Treatment Options for Perimenopause
The most effective treatment for moderate to severe perimenopausal symptoms is hormone replacement therapy (HRT), which should be prescribed at the lowest effective dose for the shortest duration needed to control symptoms.1, 2
Understanding Perimenopause
Perimenopause is characterized by:
- Wide hormonal fluctuations and irregular menstrual cycles
- Typically lasts 5+ years before menopause (defined as 12 months of amenorrhea)
- Declining fertility, though contraception is still needed 3
- Symptoms affecting quality of life for most women 4
Common Perimenopausal Symptoms and Treatment Options
1. Vasomotor Symptoms (Hot Flashes, Night Sweats)
First-line treatment: Hormone Replacement Therapy
Non-hormonal alternatives:
- SSRIs/SNRIs (paroxetine, venlafaxine)
- Gabapentin
- Clonidine 1
2. Mood and Cognitive Changes
- SSRIs or SNRIs may help with both mood symptoms and vasomotor symptoms 1
- Consider psychological evaluation for significant mood changes
3. Sleep Disturbances
- Address underlying vasomotor symptoms that may disrupt sleep
- Sleep hygiene practices
- Consider low-dose antidepressants if related to mood issues
4. Genitourinary Symptoms
- Local estrogen therapy for vaginal dryness and dyspareunia
- Unlike vasomotor symptoms, vaginal symptoms will not resolve without treatment 4
5. Sexual Function Issues
- For decreased libido: Address underlying hormonal changes
- For dyspareunia: Vaginal moisturizers, lubricants, or local estrogen therapy
HRT Considerations and Monitoring
Patient Selection
- Best candidates: Women under 60 years or within 10 years of menopause onset 1
- Confirm perimenopausal status with FSH and estradiol levels when appropriate 1
Contraindications to HRT
- History of breast cancer
- Coronary heart disease
- Previous venous thromboembolism
- Active liver disease
- Unexplained vaginal bleeding 1
Monitoring
- Annual clinical review including:
- Blood pressure
- Weight assessment
- Lipid profile
- Appropriate cancer screening (breast, cervical) 1
- Attempt to discontinue or taper medication at 3-6 month intervals 2
Important Caveats
- HRT should be avoided in women more than 10 years post-menopause as benefits decrease and risks increase 1
- Combined estrogen/progestogen therapy may increase breast cancer risk when used for more than 3-5 years 1
- HRT should be used at the lowest effective dose for the shortest time needed 1, 2
- Women should be reevaluated periodically (every 3-6 months) to determine if treatment is still necessary 2
- For women with a uterus, adequate diagnostic measures should be taken to rule out malignancy in cases of persistent or recurring abnormal vaginal bleeding 2
Lifestyle and Complementary Approaches
- Weight-bearing exercise
- Adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake for bone health 2
- Balanced nutrition and adequate fluid intake 5
- Some evidence for benefit from soy products for hot flashes and vaginal dryness 1
- Clinical hypnosis may provide some benefit for hot flashes 1
Contraception During Perimenopause
- Fertility declines but pregnancy is still possible
- Contraception should continue until menopause is confirmed (12 months of amenorrhea) 3
- Multiple effective options are available based on individual needs and medical history