Chapter 4Diagnosis and care

Menopause is a gender equity issue because women's health is under-researched, research inappropriately excludes female participants, and women are chronically underserved and underdiagnosed by medicine.[1]

4.1Over the course of the inquiry, the committee learned of the variety of barriers that can exist for patients accessing diagnosis and treatment for perimenopause and menopause symptoms.

4.2While earlier chapters of this report canvassed the impact of menopause symptoms on individuals and families, this chapter seeks to look at the systemic drivers of the lack of diagnosis and access to treatment that are affecting Australian women.

4.3The chapter begins with a discussion on the challenges associated with diagnosis, including a lack of medical awareness and training, difficulties accessing informed healthcare practitioners, availability and length of medical consultations, and access to potential diagnostic tools.

4.4The chapter then discusses the matters specific to treatment options, including access and financial barriers to menopause hormonal therapy (MHT). The chapter also explores the issues associated with certain supplements and health products being marketed to women to alleviate the symptoms of menopause.

4.5The chapter concludes with the committee’s view and recommendations to improve access to diagnosis and treatment options.

Diagnosis challenges

4.6The inquiry highlighted a range of challenges faced by Australian women in relation to getting a diagnosis of menopause and perimenopause. This included medical practitioners having a limited understanding of the variety of presentations of symptoms of perimenopause.[2]

4.7Dr Christina Jang of the Australasian Menopause Society summarised the two key issues, namely training and time:

Australian research has shown that many healthcare professionals have significant gaps in their knowledge and training in menopause such as failure to recognise symptoms of menopause and lack of confidence to counsel women about the benefits and risks of menopausal hormone therapy. Many simply lack the time. We can't do menopause in a 15-minute consultation.[3]

Medical training

4.8Several medical professionals shared with the inquiry the limited education on issues related to menopause and perimenopause that they themselves had received.[4]

4.9It was highlighted to the committee that there is a variety of existing menopause and perimenopause education in undergraduate medical degrees, as the specifics of the curricula are set by individual universities.[5]

4.10The committee heard that medical training on menopause and perimenopause can be almost non-existent at the undergraduate level, with some medical practitioners recalling that they had only one hour on menopause during their education.[6] Dr Marita Long told the committee that:

We have to start preparing our medical graduates for 21st-century medicine, but we're really preparing them for 20th-century medicine, where we just look at very acute conditions. Menopause isn't in the undergraduate training in any significant capacity. I taught primary care at UTAS and was asked to deliver a one-hour women's health lecture to the primary care students. I chose to deliver that whole hour on the vulva because no-one is taught about the vulva. That was their whole women's health exposure in undergrad. It's not taught in undergrad, and it has to start there.[7]

4.11Submitters called for more comprehensive menopause education across medical training institutions, particularly undergraduate medical degrees.[8]

4.12Dr Elaine Leung recommended a change in the approach to shift the focus beyond one unit on menopause and perimenopause to an integrated focus on women’s health:

There's so much to cover in medical school. Just as there might be one lecture on perimenopause and menopause, there might only be one lecture on prostate health, for example. I really think that women's health, perimenopause and menopause should be integrated throughout the medical curriculum and throughout the program.[9]

4.13Witnesses also pointed out that the impact of this lack of awareness was not limited just to general practitioners but extended to all doctors, as all doctors would see women experiencing menopause and perimenopause.[10] Some submitters emphasised the need for education at the post-graduate level across a range of medical specialisations.[11] For example, Dr Marita Long emphasised:

… menopause is a transition point where women become incredibly vulnerable to chronic disease, and we're not teaching our undergraduates that. We're not teaching our graduates that. They go into postgraduate training programs and get very little teaching. And it is across every college. I would argue that there's not a college that shouldn't be touching on menopause. The surgeons, endocrinologists, medical doctors, obstetricians and gynaecologists need to know about it—it's more than just GPs.[12]

4.14Further, given the whole-of-body impacts of some menopause and perimenopause symptoms, inquiry participants discussed the need for menopause-specific education to enhance education and awareness across all healthcare disciplines.[13] As further elaborated by Maridulu Budyari Gumal, a Sydney based medical research organisation:

It is essential that clinical training reflects the fact that each woman is different and there is no one-size-fits all diagnostic pathway or management strategy. Education that is easy to access and relevant to the many health professionals who interact with the women experiencing and/or being treated for the symptoms of menopause needs to be prioritised.[14]

The role of the Australian Medical Council

4.15The Australian Medical Council (AMC) has a role in maintaining the standards for accreditation for universities that provide medical practitioner education.[15] Professor Robyn Langham AM, as representative for the AMC, explained to the committee at a hearing that the AMC is responsible for the standards for accreditation that universities must adhere to in their specific curriculums.[16]

4.16When asked by the committee about the relevant guidance for medical schools related to menopause, Professor Langham AM informed the committee that the most relevant standard is standard number 1.13, which reads as follows:

Apply scientific knowledge and clinical skills to care for patients across their lifespan, including as children, adolescents and ageing people, and patients in pregnancy and childbirth.[17]

4.17Professor Langham AM explained that the accreditation standard is deliberately broad to encompass the necessary flexibility in the curriculums for individual medical schools to adapt their education based on new knowledge.[18] The accreditation standards have also been recently updated and implemented and so will not be reviewed or updated for another six years.[19]

4.18The committee was advised that the AMC also has a role in the oversight of continuing professional development for medical practitioners.[20]

Professional development for General Practitioners

4.19Beyond the limited and varied undergraduate medical education related to menopause and perimenopause, the committee learned of the high burdens placed on general practitioners (GPs) when accessing training and education to upskill or specialise in menopause and perimenopause.[21]

4.20Theramex, a pharmaceutical company, highlighted this issue by drawing attention to how few menopause specialists there are in Australia compared with the number of GPs and specialist gynaecologists. There are over 38 000 GPs and 1700 specialist gynaecologists in Australia.[22] However, there are only 877 members of the Australasian Menopause Society.[23]

4.21Dr Sara Whitburn of the Royal Australian College of General Practitioners (RACGP) highlighted the dual impacts of cost and time on general practitioners in accessing continuing professional development:

General practice being a small business, any time GPs are trying to educate they are doing it at a time that might impact not only on their ability to provide patient care but also on income. Though it's very important they do continuing education—it's part of our registration, and we should certainly do it—it often has to be squeezed in around making sure they're available for their community and the cost to take the time to do that education.[24]

4.22Dr Christina Jang of the Australasian Menopause Society (AMS) emphasised the need for targeted training to be available for GPs in a variety of forms to enhance uptake; including module courses, online learning and webinars, as well as in person conferences and training.[25]

4.23Submitters contended that women’s health training and further education related to menopause for GPs must be prioritised to support a more highly skilled general practice workforce.[26] It was suggested that the AMS may be the appropriate body to undertake this work, given they already facilitate a range of menopause specific continuing education opportunities on a voluntary basis.[27]

4.24Jean Hailes for Women’s Health was provided with $1.2 million by the Commonwealth Government to advertise and subsidise continuing professional development for health professionals on managing menopause.[28] Jean Hailes advised that this work will be undertaken in collaboration with the Australasian Menopause Society.[29]

Self-selecting to specialise in menopause and women’s health

4.25For medical practitioners participating in further specialisation related to menopause and perimenopause at the general practice level, the committee heard that often these practitioners seek out this further education and training on the basis of patient demand or professional interest.[30]

4.26At a hearing in Perth, Dr Sunita Chelvanayagam, who appeared in a private capacity, explained to the committee why she opened a GP-led menopause-specific clinic:

I have been a GP for almost 20 years, and my colleague Dr Michelle Cotellessa for almost 30. Having seen a large cohort of female patients, combined with our own lived experience, it became abundantly clear that midlife health needed a different model of care. Fifteen minutes in a regular general practice consult was simply not covering the complex and sensitive needs of women in this transitional phase.

We opened WA's first GP-led menopause-specific clinic… one year ago practically to this day. In this short time, we have seen over 2 000 patients and have grown to a practice of four GPs. The demand for specialised menopause care has been unprecedented.[31]

4.27Often, these menopause and perimenopause specialists experience high demand for services and there are exceptionally high wait times for appointments. This is due to the lack of appropriate and effective menopause awareness and care in the broader healthcare system.[32] These practitioners are also often required to charge more for the longer consultations needed for the comprehensive model of care they provide.[33]

4.28Dr Michelle Cotellessa, who also appeared in a private capacity, explained to the committee that ‘the overheads that go with running a clinic when you're on a GP Medicare rebate mean we have to charge just to give good care’.[34]

Need for longer consultations and a holistic approach to women’s mid-life healthcare

4.29Practitioners who provided evidence to the committee highlighted the complexity that can be associated with consultations related to menopause and the subsequent requirement for longer appointments for more thorough assessment of symptoms.[35] As highlighted by Professor Steve Robson of the Australian Medical Association:

The management of menopause and perimenopause can be complex. It needs a whole-of-person, multisystem approach that deals with the issues affecting women and acknowledges that women are affected differently and individually. There is often a significant intertwining between the physical, work, family, emotional and many other issues in their lives.[36]

4.30At a hearing in Perth, Professor Roger Hart further emphasised that the menopause transition can be difficult to diagnose given the broad impact of symptoms across all aspects of bodily function and the fact that women often present to general practice with one or two most pressing concerns.[37] As such, Professor Hart encouraged a holistic understanding of women’s health by GPs to assist in the process of diagnosis.[38]

4.31The fact that the severity of symptoms can be so debilitating of course means that women and their doctors will obviously spend time testing and treating for other conditions. However, both doctors and women may fail to assess the possibility that the onset of symptoms is associated with perimenopause.[39] This in turn means that women have not discussed whether MHT would be of benefit, instead of, before or with other interventions.[40]

The operation of the Medicare Benefits Schedule

4.32A number of medical practitioners also raised the issue that the operation of the Medicare Benefits Schedule (MBS) does not incentivise the longer appointments needed to discuss and diagnose menopause symptoms.[41] Many submitters discussed the need for financial incentives for longer consultations, particularly noting that the current structure of the MBS prioritises short consultations.[42]

4.33Whilst the government recently introduced a 60 minute consult item to the MBS, Dr Virginia French discussed that the remuneration for a one-hour consult would still result in a practitioner earning about half as much or less than another doctor who is doing 10-to-15-minute consultations.[43] Dr Kelly Teagle stressed the impact of this in dollar amounts:

If you're turning over rapidly, seeing lots of patients, if you were bulk-billing you could earn $6 a minute. But by the time you're doing 50-minute consultations you're earning $2 or less per minute.[44]

4.34The issue of financial renumeration acting as a disincentive to provide this more comprehensive care was also highlighted by Sexual Health and Family Planning ACT:

