What are the treatment options for perimenopause?

Treatment Options for Perimenopause

Hormone therapy is the most effective treatment for perimenopause symptoms, with 17β-estradiol being the preferred form and transdermal delivery recommended, particularly for patients with hypertension. 1

First-Line Treatment Options

Hormone Therapy

• For women with a uterus:

  • Estrogen plus progestin therapy is required to reduce endometrial cancer risk 2
  • Recommended regimens:
    • Conjugated equine estrogen: 0.625 mg/day
    • Transdermal estradiol: 0.025-0.0375 mg/day patch
    • Plus either:
      • Medroxyprogesterone acetate: 2.5 mg/day, or
      • Micronized progesterone: 200 mg orally for 12-14 days per month 1

• For women without a uterus:

  • Estrogen-only therapy is appropriate 2
  • Initial dosage range: 1-2 mg daily of estradiol, adjusted as necessary 2

Administration Guidelines

• Use the lowest effective dose for symptom control
• Cyclic administration recommended (e.g., 3 weeks on, 1 week off)
• Reevaluate every 3-6 months to determine if treatment is still necessary 2

Contraindications for Hormone Therapy

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

Non-Hormonal Alternatives

For women who cannot or choose not to use hormone therapy:

• SSRIs (paroxetine, sertraline, citalopram, fluoxetine) 3, 1
• Venlafaxine
• Vitamin E
• Relaxation techniques
• Acupuncture 1

Symptom-Specific Approaches

For Vasomotor Symptoms (Hot Flashes)

• Hormone therapy is most effective (reduces symptoms by 75-80%)
• SSRIs or SNRIs if hormone therapy is contraindicated
• Lifestyle modifications: avoiding triggers (alcohol, spicy foods, caffeine), dressing in layers 4

For Vaginal Dryness/Dyspareunia

• Local vaginal estrogen preparations (creams, tablets, rings) when symptoms are limited to vaginal area
• These have minimal systemic absorption and can be used even when systemic HT is contraindicated 5

For Mood Disturbances

• SSRIs or SNRIs
• Cognitive behavioral therapy
• Regular physical activity 4

For Sleep Disturbances

• Address underlying hot flashes with hormone therapy
• Sleep hygiene practices
• Avoid alcohol and caffeine before bedtime 4

Monitoring and Follow-up

• Initial follow-up at 3 months after starting therapy
• Annual follow-up thereafter
• Monitor blood pressure, weight, lipid profile, symptom control, and bleeding patterns 1
• No routine monitoring tests required unless prompted by specific symptoms

Important Considerations

Contraception

• Fertility may continue during perimenopause
• Contraception should continue until menopause is confirmed (12 months of amenorrhea) 6
• Hormonal contraceptives can provide both contraception and symptom relief 7

Nutritional Support

• Adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake
• Weight-bearing exercise
• Balanced diet to help manage metabolic changes 8

Duration of Therapy

• For vasomotor symptoms: Most women need treatment for 1-2 years, but some may require therapy for a decade or more 5
• For vaginal symptoms: These typically do not resolve without treatment 5
• Gradual reduction of HRT dose (25-50% every 4-8 weeks) is recommended when discontinuing 1

Risks and Benefits

• Venous thromboembolism risk is increased with HRT use (RR 2.14), with highest risk in the first year 1
• Combined estrogen/progestogen therapy can increase breast cancer risk when used for more than 3-5 years
• Benefits include relief from vasomotor symptoms, prevention of bone loss, and improvement in quality of life 1

Remember that perimenopause symptoms are highly prevalent and bothersome enough to drive almost 90% of women to seek medical advice 5. Providing effective treatment can significantly improve quality of life during this transition period.