From the Guidelines
Perimenopause symptoms 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 management. Perimenopause symptoms include irregular periods, hot flashes, night sweats, sleep disturbances, mood changes, vaginal dryness, decreased libido, fatigue, weight gain, and memory issues. These symptoms occur as estrogen and progesterone levels fluctuate and gradually decline during the years leading up to menopause. For mild symptoms, lifestyle modifications like regular exercise, stress reduction techniques, and avoiding triggers (caffeine, alcohol, spicy foods) can help.
Treatment Options
- Non-hormonal medications like SSRIs (Paxil 10-20mg daily) or gabapentin (300mg at bedtime) can address hot flashes 1.
- Over-the-counter lubricants and moisturizers can relieve vaginal dryness.
- Black cohosh (40mg twice daily) may help some women, though evidence is mixed.
Hormone Therapy
- Hormone therapy options, such as low-dose birth control pills, estrogen patches (0.025-0.05 mg), or vaginal estrogen (creams, rings, or tablets) for localized symptoms, should be considered for severe symptoms that do not respond to initial management 1.
- The USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women, highlighting the importance of individualized treatment decisions 1. These symptoms typically begin 4-8 years before menopause and result from the natural aging process of the ovaries, which causes hormonal fluctuations that affect multiple body systems. Treatment should be individualized based on symptom severity, medical history, and personal preferences.
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). Sometimes, both ovaries are removed during an operation before natural menopause takes place. The sudden drop in estrogen levels causes “surgical menopause. ” When the estrogen levels begin dropping, some women develop very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden strong feelings of heat and sweating (“hot flashes” or “hot flushes”).
Estradiol is used to reduce moderate to severe hot flashes and other symptoms associated with menopause. These symptoms occur due to a drop in estrogen levels, which can happen naturally between ages 45 and 55 or suddenly due to surgical removal of the ovaries. Key symptoms include:
- Hot flashes
- Feelings of warmth in the face, neck, and chest
- Sudden strong feelings of heat and sweating 2
From the Research
Perimenopause Symptoms
- 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 3
- Genitourinary symptoms, including vulvovaginal irritation and dryness, dyspareunia, and urinary problems, tend to be progressive 3, 4
- Other common symptoms and conditions associated with perimenopause include:
Treatment Options
- Estrogen-based hormonal therapies are the most effective treatments for many perimenopause symptoms, with a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause 3, 5
- Non-hormonal treatment options are also available, including:
- Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors for vasomotor symptoms 4
- Gabapentin for vasomotor symptoms 4
- Cognitive behavior therapy and clinical hypnosis for short-term reduction of vasomotor symptoms and associated sleep disturbances 4
- Hormone-free vaginal moisturizers for genitourinary syndrome of menopause 4
- Ospemifene and intravaginal dehydroepiandrosterone for vaginal dryness and dyspareunia associated with menopause 4
Management Approach
- A symptom-driven treatment approach with individualized decision making can improve health and quality of life for midlife women 3
- Management of perimenopause symptoms should involve shared decision-making that is informed by the best available evidence and individual risks and preferences 4, 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 6