14(6): 548Albertazzi P et al. Bone Mineral Density and Depot medroxyprogesterone acetate. Contraception 2006; 73(6):577-83Royal College of Obstetricians and Gynaecologists. Contraception for Women Aged Over 40 Years. In: Faculty of Sexual & Reproductive Healthcare Clinical Guidance, editor. 2010Dragoman MV et al. A systematic review and meta?analysis of venous thrombosis risk among users of combined oral contraception. Int J Gynaecol Obstet.2018 Jun; 141(3): 287–294 https://doi.org/10.1002/ijgo.12455.Bateson D et al. Drospirenone 4mg: A new progestogen only pill. Medicine Today 2021; 22(12):56-59Allen RE. Diaphragm Fitting. Am Fam Physician. 2004 Jan 1;69(1):97-100  Table 1:   Contraceptive methods Effectiveness (%)HormonesAdvantagesDisadvantagesOther comments Perfect useTypical use    Tubal ligation>99.5>99.5NilImmediate effectRequires hospital admission and surgery Vasectomy99.599.5NilPerformed under local anaestheticSmall risk of infection and sperm granulomaNeed semen analysis at 3 months to ensure azoospermiaMirena® IUD>99>99Progestogen onlyReduces menstrual loss.Cost effective.Suitable for women with contraindications to oestrogen.Irregular bleeding or spotting may occur in first few months.Some women have progestogenic side effectsProvides endometrial protection for women on MHT. Kyleena® IUD>99>99Progestogen onlySmaller dose of progestogen than Mirena®.Cost effective.  Suitable for women with contraindications to oestrogen Does not provide endometrial protection for women on MHT.Not suitable for women with heavy bleeding around time of menopause.Implant>99>99Progestogen onlyCost effective.Suitable for women with contraindications to oestrogen.20% of women have prolonged or heavy bleeding.  Copper IUD>99>99NilHormone free.Cost effective.Periods may be heavier and more painful DMPA injections>9996Progestogen onlyUseful for women with heavy mensesReduces bone densityNot recommended for women > 45Combined oral contraceptive pill(COCP)>9993Oestrogen and progestogenConvenienceNot suitable for women with VTE of complex migraines.Not recommended for women > 50.Consider ceasing by age 45 if cardiovascular risk factors.Vaginal ringNuvaRing®>9993Oestrogen and progestogenWorks same as the COCP but no tablet takingSame as for COCPSame as for COCPProgestogen only Mini Pill>9993Progestogen onlySuitable for women with contraindications to oestrogenMust be taken daily within a 3 hour time frame Diaphragm8682NilHormone free.Prevents STI’sRisks of urethral irritation, UTI and incorrect placement Male condom9888NilHormone free.Prevents STI’sWidely available.Some feel it interferes with sexual pleasure Female condom9579NilHormone freePrevents STI’sDifficult to find; purchased onlinenot commonly used in Australia (? NZ) Table 2:   Emergency contraception HormonesAdvantagesDisadvantagesOther commentsLevonorgestrel (LNG- EC)ProgestogenReadily available at pharmacies without a prescription.Very safe with few side effectsDoes not provide ongoing contraceptionIdeally take within 72 hours of intercourseUlipristal acetate(EllaOne®)Progesterone receptor modulator Does not provide ongoing contraceptionCan be used for up to 120 hours after intercourse.  Don’t use with LNG-EC within the same cycle.Superior efficacy to LNG-EC. Copper IUDNilHighly effectiveContraceptive effect is ongoingDifficult to access within appropriate time frame

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