The current Medicare system also incentivises short consultations. A GP conducting six 10-minute consultations would receive a Medicare rebate of $248.4/hour. This compares unfavourably to a GP doing one 45-minute consultation and one 15-minute consultation who would receive a Medicare rebate of $159.4/hour.[45]

4.35Some submitters suggested considering a menopause specific MBS item as an option to remedy this issue;[46] with some witnesses suggesting access to the funding for the new MBS item would depend on further demonstration of training on women’s health.[47]

Government reforms to the MBS

4.36The Department of Health and Aged Care (the Department) elaborated on recent reforms to the MBS that could be of benefit to women experiencing menopause and perimenopause. These include:

Funding in the 2023–24 Budget to include the introduction of a new MBS item for longer GP consultations of 60 minutes or more;

Enabling GPs to refer women to allied health professionals, including psychologists, physiotherapists and dietitians to support management of menopause conditions under a GP Management Plan and Team Care Arrangement, enabling referral of five MBS rebated allied health services per calendar year;

Patients with a chronic condition experiencing menopause may be eligible for MBS Chronic Disease Management items.[48]

4.37Ms Louise Riley, Assistant Secretary, MBS Policy and Reviews Branch at the Department, further explained at a public hearing that the new MBS item for a 60 minute consultation will be available for nurse practitioners from 1 March 2025.[49]

4.38Ms Leanne Boase, Chief Executive Officer of the Australian College of Nurse Practitioners explained that access to this new MBS item for nurse practitioners will enable nurse practitioners to deliver more comprehensive care, stating:

What that means for people who want to access the care of a nurse practitioner or midwife in primary care is that they are now fully entitled to their Medicare and PBS rebates or subsidies without needing the permission of another practitioner that they may or may not be involved with to access that. It doesn't affect clinical care in any way. Nurse practitioners have always been independent practitioners, able to practise without supervision. What it does do is uncouple it from the funding, so it will improve access to care.[50]

Mid-life health check for women

4.39Submitters discussed the potential utility of an MBS item for a women’s mid-life health assessment as an opportunity for identifying menopause, as well as enabling broader discussions on preventative healthcare checks.[51]

4.40While there is an existing MBS health assessment for a person aged 45 to 49 years old, eligibility for the rebate is dependent on a chronic disease risk. However, menopause is not currently classified as a chronic disease risk.[52] Associate Professor Madalena Simonis AM pointed out that even if menopause was included in the eligibility criteria it would not cover all women experiencing menopause symptoms as ‘an estimated 60 per cent of women go through the menopausal transition before the age of 45 or after 49’.[53]

4.41Professor Susan Davis AO suggested moving away from a specified age for mid-life health check and instead employing it in response to an event, enabling a mid-life health check MBS item number to be utilised by women experiencing menopause; regardless of the age at which it occurs.[54] Further:

The midlife health consultation happens at an age. It doesn't happen at a biological event. When you think about it, it's nonsense. If you go through menopause at 40 you've got to wait until you're 45 to have a midlife health consultation. If you have a midlife health consultation at 45 and you go through menopause at 54 it's completely irrelevant.[55]

Opportunity for preventative healthcare

4.42Participants in the inquiry discussed the opportunities for health practitioners to engage in conversations related to preventative healthcare for women living through the menopause transition, as well as further risk screening.[56]

4.43As outlined by the RACGP, menopause often occurs at ‘a time of mid-life health which includes an increasing risk of metabolic diseases including diabetes and cardiovascular disease, breast and bowel cancer, and osteoporosis’.[57] GPs treating women for menopause and perimenopause are also often best placed to conduct mid-life health risk screening and provide preventative care and treatment.[58]

4.44The AMS has developed a tool to assist with screening for mid-life health risks which encompasses a range of factors beyond the impact of menopause symptoms, including:

past medical history;

family medical history;

breast, cervical and bowel cancer screening;

social history;

smoking, diet, alcohol, drugs, exercise;

cardiovascular risks;

bone health; and

contraception.[59]

4.45Ms Iwinska from the Women’s Health and Equality Queensland emphasised the economic benefits of conducting these health checks, advising the committee that for every one dollar invested in healthcare prevention, the healthcare system is saved $14.80.[60]

Osteoporosis and bone density scans

4.46A key issue raised during the inquiry was the increased risk of osteoporosis or the precursor condition, osteopenia, as a result of the lowered production of hormones during the menopause transition.[61] As explained by Healthy Bones Australia:

Menopause is a critical period for bone health, as it is associated with a rapid loss of bone mass and strength, increasing the risk of osteoporosis and of painful, debilitating and costly fractures.[62]

4.47Dr Roy Watson made the point that osteoporosis is a ‘significant complication of menopause’, and that:

… there are around 3 800 women in Victoria alone each year who suffer a hip fracture and that the cost to the Australian healthcare system is around $1 billion per year. In addition, hip fracture carries a mortality within 30 days of eight per cent and within one year of 25 per cent.[63]

4.48A concern identified was the challenge of accessing preventative bone density scans to diagnose osteoporosis risk or to measure a baseline of bone density, due to cost barriers.[64] As the Tasmanian Government highlighted:

It is important to note in relation to Medicare-rebated bone density assessments, that these are only available in a very limited number of clinical conditions, even though all postmenopausal women are at risk of osteoporosis/osteopenia.[65]

4.49Submitters discussed that the only bone density scan that is available under the MBS has eligibility for women with certain chronic conditions, primary ovarian insufficiency or who are over the age of 70, excluding a number of other individuals who would benefit from preventative screening for their long-term health.[66]

4.50Felicity, an individual with lived experience, called for women from 35 years of age to be eligible for subsidised bone density screening to enable any concerns to be promptly addressed.[67]

4.51Jill, another submitter to the inquiry also highlighted:

It is a travesty that a routine bone densitometry is not covered by Medicare until the age of 70. For a huge proportion of post-menopausal women, the damage is well and truly done by then.[68]

The barriers to diagnosis for women living in regional and remote areas

4.52The committee heard of the additional barriers to treatment and diagnosis faced by women living in regional and remote areas.[69] It was highlighted that the issue of workforce pressure is magnified in rural areas.[70]

4.53The difficulties accessing specialist medical care in regional and remote Australia were highlighted by one submitter:

Access to specialist gynaecological services is difficult for rural women. There is a dearth of appropriately qualified professionals practicing rurally, and if a region is lucky enough to have a specialist, the waiting list for treatment and care can be many, many months.[71]

4.54Submitters recommended more telehealth options to enable women in regional and remote areas to more easily access specialist care for menopause and perimenopause.[72]

4.55Of the specific benefits associated with telehealth appointments for women living in regional and remote areas, Dr Alice Fitzgerald of the Australian College of Rural and Remote Medicine explained:

I think the advancements in telehealth are quite significant for populations in rural, remote and First Nations communities, especially since COVID, and we do recognise that many women, in particular, are more able to seek continuity of care via telehealth. I think the important thing to note is that telehealth shouldn't be a replacement for doctors on the ground but an adjunct for GPs and RGs working in rural areas that are particularly hard to staff. We really welcome the input from non-GP specialists and other allied health professionals, and use of telehealth in that space is really important.[73]

4.56The committee also heard evidence about the potential for nurse-led clinics and a greater role for nurse practitioners to support women’s health in regional areas:

I can actually give you an example of an initiative that I've been involved in recently in Queensland. You might've heard about it: the women's and girls' health clinics that are being set up. They intend for those to be nurse led, and it's an interesting model. … Honestly, we talked about why they're nurse led. We know that we don't have doctors where we need them. I always say that I don't think we're going to have them everywhere we need them, nor can we possibly even have nurses everywhere we need them. We need to look at new and flexible different types of health services and new and flexible types of funding.[74]

4.57Ms Beverly Baker, President of the National Older Women’s Network New South Wales spoke to the importance of pharmacists in regional areas, noting that:

… the pharmacy is the hub. They go there and ask [the pharmacist] before they go to the doctors. And that should be recognised and it should be built on.[75]

4.58Mr Chris Campbell of the Pharmaceutical Society of Australia also further elaborated that there are some rural towns in Australia where ‘the pharmacy is the only place that’s providing healthcare, and it’s making sure there is consistency of advice’.[76]

4.59In response to a question on notice, the Department outlined the steps taken to provide further support to women living in regional and remote areas. These include:

permanent implementation of MBS telehealth items for blood borne virus, sexual or reproductive health services, which can encompass menopause and peri-menopause care;

an investment of $3.5 billion to triple the bulk billing incentive, which commenced on 1 November 2023 and applies to the most common GP consultations; and

scaling and increasing the value of MBS bulk billing incentives for patients who live in regional, rural and remote communities.[77]

Diagnosis tools

4.60The committee heard that there are diagnosis tools either already in use or in development that should be considered to facilitate diagnosis.

MenoPROMPT

4.61Researchers from Monash University, in partnership with researchers from Melbourne University and the RACGP, Jean Hailes and the AMS, are in the process of developing software to assist GPs with the provision of informed and comprehensive menopause care.[78]

4.62The MenoPROMPT tool will involve a two-pronged approach for more comprehensive menopause primary care for women by offering:

a simple menopause assessment and decision-making tool that will be integrated into GP software, ‘so that key information is immediately accessible to GPs’; and

a pre-consultation women’s health self-assessment tool, delivered by SMS, which is subsequently integrated into the women’s electronic medical records.[79]

4.63The program is at the point of a pilot stage and is expected to be rolled out within the next 12 months.[80] It is also designed to be incorporated into the three most commonly used GP software programs: Medical Director, Best Practice and ZedMed.[81] Based on particular words used in the woman’s self-report, GPs will be prompted to step through the Practitioner’s Toolkit for Managing Menopause, as discussed below.[82]

2023 Practitioner’s Toolkit for Managing Menopause

4.64Also developed by the Monash University Women’s Health Research Program, the 2023 Practitioner’s Toolkit for Managing Menopause provides GPs with a comprehensive guide to identifying, treating and caring for patients experiencing the menopause transition.[83]

4.65The toolkit provides an easy-to-understand flowchart that guides GP decision-making in assessing:

symptoms and concerns of menopause;

whether a patient is in the menopause transition;

the relevant information required to query midlife women about;

patient care considerations;

management options and symptom treatment;

the need for bone density assessment; and

information on dosing of MHT and other medical treatments.[84]

Symptom checklists

4.66Other tools that are assisting women to access enhanced care and diagnosis from their GPs are symptom checklists, with examples developed by the AMS,[85] Jean Hailes,[86] and the New South Wales (NSW) Government.[87]

