What are the treatment options for symptoms of perimenopause?

From the Guidelines

Treatment options for perimenopausal symptoms should prioritize lifestyle modifications and non-hormonal approaches, with hormone therapy considered on a case-by-case basis due to its potential risks and benefits. For hot flashes and night sweats, non-hormonal medications such as SSRIs/SNRIs (like paroxetine 7.5-20mg daily or venlafaxine 37.5-150mg daily) and gabapentin (300-900mg daily) can be effective alternatives to hormone therapy 1. Lifestyle modifications, including regular exercise, avoiding triggers like alcohol and caffeine, and maintaining good sleep hygiene, are also important adjuncts to reduce symptoms. Cognitive behavioral therapy can address mood changes and sleep issues, and has been shown to reduce vasomotor symptoms in some studies 1. For vaginal dryness, local estrogen products (creams, rings, or tablets) can provide relief without significant systemic absorption.

Some key points to consider:

• Lifestyle modifications, such as weight loss and smoking cessation, can help alleviate hot flashes and night sweats 1
• Non-hormonal medications, such as SSRIs/SNRIs and gabapentin, can be effective alternatives to hormone therapy for hot flashes and night sweats
• Cognitive behavioral therapy can address mood changes and sleep issues, and reduce vasomotor symptoms
• Local estrogen products can provide relief for vaginal dryness without significant systemic absorption
• Hormone therapy should be considered on a case-by-case basis, taking into account the individual woman's risks and benefits, and should be used at the lowest effective dose for the shortest possible time.

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).

The treatment options for symptoms of perimenopause include:

• Hormone replacement therapy (HRT), such as estradiol, to reduce moderate to severe hot flashes and other symptoms associated with menopause.
• Lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman.
• Regular evaluation (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary. Some of the symptoms of perimenopause that can be treated with estradiol include:
• Hot flashes
• Vulval and vaginal atrophy
• Dryness, itching, and burning in or around the vagina
• Difficulty or burning on urination associated with menopause 2 2

From the Research

Treatment Options for Perimenopause Symptoms

The treatment options for symptoms of perimenopause include:

• Hormone therapy, which is considered the most effective treatment for many symptoms, particularly for women under 60 and within 10 years of the onset of menopause 3, 4
• Non-hormonal pharmacologic therapies, such as selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, clonidine, and gabapentin, which can be used to treat vasomotor symptoms 5, 6
• Nonpharmacologic therapy options, including behavioral changes and acupuncture, which can also be used to treat vasomotor symptoms 5
• Alternative therapies, such as phytoestrogens, which may be used to treat symptoms in women who cannot take hormone therapy or prefer fewer side effects 6

Hormone Therapy Administration Routes

Different administration routes for hormone therapy have been compared in studies, including:

• Oral estradiol (E2) combined with medroxyprogesterone, which has been shown to be an effective and safe option for managing perimenopausal syndrome 7
• General health guidance combined with oral E2, which may be less likely to cause nausea and vomiting, and breast pain 7
• Other administration routes, such as transdermal and vaginal hormone therapy, which may also be effective and safe options for managing perimenopausal symptoms, although more research is needed to compare these routes 3, 4

Considerations for Treatment

When considering treatment options for perimenopause symptoms, it is essential to:

• Individualize treatment decisions based on a woman's symptoms, medical history, and preferences 3, 4
• Discuss the risks and benefits of hormone therapy, as well as contraindications, with a healthcare provider 5, 4
• Consider non-hormonal and alternative therapies for women who cannot take hormone therapy or prefer fewer side effects 5, 6