Menopause and Perimenopause Health Assessment

**Menopause and Perimenopause Health Assessment (MBS Item 695)** History • Menopausal status: Patient is in perimenopause, experiencing irregular periods and hot flushes. • Symptoms discussed: Hot flushes, night sweats, mood swings, sleep disturbances, and vaginal dryness. • Menstrual history: Last menstrual period was 2 months ago; cycles have become irregular over the past year. • Medical history: Hypertension, well-controlled with medication. • Family history: Mother had early menopause at age 48. • Contraindications to treatment considered: No known contraindications to hormone therapy. • Psychosocial wellbeing: Patient reports feeling anxious and irritable due to hormonal changes, but has a supportive partner and family. Examination • Basic physical examination performed. • Blood pressure: 130/80 mmHg. • Height: 165 cm. • Weight: 75 kg. • BMI: 27.5. Investigations and Referrals • Cervical screening • Mammography • Bone densitometry (DEXA) • Additional pathology as indicated: FSH and estradiol levels. • Referrals initiated: Referral to a gynaecologist for further evaluation and management. Management • Non-pharmacological options discussed: Lifestyle modifications including regular exercise, stress management techniques, and dietary adjustments. • Pharmacological options discussed: Hormone replacement therapy (HRT) and low-dose antidepressants for mood stabilisation. • Risks and benefits explored with patient • Shared decision-making documented • Symptom-focused management plan implemented Preventative Health Care Advice • Physical activity • Smoking cessation • Alcohol use • Nutrition and calcium/vitamin D intake • Weight management • Educational resources provided as appropriate Team Involvement • Assistance provided under GP supervision by: Nurse assisted with blood pressure and weight measurement. • Allied health and other providers involved: • [list any allied health clinicians or specialists involved in current care or referred to] • [list additional external services or clinics discussed or involved] • Coordination of care and communication arranged as required Review • Follow-up planned for: Review in 3 months to assess response to treatment and discuss any concerns.