4.67These symptom checklists offer a tool for women to guide discussions with their GP, or to assist GPs in diagnosing the menopause transition.[88] Some witnesses to the inquiry spoke of the lack of awareness of these checklists and how it would be useful for these to be more widely utilised.[89]

MENO-D – diagnosis of mental health impacts of menopause

4.68As discussed in Chapter 2, many women shared their experiences of mental health challenges during the menopause transition. The impacts on women’s mental health and wellbeing were raised as an underreported and under addressed challenge of perimenopause diagnosis and treatment, requiring further medical education and upskilling.[90]

4.69Professor Jayashri Kulkarni AM discussed the impact of the menopause transition on the brain and its subsequent impact on mood; including through increased presentation of menopausal depression.[91] Professor Kulkarni highlighted the impact of fluctuating hormones such as oestrogen, progesterone and testosterone affecting fluctuating production of brain chemicals including serotonin, dopamine and noradrenaline.[92]

4.70Professor Kulkarni argued that occurrences of menopausal depression are underdiagnosed and often not clinically recognised, resulting in inappropriate treatment.[93] This was an issue that was raised in evidence by individuals who shared their experiences with the committee and talked about the incorrect prescription of anti-depressants in lieu of MHT or other menopause-specific treatment.[94]

4.71Particularly, Professor Kulkarni emphasised the need to recognise that menopausal depression is caused by fluctuating hormone levels and thus must be treated with hormone therapy.[95] Dr Louise Newson highlighted the devastating impacts it can have, stating:

We know suicide increases by a factor of seven in women in their late 40s, and a lot of it will be due to hormones, because we know they work as neurotransmitters.[96]

4.72Sexual Health and Family Planning ACT discussed the importance of continued access to Mental Health Care Plans to ‘enable those on the menopause journey to access psychological services’.[97]

4.73In response to emerging trends of menopausal depression, the HER Centre Australia developed the MENO-D rating tool to assist individual patients and/or clinicians to diagnose this condition. The tool assesses the following symptoms on a sliding scale based on experiences over the past two weeks:

low energy;

paranoid thinking;

irritability;

self esteem;

isolation;

anxiety;

somatic symptoms;

sleep disturbance;

weight;

sexual interest;

memory; and

concentration.[98]

Treatment options

4.74Following the difficulties of seeking access to a diagnosis of menopause, the inquiry also highlighted the subsequent challenges of accessing appropriate, cost effective and available treatments for menopause symptoms. This section discusses Menopause Hormonal Therapy (MHT) as a treatment, the benefits of multidisciplinary menopause clinics and considers the issue of complementary and alternative therapies.

Menopause Hormonal Therapy

4.75MHT, also known as Hormone Replacement Therapy (HRT), is a recommended treatment option for addressing problematic symptoms of menopause. MHT treatment involves replacement of the hormones that are depleted as a result of the menopause transition, including oestrogen (specifically the compound oestradiol), progesterone and also in some cases, testosterone, to treat troublesome symptoms.[99]

4.76Oestrogen is usually utilised for treating vasomotor symptoms such as hot flushes and night sweats. It also has protective factors in preventing bone loss.[100] It is available as tablets, skin patches and gels. Vaginal oestrogen in creams, pessaries or tablets is available for vaginal dryness or dyspareunia.[101]

4.77For women who have a uterus (i.e., have not had a hysterectomy), a progestogen is also recommended alongside oestrogen to counteract the risk of endometrial cancer from the oestrogen by itself.[102] Progestogens are most often taken orally, and micronized progesterone capsules are a form of body identical progesterone. Women who have had a hysterectomy do not require use of a progestogen.[103]

4.78Testosterone can also be used for women experiencing negative impacts of perimenopause and menopause on their libido.[104]

4.79A number of practitioners emphasised the ‘gold standard’ of combined MHT which include body identical transdermal estradiol, oral micronized progesterone and inclusion of testosterone where needed as preferrable because of their lower risk profile.[105]

4.80Comparatively, evidence suggests that particular oral and synthetic preparations of MHT may have higher levels of risk:

Synthetics have a higher risk of breast cancer, arterial and vascular disease compared to body identical hormones. Orals have a higher risk of arterial and vascular disease than transdermal.[106]

Fear associated with the use of MHT

4.81In relation to the use of MHT, there are continuing concerns about the Women’s Health Initiative (WHI) study in 2002. The study was designed to evaluate the role of MHT in the prevention of diseases related to aging but was concluded early, with findings that included a potentially increased risk of breast cancer associated with MHT use.[107] As explained by the Society of Hospital Pharmacists of Australia in their submission:

The release of the Women’s Health Initiative (WHI) study in 2002 on the use of hormone replacement therapy (HRT) in menopause became a catalyst for huge change in HRT use across the globe. The initial results and the proceeding media reports of increased risk of breast cancer from HRT use led to the sudden cessation of HRT in thousands of women.[108]

4.82Several submitters explained that healthcare providers, especially GPs, have a lack of confidence in prescribing, recommending and managing MHT as a form of therapy due to the WHI study findings and associated concerns about the purported increased risk of breast cancer, heart disease and stroke.[109]

4.83The WHI study has subsequently been found to have had significant limitations in its study design and findings. This includes that the study employed a synthetic progestin which is not extrapolatable to body identical hormone treatment which is currently available on the market.[110]

4.84At a hearing, Jill relayed her difficulties accessing MHT in the Australian medical system because of the ongoing hesitation to prescribe MHT:

My individual experience has been that HRT is not thought of as a first-line treatment for menopause. In fact, in a medical setting, it was rarely mentioned or discussed as a viable option. You have to, basically, demand it, and that is not a good situation for the doctor or the patient. I demanded HRT and commenced taking it at the age of 61.[111]

4.85Associate Professor Treasure McGuire also noted the WHI study contributed to the recent shortages of these products across Australia, noting that the outcomes of the WHI study ‘led to a massive cessation of hormonal therapy, and this resulted over time in discontinuation of the very products we need to use’.[112]

Costs of treatment

4.86Many women raised the issue of the cost of MHT as a barrier to effective treatment.[113]

Pharmaceutical Benefits Scheme listing

4.87There are a limited number of MHT products on the Pharmaceutical Benefits Scheme (PBS), with many medications and delivery methods not subsidised.[114]

4.88Currently, some transdermal oestrogen patches are available on the PBS.[115] However, the safest form of micronized progesterone, Prometrium, is not available on the PBS.[116] Instead, the only options available on the PBS for progesterone therapy are synthetic progestins which are identified as having a higher risk profile.[117] The combined MHT medication course of Estradiol gel and Prometrium capsules is not listed on the PBS.[118] Also, AndroFemme, the testosterone product for women, is not available on the PBS.[119]

4.89Her Health and Aesthetics elaborated that the ‘safest medications are the most expensive as they are not supported by the prescription subsidy scheme’.[120] DrKelly Teagle of WellFemme elaborated:

Regarding affordability of best evidence-based treatments: micronized (body-identical) progesterone has overwhelmingly proven to be the safest progestogen for MHT, but it is not subsidised under the PBS. Financially vulnerable women must instead settle for cheaper synthetic progestins that have been shown to increase breast cancer risk.[121]

4.90Further, pharmaceutical companies spoke to the difficulties of introducing new products to be considered for listing on the PBS, given the requirement to compete with older listed products, such as synthetic progestins, which are not comparable in production costs to body identical progestogens.[122]

Prohibitive costs

4.91These products not being on the PBS drives a higher cost burden on women seeking the most effective and safe treatments. Dr Cashell highlighted the financial impact of accessing MHT on a regular basis, noting that the ‘whole cost of HRT if you take all three hormones plus vaginal oestrogen is roughly $100 per month’.[123]

4.92Dr Cashell further explained the real impact of these issues by sharing a story of a patient who was no longer able to afford MHT and instead asked for Valium ‘because a box of 50 Valium is PBS listed and costs $15, whereas her anxiety and depression were controlled on progesterone and estradiol’.[124]

4.93This also has implications for the quality of care that doctors are able to provide to their patients. As Dr Louise Manning of the Rural Doctors Association of Australia explained:

Often I am having to have conversations like: 'This is what I think will be best for you. This is what I think will manage your symptoms best. But you can't afford it.' It's a real struggle. As a doctor, I find that really challenging ethically because I know that they will get better symptom management with X, Y or Z, but they literally cannot afford it. ... These people can't afford what will be better for them, because it's not currently on the PBS.[125]

4.94Grace, a private individual who appeared at a hearing, provided an analysis of the costs associated with accessing MHT and associated healthcare:

I'm going to share with you a list of my monthly medications, including supplements I need just to be able to function: oestrogen patches range from $21 to $35; oral progesterone, $47; vaginal oestrogen, $19; testosterone, $75; and contraceptive pills are $83 to help stop my constant heavy bleeding. This is a total of $259. Supplements: B12, $48; magnesium, $44; iron, $32; intimate cream, $23; zinc, $24; omega 3, $33; collagen powder, $59; dry eye wipes, $21; and eyedrops, $13. The total is $297.[126]

Shortages and discontinuation of MHT products

4.95There are additional barriers due to current shortages of prescribed treatments, caused by a number of factors, including discontinuation of certain products from the market and manufacturing difficulties.[127]

4.96The Department explained that there has been a global shortage of some estradiol-containing transdermal patches, including Estradot, Estraderm MX and Estalis.[128] Moreover, Climara, a transdermal estradiol patch was discontinued from the market.[129]

4.97Author Ms Kaz Cooke conducted an online survey of almost 9000 women to inform the content of her book ‘It’s the Menopause’. At a hearing in Melbourne, she emphasised the range of challenges experienced by women trying to access MHT, elaborating on the experiences shared with her when writing her book:

They are all so upset about the shortage of medications. They feel that they're held in contempt. You know, they've gone to 12 pharmacies and consider how difficult that is when you live in a regional area, to try and find this thing that they've been prescribed by a doctor. When they can't get it they're told that they can get this other thing, but it's not on the Pharmaceutical Benefits Scheme and they're spending a $1 000 to 1 500 a year on medications and other things to try and mitigate.[130]

4.98Lynette, a community pharmacist, spoke to the impacts of MHT shortages on her practice:

Over recent months, there has been a notable and distressing trend of menopause treatments being consistently out of stock or discontinued altogether. This scarcity of essential medications is causing undue hardship and distress to countless individuals who rely on these treatments to manage the symptoms associated with menopause. Many women are ringing multiple pharmacies daily, travelling for hours just to source their monthly prescription.[131]

4.99At a hearing in Perth, Dr Sunita Chelvanayagam explained difficulties in providing stable and consistent patient care, and how she often needed to adjust prescriptions and care plans on the basis of stock availability.[132]

