Menopause, prolapse and urinary symptoms

Menopause assessment

Menopause is diagnosed retrospectively after twelve months without menstruation when another cause does not explain it. Ask about vasomotor symptoms, sleep, mood, vaginal/urinary symptoms, bleeding, contraception and pregnancy possibility. Age and context determine whether investigations are needed; a fluctuating FSH is not a universal diagnostic requirement in a typical midlife presentation. Earlier ovarian insufficiency requires a different specialist assessment. Symptoms such as palpitations, sweats or weight change can have other causes, including thyroid disease, medicines and infection.

Discuss the person's priorities and functional impact rather than treating every symptom identically. Support sleep, exercise, smoking cessation and cardiovascular/bone health. Menopausal hormone therapy is effective for bothersome vasomotor symptoms in appropriate patients, with an individual benefit/risk assessment. Timing since menopause, age, breast/vascular history, unexplained bleeding and preferences matter. It is not a general prescription for primary cardiovascular prevention and does not provide reliable contraception. Review ongoing use rather than imposing either indefinite treatment or an automatic stop solely at one birthday.

Choosing a hormone strategy

A person with an intact uterus generally needs endometrial protection alongside systemic oestrogen. The progestogen strategy and regimen depend on bleeding pattern, tolerance and the chosen product; after hysterectomy the requirements differ, with some special situations needing expert advice. Oral and transdermal routes have different risk considerations, including thrombosis. Check current Australian product information, dose and interactions. Do not equate an IUD's contraceptive duration with its duration for hormone-therapy endometrial protection.

Genitourinary syndrome can cause dryness, dyspareunia, irritation and urinary symptoms. Lubricants/moisturisers and suitable local vaginal oestrogen can help when indicated; systemic therapy is not required for every isolated local symptom. Breast cancer history requires an individual discussion with the treating team. Exclude infection, vulval dermatoses, lesions and malignancy when symptoms are persistent or atypical. New bleeding after menopause requires investigation even when atrophy seems plausible. Persistent/recurrent bleeding can require sampling despite a thin endometrium on ultrasound.

Pelvic organ prolapse

Ask about a vaginal bulge, pressure, urinary/bowel emptying, sexual function and impact on daily life. Examine with consent and a chaperone offer, evaluating the compartments and associated atrophy or ulceration. Assess for retention when voiding is impaired. Symptom severity and patient goals guide treatment more than the visual degree alone. Pelvic-floor muscle therapy, lifestyle/constipation management and a pessary can help selected patients; surgery is considered according to anatomy, fitness and preference. Do not assume that every prolapse needs immediate hysterectomy.

A pessary needs fitting, education and a clear cleaning/review schedule. Pain, bleeding, discharge or inability to remove/manage it warrants assessment; a forgotten pessary can cause serious injury. Ask whether dexterity, cognition or distance from follow-up makes the proposed plan practical. Urinary retention, ulceration or a suspicious lesion requires targeted care. Discuss effects on sexual activity and the person's preferences without assuming an older patient is sexually inactive. After surgery, follow-up includes recurrence, voiding and adverse-effect assessment.

Incontinence and urgency

Stress incontinence occurs with exertion, cough or sneeze; urgency incontinence follows a compelling urge. Mixed symptoms are common. Assess infection, haematuria, diabetes, retention, medicines, mobility and constipation. A bladder diary can clarify patterns. Check post-void residual when emptying is uncertain or the history suggests overflow. Visible haematuria or persistent unexplained urinary symptoms needs appropriate investigation rather than a routine overactive-bladder label. Neurological deficits or acute retention with back symptoms raises a spinal emergency.

Initial management can include pelvic-floor training, bladder strategies and appropriate fluid/caffeine advice, tailored to the subtype. Do not tell every patient to restrict fluid severely. Antimuscarinics can worsen dry mouth, constipation and cognition, especially in older people; other medicines also have contraindications and interactions. Review benefit and harms. Surgery or specialist treatments require informed discussion of alternatives and realistic expectations. Continence aids support dignity but do not substitute for investigating a new treatable problem.

Applied consultation

A patient with hot flushes, sleep disruption and no contraindication can discuss an individual MHT plan with suitable uterine protection. A patient with new postmenopausal bleeding needs diagnostic assessment, even if also experiencing dryness. Someone with a bulge and incomplete voiding needs examination and retention assessment before a pessary is prescribed. Another person with leakage on coughing and no warning signs may begin structured pelvic-floor therapy. These choices require a symptom-specific history rather than attributing everything to age.

Check comprehension, access and follow-up, including what bleeding or urinary changes should trigger review. For intimate examinations, explain each step, allow the patient to stop and use trauma-informed care. Document the treatment indication, risks discussed and review plan. Support culturally safe communication and gender-inclusive anatomy-based assessment; the organs present and hormone exposure determine many clinical needs.

Australasian Menopause Society hormone-therapy principles.

Review checkpoints

• Systemic menopausal hormone therapy generally needs endometrial protection when a uterus is present.
• Postmenopausal bleeding requires assessment before attributing it to menopause.
• Prolapse treatment can include pelvic-floor therapy, pessary care or surgery according to need.