18 OPINION
18 OPINION
22 AUGUST 2025 ausdoc. com. au
Insight
The truth we must face
Dr Sue Ieraci Emergency physician, Sydney, NSW.
Patients deserve doctors at their sharpest.
For her range of menopause symptoms 1, 2
Estrogel significantly improves vasomotor symptoms and vaginal atrophy 3, 4
100 %
I
DON’ T know the precise demographics of Aus- Doc readers, but comments on articles about the relationship between advancing age and fitness to practise suggest this is a sensitive area.
Perhaps I’ m an outlier, but I don’ t see myself working clinically into old age.
FREQUENCY
82 % MEAN REDUCTION IN VMS
FREQUENCY 3, 4
Why not? Perhaps my self-identity extends well outside my profession.
Perhaps I’ m not caught in financial obligations that require me to work indefinitely.
I don’ t own or run a business. And I’ ve had the opportunity to reduce my working hours gradually over the
SEVERITY
43 % MEAN REDUCTION IN VMS
SEVERITY 3, 4 years, so there will be no shock in letting go. If I’ m frank, however, I recognise that cognitive speed and flexibility just don’ t last forever. There is lots of research into cognitive ageing in various demanding professions. A 2024 article noted evidence of age effects in both fatigability and cognitive slowing
RESPONDERS
86 % OF WOMEN RESPONDED( VMS) 3, 4
OF WOMEN TREATED WITH ESTROGEL ®( 1.5MG ESTRADIOL) SHOWED IMPROVEMENT IN
5
VULVOVAGINAL ATROPHY AFTER 12 WEEKS( vs 71 % for placebo, p < 0. 01; as defined by Meisel’ s score)
PBS Information: EstrogelPro, Estrogel & Prometrium are listed on the PBS. Refer to the PBS for more details.
Minimum Product Information Estrogel( estradiol hemihydrate) gel. Indications: Hormone replacement therapy( HRT) for estrogen deficiency symptoms in postmenopausal women. Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. The lowest effective dose should be used for the shortest duration. Contraindications: Known, past or suspected breast cancer; Known or suspected estrogen-dependent malignant tumours( e. g. endometrial cancer); Undiagnosed genital bleeding; Untreated endometrial hyperplasia; Previous or current venous thromboembolism( e. g. deep venous thrombosis, pulmonary embolism); Known thrombophilic disorders( e. g. protein C, protein S, or antithrombin deficiency); Active or recent arterial thromboembolic disease( e. g. angina, myocardial infarction); Acute liver disease, or a history of liver disease as long liver function tests have failed to return to normal; Known or suspected pregnancy; Lactation; Known hypersensitivity to the active substances or to any of the excipients; Porphyria. Precautions: Appraisal of the risks and benefits should be undertaken at least annually. Refer to full Product information( PI) for conditions which require supervision during treatment with Estrogel. Treatment should be withdrawn if the following occur, jaundice or deterioration in liver function; significant increase in blood pressure; new onset of migraine type headache; pregnancy. Caution: endometrial hyperplasia and carcinoma, breast cancer, ovarian cancer, venous thromboembolism, coronary artery disease( CAD), ischaemic stroke, thyroid function, elderly, ALT elevations, paediatric use( see full PI). Interactions: use of concomitant skin medications, surface active agents or strong skin cleansers and detergents should be avoided at site of application, metabolism of estrogens may be increased by concomitant use of inducers of hepatic enzymes such as anticonvulsants( phenobarbital, phenytoin, carbamezapine) and anti-infectives( rifampicin, rifabutin, nevirapine, efavirenz, ritonavir and nelfinavir) and some herbal preparations( St John’ s wort) reducing the effectiveness of estrogen. Estrogel as a transdermal administration might be less affected than other oral hormones by enzyme inducers. Concomitant use of estrogens with lamotrigine may decrease lamotrigine plasma concentrations. Caution is warranted for co-administration with hepatitis C virus( HCV) combination regimens ombitasvir / paritaprevir / ritonavir with or without dasabuvir and the regimen glecaprevir / pibrentasvir may cause greater than usual ALT elevations. Pregnancy Category B3; not for use in lactation. Adverse Effects: headache, nausea, abdominal pain, breast swelling / pain, breast enlargement, dysmenorrhea, menorrhagia, metrorraghia, leucorrhoea, endometrial hyperplasia, weight gain( increase or decrease), water retention with peripheral edema( see full PI). Dosage and Administration: Estrogel should be used daily on a continuous basis. Estrogel as an estrogen only product is indicated only for women without a uterus. In women with an intact uterus it is recommended to add a progestogen for at least 12 days of each month. Although some women will respond to 1.25 g daily( 1 pump), the usual starting dose is 2.5 g per day( 2 pumps). If after one month of treatment, effective relief of menopausal symptoms is not obtained the dosage may be increased to a maximum of 5 g( 4 pumps)( see full PI). The lowest effective dose should be used for maintenance therapy. The optimal daily maintenance dose needs to be reevaluated regularly( e. g. annually). Estrogel should only be continued for as long as the benefit outweighs the risk. The correct dose of gel should be dispensed and applied to clean, dry, intact areas of skin e. g. on the arms and