4.100Many women shared with the committee the impacts of these shortages, including having to travel to a number of different pharmacies, needing to return to their GP to change dosage, brand or formulation and; in some instances, needing to cut MHT patches against the advice of pharmacists in order to achieve appropriate relief from symptoms.[133]

4.101A further point consistently raised with the committee was the comparison of access to MHT for women to Viagra, a medication designed for male erectile dysfunction.[134] Submitters emphasised that Viagra is available on the PBS and is readily available across the country; whereas MHT is not.[135]

4.102The committee was also informed about the impact of localised medicine shortages in regional and remote areas, whereby MHT treatments may be more readily available in metropolitan areas, but shortages continue in rural locations.[136]

Potential remedies for MHT shortages

Domestic manufacturing of MHT

4.103Submitters discussed considering a domestic manufacturing capability of certain forms of MHT as a potential solution to the shortage issues regarding these medications.[137] It was highlighted to the committee that AndroFemme, a testosterone treatment for women, is manufactured in Perth, Western Australia.[138]

TGA actions to remedy shortages

4.104Participants in the inquiry emphasised the potential for the Therapeutic Goods Administration (TGA) to respond to shortages of MHT by enacting special actions to bring in different medications, as explained by Dr Christina Jang:

… when the shortages are present, the TGA have the ability to enact special actions to bring a range of different medications in. Section 19A of the TGA [Act] allows medications which are normally not available in the country to be brought in. There is an example of that currently. It is a patch called Estramon which has been brought in from Germany. That's currently available. That's in place of Estradot and Estraderm, which have been in short supply.[139]

4.105In a response to a question taken on notice, the Department explained recent actions taken under Section 19A:

From 1 January 2023 to 26 August 2024, the Pharmaceutical Benefits Advisory Committee (PBAC) considered 48 applications to list alternative brands under s19A temporarily on the PBS during shortages. Of these, 3 related to perimenopause or menopause treatments. These 3 related to different strengths of the hormone replacement therapy (HRT) medicine Estradiol (Sandoz, USA), and since 1 June 2024, this product has been available on the PBS in 37.5 microgram, 75 microgram and 100 microgram 24-hour patches. All s19A applications related to perimenopause or menopause treatments considered by PBAC during this period have been listed on the PBS.[140]

4.106At a hearing, Associate Professor Robyn Langham AM, in her capacity as Chief Medical Adviser of the Health Products Regulation Group, explained that there are a range of additional options available to the TGA to mitigate shortages.[141] These include:

approving overseas registered alternative products that can be imported and supplied in Australia without going through the TGA’s pre-market evaluation safety quality registration;

publishing identified shortages online based on information provided by sponsors;

working with community service obligation deed distributors to constrain available supplies and facilitate equitable distribution of PBS listed patches; and

where a product is particularly scarce, the TGA can issue a Serious Scarcity Substitution Instrument, but this requires a readily available substitute to be most effective.[142]

4.107Associate Professor Langham advised the committee that the TGA is also undertaking a review of medicine shortages, including comprehensive stakeholder engagement, with a series of draft recommendations expected to be put to the Minister for Health in the coming months.[143]

The need for priority access to MHT for certain cohorts

4.108Given the substantially increased impacts of menopause on women with primary ovarian insufficiency (POI), women who experience surgically induced menopause and those who are in early menopause due to the effects of cancer treatment, the need for a priority access scheme to MHT for these women was also highlighted during the inquiry.[144] As made clear by a private individual speaking to her daughter’s experiences with POI:

There is precedent for prioritising medication to those most in need during times of drug shortages. A recent example of this is the ability of pharmacists to prioritise of patients with diabetes to access the drug Ozempic. The ability of pharmacists to prioritise those at greatest risk of severe health consequences is a critical and ethical practice. The evidence strongly supports that young women with POI should receive similar prioritisation for HRT access.[145]

Multi-disciplinary clinics and the idea of a ‘one stop shop’

4.109In discussing potentially useful models of treatment, submitters emphasised the importance of multidisciplinary clinics that incorporate a range of different services that can contribute to a women’s wellbeing during menopause; for example, physiotherapy, exercise physiology, nutrition support and other allied health services.[146]

4.110Ms Leeanne Boase of the Australian College of Nurse Practitioners pointed out there is the option for these clinics to be nurse-led to address GP workforce shortages in certain areas.[147]

4.111The Monash Centre for Health Research and Implementation discussed the fact that public specialist menopause services are not available in all states and territories of Australia. It recommended ‘a specialised multidisciplinary menopause service (with telehealth remote access)’ in each state and territory in Australia to provide specialist care and support GPs.[148]

4.112More broadly, it was noted that there are limited existing multidisciplinary menopause clinics in the public health system. Some submitters recommended that the Australian Government support the roll out of these clinics through the public health system.[149]

4.113Dr Sara Whitburn, in her capacity as Deputy Medical Director and Senior Medical Officer at Sexual Health Victoria, took the example of the existing pelvic pain clinics across the country as a potential model of care for the menopause clinics:

So thinking about how the pelvic pain clinics work, I would envisage grants to set up a multidisciplinary menopause clinic that would allow you to have a longer appointment, allow to have a team looking at mental health, physiotherapy—nurse practitioners, GPs and midwives. You could allow for that access and quality care so people don't get turned away, so they do get the information they are looking for, so they do get asked around assessments and so people who are used to looking at investigations can provide that care.[150]

4.114The NSW Government highlighted its rollout of a network of Menopause Services across NSW that will provide an escalation pathway to specialist care for people experiencing severe or complex symptoms of menopause.[151]

Alternative therapies

4.115Some submitters told the committee that there are alternative and complementary therapies that can provide relief from menopause and perimenopause symptoms. According to Dr Gabriela Berger and Dr Anita Peerson, there are a range of alternative therapies that can provide relief, including aromatherapy, massage, yoga and acupuncture, dietary and herbal supplements and, to a lesser extent, exercise and reflexology.[153]

4.116The ALSWH provided an overview of the uptake of alternative therapies by women in the 1946–51 cohort, between the ages of 59 and 64:

39 per cent of menopausal women consulted a complementary practitioner (including massage therapists, naturopaths/herbalists, chiropractors/osteopaths and acupuncturists;[154] and

75 per cent had used at least one self-prescribed complementary or alternative medicine.[155]

4.117The Naturopaths and Herbalists Association of Australia explained the holistic approaches used in naturopathy that can assist in supporting the management of menopause symptoms:

Naturopaths can contribute valuable insights into lifestyle modifications, nutritional interventions, and evidence-based complementary or alternative therapies.[156]

4.118A few submitters to the inquiry also shared their experiences of turning to naturopathy and other complementary therapies for a more holistic approach to managing their symptoms.[157] Some naturopathy practitioners also specified that they saw a number of patients after they had sought help from doctors who did not recognise their symptoms.[158]

4.119The AMS has developed a comprehensive fact sheet outlining the various complementary medicine options for the treatment of menopause symptoms.[159] The fact sheet identifies the safe and effective complementary therapies as:

vitamin E;

cognitive behavioural therapy;

hypnosis; and

yoga.[160]

4.120Conversely, the fact sheet also identifies a range complementary therapies which should not be used due to safety concerns and insufficient evidence:

wild yam cream or progesterone cream;

red clover;

omega 3 supplements;

black cohosh;

evening primrose oil;

homeopathy;

magnetic therapy; and

bioidentical compounded hormone therapy.[161]

Marketing of alternative therapies to women

4.121Some submitters were concerned that there are companies that market certain products to women without an established evidence base to support the claims they make.[162] In its submission, Jean Hailes explained:

There are many, many complementary and alternative therapies being marketed to women in perimenopause and menopause that promise to ‘balance hormones’, reduce weight gain, “regain a youthful appearance” and lose weight. At best, these advertisements induce women to waste their money; at worst, they could cause real psychological harm by creating feelings of envy or inadequacy or affecting self-esteem and self-worth. The products themselves carry their own risks.[163]

4.122The Monash Centre for Health Research and Implementation highlighted the issues associated with complementary and alternative medicines (CAMs):

The use of unproven and ineffective CAMs, fuelled by misinformation on social media and the lack of counter balancing accessible evidence based information leads to a major waste of money for women and delays use of effective treatments.[164]

4.123Ms Kaz Cooke emphasised the importance of greater regulation of the alternative therapy industry targeted at menopause, explaining:

No agency in Australia now properly regulates the billion-dollar supplements industry. So-called 'supplements' are sold directly or by implication as health remedies and therapeutic goods. Women believe they are herbal equivalents of pharmaceutical hormone medications which will deliver the same effects. This is not true.[165]

4.124The Australian Medical Association also pointed out that some over the counter alternative treatments:

… are not subject to the rigorous testing for content, safety and effectiveness that prescription treatments are subject to. Despite no clinical trial evidence, natural therapies are easily purchased and tend to be very expensive. The associated marketing is sophisticated and typically use celebrity endorsement.[166]

Regulation of alternative therapies

4.125Associate Professor Robyn Langham, in her capacity as Chief Medical Adviser of the Health Products Regulation Group, outlined that there are different mechanisms for classifying different types of medicines. For example, products identified as higher risk, such as those containing hormones, must undergo a TGA evaluation of safety, quality and efficacy.[167]

4.126Comparatively, lower risk products, such as vitamins, herbal medicines and traditional medicines are classed as listed medicines and do not require TGA pre-market approval.[168] She explained to the committee that:

…they must be made under a licence of good manufacturing practice. They can only contain preapproved low-risk ingredients. They can only make low-risk preapproved health claims. And they must have evidence that supports the claims that they're making. They must also comply with all advertising and labelling requirements of the Therapeutic Goods Act.[169]

4.127Further, Associate Professor Langham advised the committee that any products that are intended for oral consumption may be regulated as a food or as a medicine, depending on several factors such as the ingredients, the overall presentation and the types of claims that are being made about the product.[170]

4.128Products for oral use that are not regulated as therapeutic goods are likely to be regulated under food legislation by Food Standards Australia New Zealand. These are different to therapeutic goods regulated by the TGA which must make a therapeutic claim, particularly:

… a claim that they're either preventing, diagnosing, curing or alleviating a disease, an ailment, a defect or an injury or anything that's influencing, inhibiting or modifying a physiological process. Claims such as 'relieving the symptoms of menopause' would be considered a therapeutic claim, therefore they are considered therapeutic goods and they are regulated by the TGA.[171]

4.129When asked by the Chair of the committee if there was an indication on packaging that a product was ‘TGA listed’, Associate Professor Langham responded that it was not part of the TGA labelling requirements under legislation.[172]

