Genitourinary syndrome of menopause (GSM) responds well to non-hormonal local measures, and several behavioural approaches have good evidence for vasomotor and mood symptoms. Be honest with patients about the weaker, more mixed evidence behind complementary and herbal options.
GSM — local, non-hormonal options
- Vaginal moisturisers (regular, non-hormonal) for day-to-day dryness; lubricants for intercourse — first-line and accessible.
- Vaginal DHEA (prasterone) is a non-systemic local option suited to women avoiding hormonal therapy; effective for dyspareunia and dryness.
- Pelvic floor physiotherapy helps dyspareunia, urgency and prolapse-related symptoms that overlap with GSM.
- Low-dose vaginal estrogen remains an option for many (including most breast cancer survivors after oncology discussion) — see companion sheets WH-05A/B.
Behavioural & lifestyle
- CBT for menopausal symptoms (CBT-MS): good evidence for VMS bother, mood and sleep, independent of flush frequency.
- Clinical hypnosis has trial evidence for reducing VMS frequency and severity.
- Regular exercise, particularly resistance training, supports mood, sleep, bone and cardiometabolic health through the transition.
- Sleep hygiene and a Mediterranean-pattern diet are reasonable, low-risk adjuncts with broader health benefits.
Complementary & herbal
- Black cohosh: evidence is mixed/inconsistent; case reports of hepatotoxicity — caution advised.
- Soy isoflavones/phytoestrogens: modest, inconsistent effect on VMS; long-term safety in hormone-sensitive cancer is unclear.
- Evening primrose oil and red clover: trial evidence does not support meaningful benefit over placebo.
- Compounded "bioidentical" hormones: unregulated dosing and purity, not TGA-evaluated — discourage in favour of TGA-approved MHT.
Be transparent with patients. Many patients ask about complementary options. Acknowledge the appeal, explain honestly that the evidence is weak or mixed for most herbal agents, and flag specific risks (hepatotoxicity with black cohosh; unknown purity/dosing with compounded "bioidenticals"). This maintains trust better than dismissing the question outright.
Safety
- Compounded bioidentical hormone preparations are not TGA-evaluated for safety, efficacy or purity — advise against routine use and recommend a registered MHT product instead.
- Black cohosh: counsel on rare but reported hepatotoxicity; stop and check LFTs if symptoms develop.
Red flags / refer
- GSM refractory to local moisturisers/lubricants and vaginal estrogen/DHEA.
- Complex psychological symptoms (significant low mood, anxiety) not responding to first-line measures.
- Patient considering compounded bioidentical hormones — discuss risks and registered alternatives.
WH-06C v1.0 · Reviewed Jun 2026 · Review Jun 2027
Companion sheets: WH-06A (SSRIs/SNRIs & established agents), WH-06B (NK receptor antagonists). See WH-05A/B for MHT and vaginal estrogen. Verify against AMS guidance and the IMS 2024 White Paper; confirm current evidence ratings before counselling patients.
