What are the symptoms and treatment options for perimenopause?

From the Guidelines

Perimenopause should be managed with lifestyle modifications and non-hormonal medications as first-line treatment, reserving hormone therapy for severe symptoms that do not respond to initial treatments, as evidenced by the most recent guidelines 1.

Management Options

Perimenopause is the transitional phase before menopause when a woman's body begins producing less estrogen, typically starting in a woman's 40s and lasting 4-8 years until menopause is reached. During this time, women may experience irregular periods, hot flashes, sleep disturbances, mood changes, vaginal dryness, and decreased fertility.

• Lifestyle modifications like regular exercise, stress reduction techniques, and maintaining a healthy diet are essential for managing symptoms.
• Non-hormonal medications like SSRIs (such as paroxetine 7.5-20mg daily or escitalopram 10-20mg daily) can help with hot flashes and mood symptoms, as recommended by the American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline 1.

Hormone Therapy

Hormone therapy, such as low-dose birth control pills or hormone replacement therapy, may be prescribed for severe symptoms that do not respond to initial treatments, using the lowest effective dose for the shortest time needed, as suggested by the NCCN clinical practice guidelines in oncology 1.

• Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism (VTE) and stroke.
• Micronized progestin may be preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk.

Vaginal Dryness

Vaginal moisturizers, lubricants, or low-dose vaginal estrogen (such as estradiol vaginal cream 0.01%, used twice weekly) can address vaginal dryness, with local hormonal treatments being effective for managing symptoms, as noted in the NCCN guidelines 1.

• Regular healthcare visits are important during this transition to monitor symptoms and discuss treatment options. These changes occur because the ovaries gradually produce less estrogen and progesterone, leading to fluctuating hormone levels that cause the various symptoms associated with perimenopause before eventually reaching menopause, defined as 12 consecutive months without a menstrual period.

From the FDA Drug Label

Estradiol is used to: reduce moderate to severe hot flashes Estrogens are hormones made by a woman's ovaries Between ages 45 and 55, the ovaries normally stop making estrogens. This leads to a drop in body estrogen levels which causes the “change of life” or menopause (the end of monthly menstrual periods).

Estradiol is used to reduce moderate to severe hot flashes associated with menopause. The drug label does not explicitly mention perimenopause, but it does discuss the decrease in estrogen levels that occurs as women approach menopause, which can cause uncomfortable symptoms such as hot flashes.

• Perimenopause is not directly addressed in the label, but it is a period of time when women's hormone levels, including estrogen, begin to fluctuate and decrease, leading to symptoms similar to those experienced during menopause.
• The label recommends that women and their healthcare providers talk regularly about whether treatment with estradiol is still needed 2.

From the Research

Definition and Symptoms of Perimenopause

• Perimenopause, or the menopausal transition, is a period of time during which newly arising symptoms can present complex management decisions for providers 3.
• Symptoms of perimenopause include hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns 3, 4.
• Vasomotor symptoms, such as hot flashes and night sweats, are most pronounced during the first four to seven years but can persist for more than a decade 4.
• Genitourinary symptoms, such as vaginal dryness and pain during sex, tend to be progressive 4.

Management and Treatment Options

• Estrogen-based hormonal therapies are the most effective treatments for many of the symptoms of perimenopause and menopause, and have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause 4, 5, 6.
• Non-hormonal treatment options, such as selective serotonin reuptake inhibitors and phytoestrogens, are also available for women who cannot or prefer not to use hormone therapy 4, 7.
• A symptom-driven treatment approach with individualized decision making can improve health and quality of life for midlife women 4, 5, 6.
• Correct perimenopause management should rely on individualized medical therapy and a multidisciplinary approach, considering lifestyle and food habits as part of general good health of a woman 5.

Importance of Early Recognition and Treatment

• The menopause transition is a disruptive process that can last for over a decade and causes symptoms in a majority of women 6.
• It is important for clinicians to recognize early signs and symptoms of the transition and be prepared to offer treatment to mitigate these symptoms 6.
• Many safe and effective options, including hormone therapy, are available to manage perimenopausal symptoms and improve quality of life 6, 7.