4.130On the issue of greater regulation for advertising of alternative therapies, MsTracey Lutton from the Department explained the powers of the TGA to:

develop educational resources for social media platforms to identify problematic social media influencers, including information on lawful content and known influencer endorsements associated with particular products;

identify advertisements that are not lawful or go against the advertising code; and

disrupt websites advertising unlawful information and removal of information from particular platforms.[173]

4.131The Department, in an answer to a question on notice, confirmed that in the 2023–24 financial year, over 4 800 removal requests were issued to various digital platforms, including social media platforms, for unlawful advertising of any therapeutic good.[174] Although it was not possible to delineate the data to menopause specific advertising, the Department advised a number of these removals were for complementary/herbal medicines that would have included those targeted at menopause and perimenopause treatments.[175]

Avoiding overmedicalisation of menopause

4.132Some inquiry participants spoke to the need to have a balanced discourse in discussions related to menopause and perimenopause, to avoid women being fearful of entering this life phase or the further perpetuation of stigma.[176]

4.133The Royal Women’s Hospital Melbourne submission elaborated:

Unfortunately, amongst many medical professionals, menopause has largely been pathologised and viewed as a “hormone deficiency”. This is both inaccurate and potentially harmful and can lead to over-diagnosis and over-treatment. It can also create negative expectations, and those with negative expectations are more likely to report problematic symptoms.[177]

4.134Professor Martha Hickey of the Australian Academy of Health and Medical Sciences explained:

Menopause isn't a disease. It doesn't need a formal diagnosis as such; it's something that happens to all those born with functioning ovaries. The important thing is that those who need help get help. … It's not necessarily helpful to take the position that menopause is a disastrous event for all women, because it isn't. As with pregnancy, for example, there are a diversity of experiences.[178]

4.135Dr Christina Jang of the AMS noted the need for accepting menopause as an important part of the process of ageing and spoke to the need to prepare women effectively:

It's a privilege that we get there [to menopause]. It's preparing them. We don't need to say it's a disaster. I think we have to embrace it: 'This is what happens. This is how you go into it. This is what's going to happen. Stay healthy. These are the things that you can do. Be empowered and let's go forth'.[179]

Committee view

4.136Throughout the inquiry, the committee heard from women, doctors, advocates and experts about the various barriers to diagnosis and treatment. The committee was concerned to see how arduous and expensive the journey to diagnosis and treatment can be for women who, at times, can experience debilitating symptoms.

Medical practitioner training

4.137The issue of menopause training for medical practitioners cannot be underestimated. The current level of education received at medical schools is clearly insufficient. The committee was alarmed to hear that most medical students only spent an hour on the topic of menopause during their undergraduate studies given it will affect more than half the population.

4.138The Australian Medical Council explained to the committee that there are certain accreditation standards which individual medical schools are responsible for assessing core competencies for their graduates. The committee is deeply concerned that there is no key standard that speaks specifically to women’s health or menopause, which makes it difficult to ascertain the specific women’s health education outcomes in the Australian medical education system.

4.139The committee acknowledges that the Australian Government has committed $1.2 million for Jean Hailes for Women’s Health to advertise and subsidise continuing professional development.

4.140The committee is of the view that all Australian universities have a role to play in ensuring that undergraduate medical students receive appropriate information and training.

4.141The committee recommends that the Australian Government encourage the Australian Medical Council to consider explicitly including menopause and perimenopause in the Graduate Outcome Statements of the Standards for Assessment and Accreditation of Primary Medical Programs. The committee further recommends that menopause and perimenopause be included in graduate outcomes for other health professionals, including nurses and physiotherapists.

4.142The committee recommends that the Australian Medical Council work with Medical Deans Australia and New Zealand to ensure that menopause and perimenopause modules are included in all medical university curriculums.

4.143The committee acknowledges that there are barriers to continuing professional development for GPs in Australia, including the costs of maintaining a practice and managing a patient load, which can mean that professional development is de-prioritised.

4.144Further, the comparative lack of AMS accredited menopause specialists when compared to the number of GPs and specialist gynaecologists in Australia suggests that there is an even smaller number of GPs who are prioritising menopause specific professional development.

4.145Women deserve access to medical practitioners who are informed and aware of menopause and its symptoms, and who are confident in providing advice on the best management options currently available. As such, the committee is of the view that initiatives and incentives to ensure better training of medical practitioners should be considered by the Australian Government as well as state and territory governments.

4.146The committee recommends that all governments and the medical colleges work together to require and facilitate further education on menopause and perimenopause for physicians practising in the public health system across Australia.

4.147The committee recommends that the Australian Government considers increasing funding and expand the recipient base for the delivery of incentivised continuing professional development to medical practitioners on perimenopause and menopause.

4.148The committee recommends that the Australian Government consider how to expand the scope of practice of nurse practitioners to ensure better support for women experiencing menopause in rural and regional areas.

Healthcare reforms

4.149The primary healthcare system in Australia is of the utmost importance to ensuring that Australians receive timely and effective access to diagnosis and care. Firstly, the lack of awareness and understanding in relation to the symptoms and presentations of menopause is a significant barrier to accurate diagnosis.

4.150The committee acknowledges the important work that has taken place in building awareness and supporting GPs through tools such as MenoPROMPT, the Practitioner’s Toolkit for Managing Menopause and symptom checklists. These are useful tools that can assist practitioners and patients to more effectively work through a diagnosis of menopause and perimenopause. The committee encourages further dissemination and promotion of these resources.

4.151Menopause consultations require a comprehensive health approach and an understanding of the various facets of a woman’s life that are affected. They can require a lot longer than the standard 15 minute consultation. The committee heard that that the Medicare system incentivises general practitioners to provide short appointments. This results in the GPs who are providing longer consults and more comprehensive care, being financially disadvantaged. These GPs are often required to pass these additional costs on to their patients.

4.152The committee welcomes the recent introduction of the 60 minute consultation. However, the committee recognises that this may not go far enough for women seeking access to menopause care or for the practitioners currently providing this care.

4.153As explained by submitters, the committee notes that these longer consultations provide an important opportunity for preventative healthcare to avoid developing the chronic health conditions that can occur during midlife or menopause.

4.154The committee notes that expansion of the eligibility for mid-life health check appears to be a potential option to enable greater access to comprehensive preventive care. However, more work needs to be done to determine the best mechanism for ensuring women can access the care they need during the menopause transition.

4.155The committee recommends that the Department of Health and Aged Care, through the Medicare Benefits Schedule (MBS) Continuous Review, review existing MBS item numbers relevant for menopause and perimenopause consultations, including for longer consultations and mid-life health checks, to assess whether these items are adequate to meet the needs of women experiencing menopause.

4.156The committee recommends that the Australian Government consider whether a new MBS item number or the expansion of criteria for the mid-life health check, is needed to support greater access to primary care consultations for women during the menopause transition.

4.157It is clear that menopause is a period of high risk for the development of secondary health conditions, including cardiovascular disease, osteoporosis and diabetes. Prevention is a greater tool than treatment. Given women who are post menopause are at a much higher risk of developing osteoporosis than the general population, it is obvious that they should be supported to access the appropriate prevention tools.

4.158Currently, bone density scans are only available under the Medicare Benefits Schedule (MBS) under certain circumstances, including, having certain chronic conditions, being over the age of 70 or being at high risk of primary ovarian insufficiency (POI). The committee is of the view that all women identified by their GPs as having a risk of developing osteoporosis through the menopause transition should be eligible under the MBS to access bone density scans.

4.159The committee notes that the Department of Health and Aged Care may have a role to play in considering an extension of MBS rebate eligibility for bone density scans to women in perimenopause who are identified by their GPs as having a risk of developing osteoporosis.

Access to treatment

4.160The barriers to accessing menopause hormonal therapy treatments in Australia are unacceptable and are having a disproportionate negative impact on too many women’s lives. It is urgent to address the two key barriers to access MHT, namely high costs and supply issues.

4.161While acknowledging the issues of global supply chain disruptions and the removal of certain products from the Australian market, it is deeply concerning that so many Australian women are unable to access the products they rely upon for their quality of life.

4.162It is also of great concern that some of the most effective and safe products are not available on the Pharmaceutical Benefits Scheme (PBS), forcing women to choose between cost and efficacy.

4.163The committee is of the view that the Australian Government must undertake work to ensure a more stable supply of these products. It must investigate options for the inclusion of more of the safest body identical hormone treatments onto the PBS.

4.164It was also of great concern to the committee to learn of the disproportionate impacts and significantly increased risks for women who experience early menopause, through diagnosis of POI or through surgical menopause or side effects of cancer treatment. Given the extended period of time that these women live without natural hormone production, MHT is particularly important for them as a preventative health measure. The committee is of the view that the Australian Government should give consideration to mechanisms that may enable these women to have greater access to these treatments.

4.165The committee acknowledges the wide variety of complementary and alternative medicines and treatments that are available in the Australian market. While some of these products are useful to support women to more effectively manage their symptoms, it is concerning that there are still too many products being marketed that may not be effective or may cause harm. The committee encourages the TGA to continue to monitor this situation in Australia and take action as appropriate. Further, to address the issue, the committee encourages the Department of Health and Aged Care to consider reviewing the labelling of TGA approved medicines. This would ensure consumers can clearly identify products that are approved by the TGA and reduce the risk of them being misled in buying food products, which have no proven efficacy in the management of menopause symptoms.

4.166The committee recommends that the Department of Health and Aged Care, including the Therapeutic Goods Administration, consider action to address the shortages of menopause hormonal therapy (MHT) in the Australian market and consider options to secure sufficient supply, including a review of the supply chains and pricing trends of MHT, with a view to enabling universal affordable access to treatment and care.

4.167The committee recommends the Therapeutic Goods Administration continue to monitor the advertising alternative medicines and treatments in Australia and take action as appropriate. The committee further recommends the Department of Health and Aged Care consider reviewing the labelling of TGA approved medicines.

4.168The committee recommends that the Australian Government examine options to implement a means of ensuring that MHT items are affordable and accessible, including consideration of domestic manufacturing and alternate means of subsidising costs to the consumer. Such examination should include, but not be limited to, considering ways to encourage pharmaceutical sponsors to list a broader range of MHT items, such as body identical hormone therapy products, on the Pharmaceutical Benefits Scheme to ensure appropriate access and lowered costs for all women who need it.

4.169The committee recommends that the Pharmaceutical Benefits Advisory Committee (PBAC) reforms comparator selection during evaluation of new MHT items to include quality of life health impacts. The committee also recommends that the PBAC regards body identical hormone therapy products in a separate drug class to remove the lowest cost comparator to synthetic therapies.

4.170The committee notes that there is a need to educate mental health and primary health practitioners about menopause related mental health issues and hormone therapy to enable more options to be discussed with women they are treating. The committee heard that too many health practitioners are still unaware of the hormone - mental health link.

