Menopause Hormone Therapy: What’s Approved and What the Evidence Shows

Understanding Perimenopause, Menopause, and Symptom Management

Hello and welcome to Menopause & Me.I’m Jenna, Nurse Practitioner and menopause educator.

Many women are told that menopause hormone therapy is only for use after menopause, once periods have stopped.

At the same time, many women experience symptoms years earlier during perimenopause and are left wondering:

“Why are my symptoms being treated if these medications are only approved for menopause?”

This can feel confusing.

Understanding the difference between regulatory approval and clinical evidence can help explain why care during this stage is often more individualised than expected.

What is menopause hormone therapy (MHT)?

Menopause hormone therapy may include the use of:

• Oestrogen

• Progesterone

• And in some cases, testosterone

  
  

In Australia, many menopause hormone therapies are approved for menopause or postmenopausal use, primarily for:

• Vasomotor symptoms such as hot flushes and night sweats

• Genitourinary symptoms

• Bone protection in selected cases

Why this can feel different in perimenopause

Perimenopause is not a state of stable hormone deficiency.

Instead, it is characterised by:

• Fluctuating oestrogen levels

• Irregular ovulation

• Variable progesterone exposure

This hormonal variability can contribute to symptoms such as:

• Sleep disturbance

• Mood changes

• Anxiety or low mood

• Cognitive changes

• Changes in libido

• Joint discomfort

• Irregular bleeding

For many women, these symptoms begin well before menopause is reached.

What the evidence shows

While regulatory approvals focus on postmenopause, the broader clinical evidence reflects a more complex picture.

The Journal Club article for this issue, Management of perimenopausal and menopausal symptoms, is a 2023 State of the Art Review published in The BMJ.

It brings together findings from systematic reviews, meta-analyses, randomised controlled trials, and guideline statements.

The review shows that:

• 60 to 86 per cent of women experience symptoms significant enough to seek care

• Symptoms are multi-system and not limited to vasomotor symptoms

• These may include mood changes, sleep disturbance, cognitive changes, sexual health concerns, musculoskeletal symptoms, and metabolic changes

Importantly, it also confirms that:

• Oestrogen-based therapies are the most effective treatment for many menopausal symptoms

• Benefits may extend to sleep, mood in perimenopause, and genitourinary symptoms

  
  

At the same time, responses vary and treatment should always be individualised.

Why prescribing may be described as off-label

In Australia, many menopause hormone therapies are generally approved for postmenopausal use.

When used for perimenopausal symptoms, prescribing may sometimes be described as off-label.

Off-label prescribing is a recognised part of medical practice and reflects that:

• Evidence may extend beyond regulatory wording

• Treatment decisions are guided by symptoms, clinical judgement, and current guidelines

• Care is tailored to the individual rather than defined by a single stage

Looking beyond hot flushes

One of the key messages from current research is that menopause symptoms extend well beyond vasomotor symptoms.

The menopause transition can affect:

• Brain function, including mood and cognition

• Sleep regulation

• Musculoskeletal health

• Sexual wellbeing

• Metabolic health

For some women, these symptoms may be more disruptive than hot flushes.

Recognising this broader picture supports more accurate assessment and more meaningful treatment discussions.

When hormone therapy may be considered

Hormone therapy may be considered when symptoms are:

• Persistent

• Impacting quality of life

• Consistent with hormonal change

However, it is not appropriate for everyone.

Decisions are based on:

• Stage of menopause

• Medical history

• Individual risk factors

• Personal preferences

  
  

Non-hormonal options also remain important and appropriate in many situations.

Journal Club: Placing the evidence in context

Management of Perimenopausal and Menopausal Symptoms (BMJ, 2023)

Study designState of the Art Review incorporating systematic reviews, meta-analyses, randomised controlled trials, and high-quality observational studies.

What was examined

• Symptom patterns across perimenopause and postmenopause

• Hormonal and non-hormonal treatment options

• Benefits and risks of menopause hormone therapy

• Clinical guideline comparisons and treatment approaches

Key findings

• 60 to 86 per cent of women experience symptoms that lead them to seek care

• Symptoms extend beyond vasomotor symptoms and include mood, sleep, cognitive, sexual, and metabolic changes

• Oestrogen-based therapies are the most effective treatment for many symptoms

• Hormone therapy may improve sleep and mood in perimenopause in some women

• Symptoms often occur in overlapping patterns and vary significantly between individuals

Why this matters clinicallyThis review reinforces that menopause is a multi-system transition and not limited to hot flushes.

It supports a symptom-based approach to care and highlights that effective treatments are available, yet many women remain undertreated.

How this informs practiceEvidence-informed care may include:

• Assessing the full range of symptoms rather than focusing on a single complaint

• Considering hormone therapy where clinically appropriate and not contraindicated

• Using an individualised approach based on symptom burden, risk profile, and patient preference

• Incorporating non-hormonal strategies where needed

This supports shared decision-making rather than a one-size-fits-all approach.

Limitations

• The review includes a mix of study types rather than a single pooled meta-analysis

• Some recommendations are based on evolving evidence and expert consensus

• Individual responses to treatment remain variable

A simple 3-step check-in

If you are experiencing symptoms during perimenopause or menopause, it may help to:

1. Notice your pattern of symptoms, including sleep, mood, energy, and cycle changes

2. Seek a review with a menopause-trained healthcare provider

3. Ask: “Are my symptoms consistent with hormonal change, and what are my options?”

You’re not alone on this journey, and understanding how different treatments work can support more informed, confident decisions.

If you’d like support or a personalised review, you’re welcome to reach me at:📧 hello@menopauseandme.com.au🌐 www.menopauseandme.com.au

Warmly, Jenna Nurse Practitioner & Menopause Educator

Sources

Australasian Menopause Society | International Menopause Society | North American Menopause Society 2022 Hormone Therapy Position Statement | NICE Menopause Guidelines | BMJ State of the Art Review (2023)

Journal Club feature:

Duralde, E. R., Sobel, T. H., & Manson, J. E. (2023). Management of perimenopausal and menopausal symptoms. BMJ, 382, e072612. https://doi.org/10.1136/bmj-2022-072612

Important  Disclaimer: The information in this blog/newsletter is general in nature and intended for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your Nurse  Practitioner, doctor, or another qualified health practitioner with any questions you may have regarding a medical condition or before commencing any new treatment, exercise program, changing your diet, or taking supplements –  particularly if you have existing health conditions, are on medication, or have had fractures or falls in the past.  Individual needs and responses vary.