From the Guidelines
The best approach to diagnose and manage perimenopause involves a combination of clinical evaluation and targeted treatments based on symptom severity, prioritizing the use of hormone therapy for moderate to severe vasomotor symptoms, as recommended by recent guidelines 1.
Diagnosis
Diagnosis primarily relies on a woman's age (typically 40s to early 50s), menstrual irregularities, and characteristic symptoms like hot flashes, sleep disturbances, mood changes, and vaginal dryness, rather than hormone testing which is generally not recommended due to fluctuating hormone levels.
Symptom Management
For symptom management,
- Hormone therapy is most effective for moderate to severe vasomotor symptoms, typically starting with low-dose estrogen (such as 0.3-0.45 mg conjugated estrogens, 0.5 mg oral estradiol, or 0.025 mg estradiol patch) combined with progesterone (if the uterus is intact) like 100-200 mg micronized progesterone daily or 2.5-5 mg medroxyprogesterone acetate.
- Non-hormonal options include SSRIs/SNRIs (like paroxetine 7.5-25 mg, venlafaxine 37.5-150 mg, or escitalopram 10-20 mg daily), gabapentin (300-900 mg daily), or clonidine (0.1-0.2 mg daily).
- Lifestyle modifications are foundational and include:
- Regular exercise
- Maintaining healthy weight
- Avoiding triggers (caffeine, alcohol, spicy foods)
- Stress reduction techniques
- Good sleep hygiene
- Vaginal symptoms can be treated with local estrogen preparations (creams, tablets, or rings) or moisturizers.
Treatment Approach
Treatment should be individualized based on symptom severity, personal preferences, and medical history, with regular follow-up to adjust therapy as needed through the transition to menopause, as suggested by recent studies 1.
Key Considerations
Key considerations in managing perimenopause include the potential benefits and risks of hormone therapy, the importance of lifestyle modifications, and the need for individualized treatment approaches, as highlighted in recent guidelines 1.
From the Research
Diagnosis of Perimenopause
- Perimenopause, or the menopausal transition, is a period of time during which newly arising symptoms can present complex management decisions for providers 2.
- The symptoms of perimenopause can include hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns 2, 3.
- The effect of these symptoms on quality of life can be significant, even before a woman enters menopause 2.
Management of Perimenopause Symptoms
- Estrogen-based hormonal therapies are the most effective treatments for many of the symptoms of perimenopause, and have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause 3.
- Non-hormonal treatment options are also available, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and gabapentin 4.
- Hormonal contraceptives can confer many non-contraceptive benefits for women approaching menopause, including treatment of abnormal uterine bleeding, relief from vasomotor symptoms, and endometrial protection 5.
- A symptom-driven treatment approach with individualized decision making can improve health and quality of life for midlife women 3.
Treatment Options
- Hormone therapy (HT) can be effective for perimenopausal symptoms, but its use has been limited by concerns about health risks observed in postmenopausal HT users who are older than 60 and/or women who have been postmenopausal for greater than 10 years 6.
- Non-pharmacologic treatments such as cognitive behavior therapy and clinical hypnosis can be effective for short-term reduction of vasomotor symptoms and associated sleep disturbances 4.
- Hormone-free vaginal moisturizers are non-inferior to estrogen-based therapies for treating genitourinary syndrome of menopause 4.
- Other treatment options for vaginal dryness and dyspareunia associated with menopause include ospemifene and intravaginal dehydroepiandrosterone 4.