4.171Further, the committee notes the call for more research to build an evidence base for the use of hormone therapy in mental ill health. The committee encourages the AMS and other peak bodies ensure their guidance and factsheets around the use of MHT reflect new findings, especially in the area of menopause and mental health symptoms.

4.172The committee recommends the Australasian Menopause Society regularly review and update their guidance for medical practitioners around best practices in the treatment and management of mental health symptoms.

Multidisciplinary care clinics

4.173The committee agrees with submitters that there is great benefit associated with menopause multidisciplinary care clinics that offer a range of specialists, as well as allied health professionals, in one location through the public health system. The committee acknowledges that the majority of menopause clinics are currently operating in the private health sector.

4.174The committee is of the view that there is an opportunity to engage in effective primary care through the provision of public health menopause care clinics in each state and territory across Australia. The incentivisation of professional development courses and opportunities for specialisation in women’s health and menopause and perimenopause would likely greatly assist with the staffing of these clinics.

4.175The committee recommends that the Australian Government work with state and territory governments to implement or leverage existing women’s health facilities with multidisciplinary care, including in the public health system, to better support women during the menopause transition across Australia.

Footnotes

[1]Royal Australian and New Zealand College of Psychiatrists, Submission 19, p. 2.

[2]See, for example, Bronwyn, Submission 61, [p. 2]; Name Withheld, Submission 126, [p. 2]; Name Withheld, Submission 129, [p. 1]; Name Withheld, Submission 180, p. 5; Ieva, Submission 199, [p. 2]; Kerry, Submission 202, [p. 2]; Name Withheld, Submission 207, [p. 1]; Simone, Submission 236, [p. 7]; Jo, Submission 242, [pp. 1–7]; Name Withheld, Submission 247, [p. 6]; Julie, Submission 257, [p. 2]; Ms Grace Molloy, Chief Executive Officer and Co-Founder, Menopause Friendly Australia, Committee Hansard, 17 June 2024, p. 13; Associate Professor Amanda Vincent, Clinical Associate, Early Menopause Lead, Monash Centre for Health Research and Implementation, Committee Hansard, 29 July 2024, p. 18;Jill, Private capacity, Committee Hansard, 30 July 2024, p. 33; Dr Lucy Caratti, Private capacity, Committee Hansard, 6 August 2024, p. 39; Dr Antonia Hendrick, Senior Lecturer, School of Allied Health, University of Western Australia, Committee Hansard, 13 August 2024, p. 2.

[3]Dr Christina Jang, Board Director and President-elect, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 58.

[4]See, for example, Dr Alice Fitzgerald, Board Member, Australian College of Rural and Remote Medicine, Committee Hansard, 29 July 2024, p. 6; Mr Grant Burton, Assistant Secretary, Queensland Nurses and Midwives Union, Committee Hansard, 29 July 2024, p. 5; Dr Louise Manning, President, Rural Doctors Association of Victoria, Committee Hansard, 30 July 2024, pp. 16–17; Dr Jessica Floreani, General Practitioner, AWARE Women’s Health, Committee Hansard, 5 August 2024, p. 16; Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 17 June 2024, p. 7.

[5]See, for example, Dr Elaine Leung, Senior Lecturer, Medical Deans Australia and New Zealand, Committee Hansard, 5 August 2024, pp. 44–45; Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 9; Professor Steve Robson, President, Australian Medical Association, Committee Hansard, 30 July 2024, p. 23;DrCarmel Reynolds, Board Member, Australasian Menopause Society, Committee Hansard, 5August 2024, p. 17.

[6]See, for example, Dr Jessica Floreani, General Practitioner, AWARE Women’s Health, Committee Hansard, 5 August 2024, p. 16; Dr Marita Long, Board Member and Victoria and Tasmania Representative, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 59; Ms Kaz Cooke, Private capacity, Committee Hansard, 18 June 2024, p. 2.

[7]Dr Marita Long, Board Member and Victoria and Tasmania Representative, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 59.

[8]See, for example, Victorian Women’s Trust, Submission 99, p. 45; Maridulu Budyari Gumal, Submission 109, p. 7; Menopause Friendly Australia, Submission 147, [p. 2]; Theramex, Submission 124, [p. 2]; Ms Yumi Lee, Chief Executive Officer, Older Women’s Network New South Wales, Committee Hansard, 17 June 2024, p. 50.

[9]Dr Elaine Leung, Senior Lecturer, Medical Deans Australia and New Zealand, Committee Hansard, 5 August 2024, pp. 43–44.

[10]Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 17 June 2024, p. 7. See, for example, Dr Christina Jang, Board Member and President-elect, Australasian Menopause Society, Committee Hansard, 18 Jun 2024, p. 63.

[11]See, for example, Australasian Menopause Society, Submission 177, pp. 20–25; Women’s Health Road, Submission 117, [pp. 4–5]; Avalon Family Medical Practice, Submission 142, [p. 2]; Private Healthcare Australia, Submission 155, p. 4; The Society of Hospital Pharmacists, Submission 3, [pp.3–4]; Organon, Submission 24, p. 6; Sexual Health and Family Planning ACT, Submission 102, p. 6.

[12]Dr Marita Long, Board Member and Victoria and Tasmania Representative, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 59.

[13]See, for example, Menopause Friendly Australia, Submission 147, [p. 2]; Women’s Health Road, Submission 117, [pp. 4–5]; Theramex, Submission 124, [p. 2]; Private Healthcare Australia, Submission 155, p. 4; The Australian College of Midwives, Submission 157, p. 2; Organon, Submission 24, p. 7; Affiliation of Women’s Action Alliances, Submission 31, p. 8; Sexual Health and Family Planning ACT, Submission 102, p. 6; Women’s Health Services Network, Submission 149, p. 8.

[14]Maridulu Budyari Gumal, Submission 109, p. 7.

[15]Australian Medical Council Limited, Accreditation standards and procedures, January 2024, www.amc.org.au/accredited-organisations/accreditation-standards-and-procedures/ (accessed 20 August 2024).

[16]Professor Robyn Langham, Specialist Education Accreditation Committee and Board Director, Australian Medical Council, Committee Hansard, 13 August 2024, pp. 5–6 and 8–9.

[17]Australian Medical Council Limited, Standards for Assessment and Accreditation of Primary Medical Programs, January 2024, p. 10. See also, for example, Professor Robyn Langham, Specialist Education Accreditation Committee and Board Director, Australian Medical Council, Committee Hansard, 13 August 2024, pp. 5–6 and 8–9.

[18]Professor Robyn Langham, Specialist Education Accreditation Committee and Board Director, Australian Medical Council, Committee Hansard, 13 August 2024, pp. 5–6 and 8–9.

[19]Professor Robyn Langham, Specialist Education Accreditation Committee and Board Director, Australian Medical Council, Committee Hansard, 13 August 2024, p. 9.

[20]Professor Robyn Langham, Specialist Education Accreditation Committee and Board Director, Australian Medical Council, Committee Hansard, 13 August 2024, p. 5.

[21]See, for example, Dr Sarah White, Chief Executive Officer, Jean Hailes for Women’s Health, Committee Hansard, 18 June 2024, p. 52; Dr Sara Whitburn, Chair, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, p. 18.

[22]Theramex, Submission 124, [p. 2].

[23]Theramex, Submission 124, [p. 2].

[24]Dr Sara Whitburn, Chair, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, p. 18.

[25]Dr Christina Jang, Board Director and President-elect, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 59.

[26]See, for example, Monash Centre for Health Research and Implementation, Submission 34, p. 6; Bayer Australia, Submission 30, p. 5; Women’s Action Alliance, Submission 31, p. 8.

[27]Dr Kelly Teagle, Submission 111, [p. 3]. See also, for example, Jean Hailes for Women’s Health, Submission 119, pp. 28–29; Women’s Health Services Network, Submission 149, p. 13.

[28]Dr Sarah White, Chief Executive Officer, Jean Hailes for Women’s Health, Committee Hansard, 18 June 2024, pp. 49–50.

[29]Dr Sarah White, Chief Executive Officer, Jean Hailes for Women’s Health, Committee Hansard, 18 June 2024, pp. 49–50.

[30]See, for example, Dr Jessica Floreani, General Practitioner, AWARE Women’s Health, Committee Hansard, 5 August 2024, p. 16; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6August 2024, p. 24.

[31]Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 24.

[32]See, for example, Mrs Rebecca Thomson, Founder, Your Menopause, Committee Hansard, 6 August 2024, p. 14; Australasian Menopause Society, Submission 177, p. 14; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 24.

[33]Her Health and Aesthetics, Submission 179, [p. 5].

[34]Dr Michelle Cotellessa, Private capacity, Committee Hansard, 6 August 2024, p. 24.

[35]See, for example, Dr Virginia French, Her Health and Aesthetics, Committee Hansard, 30 July 2024, p. 2; Dr Danielle McMullen, Vice President, Australian Medical Association, Committee Hansard, 30 July 2024, p. 18; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p.24.

[36]Professor Steve Robson, President, Australian Medical Association, Committee Hansard, 30 July 2024, p. 16.

[37]Professor Roger Hart, Director, Menopause Alliance Australia, Committee Hansard, 6 August 2024, p. 18.

[38]Professor Roger Hart, Director, Menopause Alliance Australia, Committee Hansard, 6 August 2024, p. 18.

[39]See, for example, Dr Christabel Samy, Medical Director, Samy Medical Group Pty Ltd, Committee Hansard, 6 August 2024, p. 41; Associate Professor Ravani Duggan, Associate Professor, Curtin University and Sir Charles Gairdner Osborne Park Health Care Group, Committee Hansard, 6 August, p. 38.

[40]See, for example, Dr Christabel Samy, Medical Director, Samy Medical Group Pty Ltd, Committee Hansard, 6 August 2024, p. 41; Dr Lucy Caratti, Private capacity, Committee Hansard, 6 August 2024, pp. 41–42.

[41]See, for example, Dr Alice Fitzgerald, Board Member, Australian College of Rural and Remote Medicine, Committee Hansard, 29 July 2024, p. 4; Dr Sara Whitburn, Chair, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, p. 23; Sexual Health and Family Planning ACT, Submission 102, p. 4; Theramex, Submission 124, [pp.4–5]; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 24.

[42]See, for example, Professor Steve Robson, President, Australian Medical Association, Committee Hansard, 30 July 2024, p. 16; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 27;Besins Healthcare, Submission 146, [p. 7]; Women’s Health Services Network, Submission 149, p. 15; Australian College of Midwives, Submission 157, pp. 5–6; Australasian Menopause Society, Submission 177, pp. 20–21; Dr Keturah Hoffman, Submission 76, [p. 4]; Women’s Health Road, Submission 117, [p. 6]; Theramex, Submission 124, [p. 4–5]; Avalon Family Medical Practice, Submission 142, [p. 1].

