What are the treatment options for peri-menopause?

Treatment Options for Perimenopause

For women experiencing perimenopausal symptoms, hormone replacement therapy (HRT) should be used at the lowest effective dose for the shortest duration possible, with treatment decisions based on individual risk factors, symptom severity, and personal preferences.

Hormone Replacement Therapy (HRT)

First-Line Treatment Options:

• Transdermal estradiol is preferred over oral formulations due to:

  • Lower thrombotic risk
  • Avoidance of first-pass liver metabolism
  • More physiological estrogen levels 1
  • Typical dosage: 0.025-0.0375 mg/day patch 1

• For women with an intact uterus: Must combine estrogen with progesterone to prevent endometrial cancer 2

  • Preferred regimen: Transdermal estradiol with oral micronized progesterone (200 mg daily for 12-14 days per month) 1
  • Administration options:
    • Sequential regimen (allows for withdrawal bleeding)
    • Continuous regimen (prevents withdrawal bleeding) 1

• For women without a uterus: Estrogen-only therapy is appropriate 2

Dosing Considerations:

• Start with lowest effective dose (typically 1-2 mg daily of estradiol) 2
• Adjust based on symptom control 1
• Reevaluate every 3-6 months to determine if treatment is still necessary 2
• Continue until average age of natural menopause (50-51 years) for premature ovarian insufficiency 1

Non-Hormonal Treatment Options

For women who cannot or prefer not to use HRT:

Pharmacological Options:

• For vasomotor symptoms:
  • Low-dose paroxetine
  • Venlafaxine
  • Gabapentin 1
  • Clonidine 1

Lifestyle and Complementary Approaches:

• Nutritional interventions:

  • Adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake 2
  • Balanced diet to reduce risk of obesity, metabolic syndrome, and cardiovascular disease 3
  • Soy products for modest improvement in hot flashes and vaginal dryness 1

• Other approaches:

  • Weight-bearing exercise 2
  • Clinical hypnosis (some benefit for hot flashes) 1

Special Considerations

Contraception

• Fertility may decline but pregnancy is still possible during perimenopause
• Contraception should continue until menopause is confirmed (12 months of amenorrhea) 4

Symptom-Specific Management

• Genitourinary symptoms (vaginal dryness, dyspareunia):

  • Consider topical vaginal estrogen products for isolated symptoms 2
  • Unlike vasomotor symptoms, these will not resolve without treatment 5

• Sleep disturbances:

  • Address through management of hot flashes
  • Consider sleep hygiene measures 1

Monitoring and Follow-up

• Initial follow-up at 3 months to assess symptom control and side effects 1
• Annual monitoring of:
  • Blood pressure
  • Weight
  • Lipid profile
  • Symptom control
  • Bleeding patterns 1

Contraindications to HRT

• Active liver disease
• History of breast cancer
• History of coronary heart disease
• Previous venous thromboembolism or stroke
• Positive antiphospholipid antibodies 1

Important Caveats

• Perimenopausal symptoms may last much longer than previously thought (median 11.8 years if starting in early perimenopause) 6
• Symptoms can be diverse and include sleep disturbances, mood swings, joint pain, cognitive changes ("brain fog"), and more 6
• Medical conditions that may mimic menopausal symptoms (thyroid disorders, diabetes, anxiety, depression) should be ruled out 1

Remember that while HRT is effective for symptom management, it should not be routinely used for the specific purpose of preventing chronic disease in women 7. The decision to use HRT should be based on a shared decision-making approach that considers individual risk factors and preferences.