shoulders, and / or inner thighs. The area of application should be as large as possible. Refer to Full Product Information before prescribing. Minimum Product Information Prometrium( oral, micronised progesterone) Indications: menstrual irregularities; adjunctive use with an estrogen in postmenopausal women with an intact uterus. Contraindications: known allergy / hypersensitivity to progesterone or excipients; severe hepatic dysfunction; undiagnosed vaginal bleeding; known missed abortion / ectopic pregnancy; mammary / genital tract carcinoma; thromboembolic disorders; thrombophlebitis; cerebral haemorrhage; porphyria. Clinically Significant Precautions: not a treatment for premature labour; not a contraceptive; discontinue if unexplained visual loss / changes, proptosis, diplopia, papilloedema, retina vascular lesions or migraine; use caution in conditions affected by fluid retention and history of depression, diabetes, hepatic dysfunction, migraine, photosensitivity and during lactation; increased risk of breast cancer and venous thromboembolism with estrogen concomitant therapy( refer estrogen PI); may cause drowsiness; may affect laboratory test results. Clinically Significant Interactions: caution with P450 enzyme inducers and inhibitors; may increase antidiabetic medication; bioavailability may be reduced by smoking and increased by alcohol abuse. Very Common and Common Adverse Effects: menstrual disturbances; headache. Dosage and Use: take capsules( 100mg / 200mg) orally, OD at bedtime without food. Hormone Replacement Therapy: 200 mg / d for 12d( d15 – d26) of the cycle; or 100mg can be given from d1 – d25. Secondary amenorrhoea: 400mg / d for 10d. Ovulation disorders / anovulation: 200 – 300mg for 10d( d17 – d26, inclusive).
References: 1. Estrogel ®( estradiol hemihydrate) Product Information, updated updated 18 December 2023. 2. Prometrium ®( micronised progesterone) Product Information, updated 1 Feb 2022. 3. Archer DF, et al. Menopause. 2003; 10( 6): 516 – 521. 4. Archer DF et al. Menopause 2012; 19( 6): 622 – 629. 5. Kornafel KL et al. South Med J 1992; 85( 3): 270 – 73. Estrogel ® and Prometrium ® are registered trademarks of Besins Healthcare. Besins Healthcare Australia Pty Ltd ABN 68 164 882 062. Suite 5.02, 12 Help Street, Chatswood NSW 2067. Office phone( 02) 9904 7473. For medical information call 1800 BESINS( 237 467). www. besins-healthcare. com. au EPR-EST-PRM-2392 April 2025 among pilots and air-traffic controllers. 1
The authors referred to various studies showing the effects of age on the performance of pilots, including the ability to adapt to new technology and equipment.
These effects are somewhat tempered by experience and judgement and also that
For her.
Medicine co-pack containing one pack of Estrogel ®( estradiol hemihydrate) plus one pack of Prometrium ®( micronised progesterone) for women with a uterus
Please review the Product Information before prescribing, accessible at besins-healthcare. com. au / PI or 1800 BESINS( 237 467), or by scanning the QR code: there is heterogeneity between individuals. Cognitive decline with age can be influenced by genetics, culture and lifestyle, as well as intercurrent illness.
Another relevant factor is sociocultural ageing. This relates to exposure to current societal attitudes to all sorts of things— from gender identity and roles to reproductive health, professional – client relationships, cultural mores and risk tolerance.
In Australia, the percentage of GPs in solo practice has been reducing, with those left likely to be older. This is a risk factor for professional isolation, limiting opportunities for consulting colleagues and benchmarking off peers. AHPRA data reveal that notifications for medical practitioners aged 80 and over have increased by more than 180 % between 2015 and 2023.2 This age group carries the greatest risk for the combination of health issues, cognitive ageing, professional isolation and sociocultural ageing.
With so much evidence about age-related cognitive decline in our demanding profession, it’ s essential we don’ t dismiss this phenomenon.
Throughout my long career in public hospital emergency medicine, I worked 10-hour shifts, often in the midst of chaos.
There were constant interruptions, supervising juniors, under time targets and juggling beds, admissions and referrals, running resuscitations and holding responsibility for the safety of both patients and staff. Most of the time, I thrived.
I have now moved into emergency telemedicine, seeing one patient at a time without any junior staff to supervise and in shorter shifts.
There is no way I could still juggle the multitude of competing demands and interruptions over a 10-hour shift without significant fatigue— a serious risk for error.
I have been fortunate( and a bit strategic) in being able to do many of the things known to minimise these risks— shorter hours, less multitasking and interruptions, and group work with embedded audit and education. We owe it to ourselves, our families and— most importantly— our patients to be sanguine about the effects of ageing.
It’ s not ageism for the community to expect us to be working at the top of our game.
Sure, experience can balance cognitive sharpness to some extent. Eventually, however, the two lines will cross. 1. bit. ly / 45b70AS 2. bit. ly / 4kZWemH