[43]Dr Virginia French, Her Health and Aesthetics, Committee Hansard, 30 July 2024, p. 4.

[44]Dr Kelly Teagle, Founder, Shareholder, Director and Principal Clinician, WellFemme, Committee Hansard, 30 July 2024, p. 4.

[45]Sexual Health and Family Planning ACT, Submission 102, p. 4.

[46]Sexual Health and Family Planning ACT, Submission 102, p. 4. See, for example, Multicultural Centre for Women’s Health, Submission 148, p. 14.

[47]Dr Virginia French, Her Health and Aesthetics, Committee Hansard, 30 July 2024, pp. 3–4. See, for example, Dr Purity Carr, Founder, Purity Health Menopause and Wellbeing Centre, Committee Hansard, 6 August 2024, p. 42; Dr Caroline Rogers FRACGP, Submission 50, [p. 1]; Women’s Health Road, Submission 117, [p. 6].

[48]Department of Health and Aged Care, Submission 15, p. 8.

[49]Ms Louise Riley, Assistant Secretary, Medicare Benefits Schedule Policy and Reviews Branch, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 25.

[50]Ms Leanne Boase, Chief Executive Officer, Australian College of Nurse Practitioners, Committee Hansard, 18 June 2024, p. 14.

[51]Besins Healthcare, Submission 146, [pp. 6­–7]. See, for example, Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 17 June 2024, p.10; Dr Sara Whitburn, Chair, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, pp. 23–24.

[52]Besins Healthcare, Submission 146, [pp. 6–7]. See also, for example, Her Health and Aesthetics, Submissions 179, [p. 6].

[53]Associate Professor Magdalena Simonis AM, Submission 45, [p. 5].

[54]Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 10.

[55]Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 10.

[56]See, for example, Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p.24; RACGP, Submission 1, p. 4; Sexual Health Victoria, Submission 17, [p. 1]; Organon, Submission 24, p. 4; Dr Fatima Khan, Submission 46, [p. 2]; Family Planning Alliance Australia, Submission 103, [p. 1].

[57]RACGP, Submission 1, p. 4.

[58]Besins Healthcare, Submission 146, pp. 6–7.

[59]Australasian Menopause Society, Template for Menopause Consult, 16 March 2022, www.menopause.org.au/hp/gp-hp-resources/ams-template-for-menopause-consult(accessed 26 August 2024).

[60]Ms Emma Iwinska, Chief Executive Officer, Women’s Health and Equality Queensland, Committee Hansard, 29 July 2024, p. 49.

[61]Dr Roy Watson, Proxy for Chair, Gynaecology Community of Practice, Strategic Executive Committee, SA Health Maternal, Neonatal & Gynaecology Community of Practice, Committee Hansard, 5 August 2024, p. 36.

[62]Healthy Bones Australia, Submission 132, [p. 1].

[63]Dr Roy Watson, Proxy for Chair, Gynaecology Community of Practice, Strategic Executive Committee, SA Health Maternal, Neonatal & Gynaecology Community of Practice, Committee Hansard, 5 August 2024, p. 36.

[64]See, for example, Australian and New Zealand College of Anaesthetists, Submission 5, [p. 5]; Allison, Submission 80, [p. 2];MsSharon Best, Submission 230, [p. 7]; Name withheld, Submission 253, [p. 2]; Grace, Private capacity, Committee Hansard, 6 August 2024, p. 10.

[65]Tasmanian Government, Submission 7, [p. 3].

[66]Family Planning Alliance Australia, Submission 103, [p. 2]. See also, for example, Dr Roy Watson, Proxy for Chair, Gynaecology Community of Practice, Strategic Executive Committee, SA Health Maternal, Neonatal & Gynaecology Community of Practice, Committee Hansard, 5 August 2024, p.37.

[67]Ms Felicity Brazil, Submission 225, p. 3.

[68]Jill, Supplementary submission 224.1, [p. 2].

[69]See, for example, Mrs Joy Beames, President, Country Women’s Association of New South Wales, Committee Hansard, 17 June 2024, p. 47; Dr Louise Manning, President, Rural Doctors Association of Victoria, Committee Hansard, 30 July 2024, p. 20.

[70]Dr Louise Manning, President, Rural Doctors Association of Victoria, Committee Hansard, 30 July 2024, p. 20.

[71]Name withheld, Submission 97, [p. 1].

[72]See, for example, Mrs Danica Leys, Chief Executive Officer, Country Women’s Association of New South Wales, Committee Hansard, 17 June 2024, p. 50; Name withheld, Submission 186, [p. 2].

[73]Dr Alice Fitzgerald, Board Member, Australian College of Rural and Remote Medicine, Committee Hansard, 29 July 2024, p. 4.

[74]Ms Leeanne Boase, Chief Executive Officer, Australian College of Nurse Practitioners, Committee Hansard, 18 June 2024, p. 17.

[75]Ms Beverly Baker, President, National Older Women’s Network and Chair, Older Women’s Network New South Wales, Committee Hansard, 17 June 2024, p. 51.

[76]Mr Chris Campbell, General Manager, Policy and Program Delivery, Pharmaceutical Society of Australia, Committee Hansard, 29 July 2024, p. 12.

[77]Department of Health and Aged Care, response to a question on notice IQ24-000103, 13 August 2024 (received 30 August 2024).

[78]Monash University, MenoPROMPT: a co-designed, comprehensive, evidence-based program to improve thecareofwomenatandaftermenopause,www.monash.edu/medicine/sphpm/units/womenshealth/research/menoprompt (accessed 21 August 2024).

[79]Monash University, MenoPROMPT: a co-designed, comprehensive, evidence-based program to improve thecareofwomenatandaftermenopause,www.monash.edu/medicine/sphpm/units/womenshealth/research/menoprompt (accessed 21 August 2024).

[80]Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 9.

[81]Document tabled by Professor Susan Davis AO, MenoPROMPT, [p. 2] (tabled 18 June 2024).

[82]Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 8.

[83]Monash University Women’s Health Research Program, A Practitioner’s Toolkit for Managing Menopause,a-practitioners-toolkit-for-managing-menopause.pdf(monash.edu)(accessed21 August 2024).

[84]Monash University Women’s Health Research Program, A Practitioner’s Toolkit for Managing Menopause,a-practitioners-toolkit-for-managing-menopause.pdf(monash.edu)(accessed21 August 2024).

[85]AustralasianMenopauseSociety,AMSSymptomScoreCard,March2021, www.menopause.org.au/hp/information-sheets/ams-symptom-score-card(accessed21August 2024).

[86]Jean Hailes for Women’s Health, Perimenopause and menopause symptom checklist, www.jeanhailes.org.au/resources/perimenopause-and-menopause-symptom-checklist(accessed 21 August 2024).

[87]Women NSW, Perimenopause and menopause checklist, 1 June 2022, www.nsw.gov.au/women-nsw/toolkits-and-resources/perimenopause-and-menopause-toolkit/symptom-checklist(accessed 21 August 2024).

[88]Dr Sarah White, Chief Executive Officer, Jean Hailes for Women’s Health, Committee Hansard, 18 June 2024, p. 53.

[89]See, for example, Tara, Private capacity, Committee Hansard, 17 June 2024, p. 43; Dr Sara Whitburn, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, p. 19; Jill, Private capacity, Committee Hansard, 30 July 2024, p. 33.

[90]See, for example, Dr Alexandra Murray, Senior Policy Adviser, Australian Psychological Society, Committee Hansard, 18 June 2024, p. 67; Australasian Menopause Society, Submission 177, p. 3; Viv Health, Submission 5, [p. 4]; HER Centre Australia, Submission 8, [p. 9];

[91]Professor Jayashri Kulkarni, Director, HER Centre Australia, Committee Hansard, 30 July 2024, p. 10.

[92]Professor Jayashri Kulkarni, Director, HER Centre Australia, Committee Hansard, 30 July 2024, p. 10.

[93]Professor Jayashri Kulkarni, Director, HER Centre Australia, Committee Hansard, 30 July 2024, p. 10.

[94]See, for example, Sonya, Private capacity, Committee Hansard, 17 June 2024, p. 40; Sandy, Private capacity, Committee Hansard, 18 June 2024, p. 37; Imogen, Private capacity, Committee Hansard, 18 June 2024, p. 41; Jennifer, Private capacity, Committee Hansard, 29 July 2024, p. 40; Felicity, Private capacity, Committee Hansard, 30 July 2024, p. 29; Cathy, Private capacity, Committee Hansard, 30 July 2024, p. 32; Karen, Private capacity, Committee Hansard, 6 August 2024, p. 9; Name withheld, Submission 253, [p. 3]; Rachel, Submission 77, [p. 1].

[95]Professor Jayashri Kulkarni, Director, HER Centre Australia, Committee Hansard, 30 July 2024, p. 10.

[96]Dr Louise Newson, Founder and Menopause Specialist, Newson Health, Committee Hansard, 30 July 2024, p. 63.

[97]Sexual Health and Family Planning ACT, Submission 102, pp. 5–6.

[98]HER Centre Australia, MENO-D: A rating scale to detect depression in menopause;Meno-D-Rating-Scale-Sheet_HER-Centre-Australia.pdf (monash.edu)(accessed 20 August 2024).

[99]Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[100]Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[101]Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[102]The term ‘progestogen’ encompasses natural progesterone and synthetic preparations which act on the progesterone receptor. The phrase ‘progestin’ is used purely for synthetic preparations. For further information, see Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[103]Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[104]Australasian Menopause Society, Combined Menopausal Hormone Therapy (MHT), September 2018, www.menopause.org.au/hp/information-sheets/combined-menopausal-hormone-therapy-mht (accessed 21 August 2024).

[105]Avalon Family Medical Practice, Submission 142, [p. 5]. See also, for example, Dr Kelly Teagle, Submission 111, [p. 2]; Women’s Health Road, Submission 117, [p. 5]; Dr Ceri Cashell, Submission 44, [p. 11].

[106]Avalon Family Medical Practice, Submission 142, [p. 5]. For further discussion on the associated risks of MHT use, see, for example, Samy Medical Group, Submission 41, pp. 5–6.

[107]Australasian Menopause Society, Women’s Health Initiative – Update 2013, October 2013, www.menopause.org.au/hp/news/womens-health-initiative-update-2013 (accessed 2 September 2024).

[108]Society of Hospital Pharmacists of Australia, Submission 3, [p. 3].

