In July 2025, The Lancet Diabetes & Endocrinology published findings from the Australian Women’s Midlife Years (AMY) Study—one of the most comprehensive investigations to date into the symptoms of menopause across its transition phasesⁱ. For clinicians supporting women in midlife, this research highlights some of the challenges and potential pitfalls of the current standard conventional staging method (STRAW+10) and offers some strong recommendations to consider to improve diagnosis and care, particularly during the often-overlooked perimenopausal period.

Why This Study Matters

Traditionally, the onset of perimenopause has been defined using the STRAW+10 criteria, which primarily rely on changes in menstrual cycle timingⁱⁱ. However, this approach falls short for many patients—particularly those using hormonal contraception, those who’ve undergone uterine procedures, or those with naturally irregular cycles. In all of these instances, observation of menstrual timing is difficult, or monitoring change in patterns is difficult.  Additionally, as you’ve likely seen in your own practice, common perimenopausal symptoms such as hot flashes, sleep disruption, poor memory, and low mood often appear before any change in bleeding patterns.  These women are often left undiagnosed and untreated, despite suffering with many symptoms of perimenopause.

The AMY Study addressed this clinical blind spot by surveying over 8,000 Australian women aged 40–69 years and classifying 5,509 of them using STRAW+10. Using the validated MENQOL (Menopause-Specific Quality of Life) instrument, researchers assessed symptom prevalence and severity across the late reproductive stage into the late postmenopausal stageⁱ.

Key Findings

1. Vasomotor Symptoms as a Diagnostic Anchor

Among all 25  symptoms analyzed, moderately-to-severely bothersome vasomotor symptoms (VMS)—hot flashes and night sweats—emerged as the most reliable indicators of the menopause transition. VMS prevalence increased from just 8.8% in premenopausal women to 37.3% in late perimenopause (adjusted prevalence ratio [PR] 4.74, which accounts for other factors that could influence the stage of menopause, such as BMI, ethnicity, alcohol consumption, and demographic variables). Importantly, women with both VMS and changes in menstrual flow were symptomatically indistinguishable from those in early perimenopause—suggesting these patients are being misclassified and undertreatedⁱ.

Clinical Implication

VMS symptoms—especially when accompanied by altered flow—should be considered a hallmark of perimenopause. Clinicians may need to revise their diagnostic approach and initiate earlier conversations about symptom management, even in women with regular cycles.  

2. Vaginal Dryness and Sexual Symptoms

Vaginal dryness also sharply increased in prevalence from premenopause to late perimenopause (adjusted PR 2.54). While sexual desire decreased across the transition, it did not significantly differ between perimenopausal and postmenopausal stages. Notably, women who had undergone bilateral oophorectomy reported the highest symptom burden and were the least likely to have received treatment¹.

Clinical Implication

Vaginal symptoms are persistent and undertreated despite the availability of safe and cost-effective local estrogen therapies availableⁱⁱⁱ. Screening for genitourinary symptoms and proactive counseling about treatment options should be standard during visits with women in late reproductive through menopausal stages.

3. Psychological and Cognitive Symptoms: High Prevalence, Low Specificity

Symptoms such as poor memory, low mood, and fatigue were commonly reported across all stages. However, these symptoms showed only modest increases in prevalence during perimenopause and were not specific enough to aid in diagnostic staging. For instance, 23% of premenopausal women and nearly 37% of early perimenopausal women reported bothersome memory issues, but this symptom alone had limited diagnostic utilityⁱ.

Clinical Implication

While psychological symptoms should not be dismissed, they are multifactorial and common in midlife. Clinicians should explore other causes and avoid reflexively attributing them to hormonal changes unless accompanied by hallmark symptoms like VMS. For example, poor sleep, stress, alcohol use, and social isolation are all known contributors to midlife mood disorders, and these symptoms also can be driven by other root causes such as thyroid dysfunction or autoimmune conditions^iv.  Make sure you are appropriately considering all potential differential diagnoses.  

4. Closing the Care Gap: Treatment Timing and Guidelines

One of the most concerning findings was that nearly 40% of late perimenopausal women reported bothersome VMS symptoms—yet according to this study, most were untreated. This gap reflects outdated prescribing indications that limit menopausal hormone therapy (MHT) to postmenopausal individuals. Meanwhile, no therapies are specifically approved for perimenopause, despite high symptom burdenⁱ.

Clinical Implication

Guidelines and regulatory indications must evolve to reflect the reality that many women experience debilitating symptoms well before menopause is clinically confirmed. Until then, clinicians may need to adopt a pragmatic, symptom-oriented approach that weighs risks and benefits based on the patient’s overall health and reproductive status, not just cycle patterns^v.

Recommendations for Clinical Practice: The Bottom Line

1. Reconsider how perimenopause is diagnosed.

Symptoms—especially VMS symptoms and changes in flow (either heavier or scant bleeding)—may be more clinically useful than calendar-based criteria.  Be sure you are considering not only changes in menstrual cycle length and FSH (from the STRAW+10 criteria) but also the sensitive markers of VMS symptoms and changes in sexual function and vaginal dryness.

2. Routinely assess symptom severity, not just presence.

Using validated tools like MENQOL^vi can help quantify symptom impact and guide treatment decisions. Be sure you are also assessing not just the presence of a symptom, but the frequency and severity.  

3. Don’t delay treatment based on rigid definitions.

Many patients suffer for years before their symptoms are labeled as “menopausal” and they are finally treated.  Earlier intervention can improve quality of life and prevent downstream consequences, including work disruption and mental health issues. It’s important to note that society guidelines do NOT specify that initiation of treatment must wait until 1 year after cessation of menses. While many providers hesitate to initiate menopausal hormone therapy until this time, it is unnecessary and leaves women untreated unnecessarily.

4. Normalize conversations about vaginal and sexual health.

These symptoms are prevalent, persist into late postmenopause, and remain significantly undertreated. Get comfortable asking patients about vaginal and sexual health in midlife and be sure you are initiating these conversations.

5. Advocate for better treatment options.

The field urgently needs safe, effective, and regulatory-approved therapies for perimenopausal women. Where you can advocate, do so!  Let’s make women’s health accessible and helpful for women throughout their reproductive to menopausal transition!

In Summary

The AMY Study is a landmark contribution that validates what many clinicians have long observed: the menopause transition starts earlier and with more complexity than traditional definitions capture. It’s time to reframe perimenopause using symptom-based, patient-centered care—and ensure that treatment guidelines catch up to womens’ lived experiences. Read the research abstract here.

References

i. Islam RM, Bond M, Ghalebeigi A, et al. Prevalence and severity of symptoms across the menopause transition: cross-sectional findings from the Australian Women’s Midlife Years (AMY) Study. Lancet Diabetes Endocrinol. 2025.

ii. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab. 2012;97(4):1159–1168.

iii. North American Menopause Society. The 2022 hormone therapy position statement. Menopause. 2022;29(7):767–794.

iv. Brown L, Hunter MS, Chen R, et al. Promoting good mental health over the menopause transition. Lancet. 2024;403:969–83.

v. Hemachandra C, Taylor S, Islam RM, Fooladi E, Davis SR. A systematic review and critical appraisal of menopause guidelines. BMJ Sex Reprod Health. 2024;50:122–138.

vi. Radtke JV, Terhorst L, Cohen SM. The Menopause-Specific Quality of Life Questionnaire: psychometric evaluation among breast cancer survivors. Menopause. 2011 Mar;18(3):289-95. doi: 10.1097/gme.0b013e3181ef975a. PMID: 20881889; PMCID: PMC3017657.