What are the treatment options for perimenopause symptoms?

Treatment Options for Perimenopause

The most effective treatment for perimenopausal symptoms is menopausal hormone therapy (MHT), though non-hormonal options should be considered first-line for most women due to safety considerations. 1

Assessment of Perimenopausal Symptoms

• Evaluate for medical causes of symptoms such as thyroid disease and diabetes before attributing to perimenopause 1
• Laboratory evaluation may include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin as clinically indicated 1
• Note that FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or those on tamoxifen 1
• For vaginal dryness complaints, a pelvic evaluation should assess for vaginal atrophy 1

Non-Hormonal Treatment Options

Pharmacologic Options for Hot Flashes

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) can effectively reduce vasomotor symptoms 1
• Caution with paroxetine in women taking tamoxifen due to CYP2D6 inhibition that may affect tamoxifen metabolism 1
• Anticonvulsants such as gabapentin and pregabalin have shown efficacy for vasomotor symptoms 1
• Certain antihypertensives like clonidine may help decrease hot flash intensity 1
• Doses for managing vasomotor symptoms are typically lower than those used for depression or other primary indications 1

Lifestyle Modifications

• Weight loss of ≥10% may help eliminate hot flash symptoms 1
• Smoking cessation can improve frequency and severity of hot flashes 1
• Limiting alcohol intake if it triggers hot flashes in individual women 1
• Cognitive behavioral therapy (CBT) can reduce the perceived burden of hot flashes 1
• Physical activity is recommended for overall health benefits, though evidence for direct improvement of vasomotor symptoms is limited 1

Non-Pharmacologic Options for Vaginal Symptoms

• Water-based lubricants and moisturizers are primary treatments for vaginal dryness 1
• Silicone-based products may last longer than water-based or glycerin-based products 1
• Vaginal dilators or pelvic floor relaxation techniques may help with dyspareunia 1

Hormonal Treatment Options

Menopausal Hormone Therapy (MHT)

• MHT is the most effective treatment for vasomotor symptoms but carries risks that must be considered 1, 2
• General recommendations:
  • Combination estrogen and progestins for women with an intact uterus 1
  • Estrogen alone for women without a uterus 1
• Contraindications include:
  • History of hormone-related cancers 1
  • History of abnormal vaginal bleeding 1
  • Active liver disease 1
  • Recent history of pregnancy 1

Local Estrogen Therapy

• Low-dose estrogen vaginal tablets or estradiol vaginal rings may be recommended for vaginal dryness due to urogenital atrophy 1
• Results typically take 6-12 weeks to become apparent 1
• Safety in women with a history of breast cancer is not well established 1
• Not recommended for women on aromatase inhibitors 1

Other Hormonal Options

• For young women experiencing perimenopause at an early age, oral contraceptives may provide symptom relief 1, 3
• Hormonal contraceptives can provide non-contraceptive benefits including treatment of abnormal uterine bleeding and relief from vasomotor symptoms 3

Special Considerations

• If MHT is used, appropriate specialist management of dosing is recommended 1
• Custom-compounded bioidentical hormones have no data supporting claims of being safer or more effective than standard hormone therapies 1
• The risks of MHT are generally low for most healthy women aged 50-59 years 4
• For women with a history of breast cancer, non-hormonal options are strongly preferred 1
• Tibolone (where available) may improve sexual function more effectively than standard hormone therapy but is contraindicated in hormone-dependent cancers 1

Treatment Algorithm

1. Rule out medical causes of symptoms (thyroid disease, diabetes)
2. Start with non-hormonal approaches:
   • Lifestyle modifications (weight loss, smoking cessation)
   • For hot flashes: SNRIs/SSRIs, gabapentin, or clonidine
   • For vaginal symptoms: lubricants and moisturizers
3. If symptoms persist and significantly impact quality of life, consider hormonal options after risk assessment:
   • For women without contraindications: MHT (estrogen plus progestin for intact uterus, estrogen alone for those without)
   • For localized vaginal symptoms: low-dose vaginal estrogen
   • For younger perimenopausal women: consider oral contraceptives

Remember that treatment should prioritize quality of life while minimizing risks, with the understanding that perimenopause is a transition that can last for over a decade and cause significant symptoms in the majority of women 5, 6.