[109]See, for example, Associate Professor Treasure McGuire, Women’s and Newborn Health Committee, Society of Hospital Pharmacists of Australia, Committee Hansard, 29 July 2024, p. 11; Ms Karen Castle, Policy Pharmacist, Pharmaceutical Society of Australia, Committee Hansard, 29 July 2024, pp. 12–13; Dr Virginia French, Her Health and Aesthetics, Committee Hansard, 30 July 2024, p.7; Dr Sara Whitburn, Chair, Sexual Health Specific Interest Group, Royal Australian College of General Practitioners, Committee Hansard, 30 July 2024, p. 18; Dr Christina Jang, Board Member and President-elect, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 59;Dr Christabel Samy, Medical Director, Samy Medical Group, Committee Hansard, 6 August 2024, p. 39; Associate Professor Ravani Duggan and Ms Lucy Gent, Submission 51, p. 3; Chelvanayagam, Bouse, Cotellessa and de Lacy, Submission 59, pp. 11–12; Sexual Health and Family Planning ACT, Submission 102, p. 6; Women’s Health in the South East, Submission 120, [p. 19]; Professor Susan Davis AO, Director, Monash University Women’s Health Research Program, Committee Hansard, 18 June 2024, p. 8; Besins Healthcare, Submission 146, [pp. 8–­9].

[110]See, for example, Women’s Health in the South East, Submission 120, [p. 19]; Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 18 June 2024, p. 2; Theramex, Submission 124, [p. 2].

[111]Jill, Private capacity, Committee Hansard, 30 July 2024, p. 33.

[112]Associate Professor Treasure McGuire, Women’s and Newborn Health Committee, Society of Hospital Pharmacists of Australia, Committee Hansard, 29 July 2024, p. 11.

[113]See, for example, Name withheld, Submission 90, [p. 1]; Allison, Submission 80, [p. 2]; Name withheld, Submission 95, [p. 2]; Name withheld, Submission 96, p. 4; Name withheld, Submission 130, [pp. 6–7]; Rachel, Submission 181, p. 2; Name withheld, Submission 189, [p. 1]; Naomi, Submission 196, [p. 2]; Ms Cilla de Lacy, Submission 223, p. 8.

[114]Tasmanian Government, Submission 7, [p. 3]. See, for example, Sexual Health Victoria, Submission 17, [p. 4]; Royal Australian College of Psychiatrists, Submission 19, p. 4; Monash Centre for Health Research Implementation, Submission 34, p. 7.

[115]Viv Health, Submission 5, [p. 6].

[116]Viv Health, Submission 5, [p. 6]. See, for example, Dr Ceri Cashell, Submission 44, [p. 14].

[117]Viv Health, Submission 5, [p. 6]. See, for example, Dr Ceri Cashell, Submission 44, [p. 10].

[118]Dr Caroline Rogers FRACGP, Submission 50, [p. 1].

[119]Dr Ceri Cashell, Submission 44, [p. 14].

[120]Her Health and Aesthetics, Submission 179, [p. 5].

[121]Dr Kelly Teagle, Submission 111, [p. 2].

[122]See, for example, Organon, Submission 24, p. 9; Bayer Australia, Submission 30, p. 4; Besins Healthcare, Submission 146, [p. 11].

[123]Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 17 June 2024, p. 6.

[124]Dr Ceri Cashell, General Practitioner and Co-Owner, Avalon Family Medical Practice, Committee Hansard, 17 June 2024, p. 5.

[125]Dr Louise Manning, President, Rural Doctors Association of Victoria, Committee Hansard, 30 July 2024, p. 24.

[126]Grace, Private capacity, Committee Hansard, 6 August 2024, p. 10.

[127]Department of Health and Aged Care, Submission 15, p. 13.

[128]Department of Health and Aged Care, Submission 15, p. 13.

[129]Department of Health and Aged Care, Submission 15, p. 13.

[130]Ms Kaz Cooke, Private capacity, Committee Hansard, 18 June 2024, p. 4.

[131]Lynette, Submission 60, [p. 1].

[132]Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 27.

[133]See, for example, Clare, Submission 74, p. 2; Rachel, Submission 181, pp. 2–3; Sandy, Submission 75, p. 11; Name withheld, Submission 85, [p. 2]; Name withheld, Submission 208, [p. 3].

[134]See, for example, Name withheld, Submission 90, [p. 1]; Name withheld, Submission 129, [p. 1]; Name withheld, Submission 130, [pp. 3–4]; Sandy, Submission 75, p. 6.

[135]See, for example, Name withheld, Submission 90, [p. 1]; Name withheld, Submission 129, [p. 1]; Name withheld, Submission 130, [pp. 3–4]; Sandy, Submission 75, p. 6.

[136]Mr Chris Campbell, General Manager, Policy and Program Delivery, Pharmaceutical Society of Australia, Committee Hansard, 29 July 2024, p. 14. See, for example, Dr Louise Manning, President, Rural Doctors Association of Victoria, Committee Hansard, 30 July 2024, p. 20.

[137]See, for example, Professor Steve Robson, President, Australian Medical Association, Committee Hansard, 30 July 2024, p. 19; Dr Michelle Cotellessa, Private capacity, Committee Hansard, 6 August 2024, p. 27;Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 27.

[138]Ms Kirstin Bouse, Private capacity, Committee Hansard, 6 August 2024, p. 27.

[139]Dr Christina Jang, Board Director and President-elect, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 60.

[140]Department of Health and Aged Care, answer to a question on notice IQ24-000106, 13 August 2024 (received 30 August 2024).

[141]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 26.

[142]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 26.

[143]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 26.

[144]See, for example, Clinical Associate Professor Amanda Vincent, Early Menopause Lead, Monash Centre for Health Research and Implementation, Committee Hansard, 29 July 2024, p. 18; Janine, Private capacity, Committee Hansard, 29 July 2024, p. 43; Belinda, Private capacity, Committee Hansard, 30 July 2024, p. 35.

[145]Name withheld, Supplementary submission 180.2, [p. 1].

[146]See, for example, Ms Emma Iwinska, Chief Executive Officer, Women’s Health and Equality Queensland, Committee Hansard, 29 July 2024, p. 50; Ms Catherine Willis, Board Director, Australian Physiotherapy Association, Committee Hansard, 18 June 2024, p. 72; Ms Mirjana Jovetic, Senior Policy Adviser, Australian Physiotherapy Association, Committee Hansard, 18 June 2024, p. 72; Dr Richelle Douglas, Medical Director, Derbal Yerrigan Health Service, Committee Hansard, 6 August 2024, p. 5; Dr Lesley Ramage, Director, Menopause Alliance Australia, Committee Hansard, 6 August 2024, p.21; Dr Sunita Chelvanayagam, Private capacity, Committee Hansard, 6 August 2024, p. 25; Dietitians Australia, Submission 104, pp. 2–3; Ms Rebecca Madill and Dr Alessandra Briglia, Submission 168, p.5.

[147]Ms Leanne Boase, Chief Executive Officer, Australian College of Nurse Practitioners, Committee Hansard, 18 June 2024, p. 14.

[148]Monash Centre for Health Research and Implementation, Submission 34, p. 17.

[149]See, for example, Professor Helena Teede, Director, Monash Centre for Health Research and Implementation, Committee Hansard, 18 June 2024, p. 23; Dr Fatima Khan, Submission 46, [p. 2]; Chelvanayagam, Bouse, Cotellessa and de Lacy, Submission 59, p. 11.

[150]Dr Sara Whitburn, Deputy Medical Director and Senior Medical Officer, Sexual Health Victoria, Committee Hansard, 30 July 2024, p. 48.

[151]NSW Government, Submission 53, p. 5. See also, for example, NSW Health, Menopause services, 23 October 2023, www.health.nsw.gov.au/women/Pages/menopause.aspx (accessed 25 August 2024).

[152]The Menopause Centre, The Menopause Centre, 2024, www.themenopausecentre.com.au/(accessed 25 August 2024).

[153]Dr Gabriela Berger and Dr Anita Peerson, Submission 52, p. 4.

[154]Australian Longitudinal Study on Women’s Health, Submission 35, pp. 19–20.

[155]Australian Longitudinal Study on Women’s Health, Submission 35, pp. 19–20.

[156]Naturopaths and Herbalists Association of Australia, Submission 54, p. 4.

[157]See, for example, Kerry – Peripausers, Submission 202, [p. 3]; Megan, Submission 68, p. 3; Maria, Submission 232, p. 3; Bronwen, Submission 249, [p. 2].

[158]See, for example, Simone, Submission 236, [p. 6]; Ms Natasha Langovski and Ms Louise Rubic, Submission 233, [p. 2].

[159]Australasian Menopause Society, Complementary medicine options for menopausal symptoms; January 2018, www.menopause.org.au/health-info/fact-sheets/complementary-medicine-options(accessed 29 August 2024).

[160]Australasian Menopause Society, Complementary medicine options for menopausal symptoms; January 2018, www.menopause.org.au/health-info/fact-sheets/complementary-medicine-options(accessed 29 August 2024).

[161]Australasian Menopause Society, Complementary medicine options for menopausal symptoms; January 2018, www.menopause.org.au/health-info/fact-sheets/complementary-medicine-options(accessed 29 August 2024).

[162]Chief Executive Women, Submission 136, p. 7.

[163]Jean Hailes for Women’s Health, Submission 119, p. 37.

[164]Monash Centre for Health Research and Implementation, Submission 34, pp. 13–14.

[165]Ms Kaz Cooke, Private capacity, Committee Hansard, 18 June 2024, p. 1.

[166]Australian Medical Association, Submission 115, p. 2.

[167]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 23.

[168]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 23.

[169]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 23.

[170]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 24.

[171]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 24.

[172]Associate Professor Robyn Langham, Chief Medical Adviser, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 24.

[173]Ms Tracey Lutton, Assistant Secretary, Regulatory Compliance Branch, Health Products Regulation Group, Department of Health and Aged Care, Committee Hansard, 13 August 2024, p. 23.

[174]Department of Health and Aged Care, answer to a question on notice IQ24-000102, 13 August 2024 (received 30 August 2024).

[175]Department of Health and Aged Care, answer to a question on notice IQ24-000102, 13 August 2024 (received 30 August 2024).

[176]See, for example, Jean Hailes for Women’s Health, Submission 119, p. 22; FECCA, Submission 169, pp. 3–4; Health Care Consumers’ Association, Submission 170, p. 13; Australian Psychological Society, Submission 6, p. 5; Royal Women’s Hospital Melbourne, Submission 33, p. 7.

[177]Royal Women’s Hospital Melbourne, Submission 33, p. 7.

[178]Professor Martha Hickey, Fellow, Australian Academy of Health and Medical Sciences, Committee Hansard, 5 August 2024, pp. 2–3.

[179]Dr Christina Jang, Board Director and President-elect, Australasian Menopause Society, Committee Hansard, 18 June 2024, p. 62.