What are the guidelines for managing perimenopause?

Management of Perimenopause

For perimenopausal women experiencing vasomotor symptoms, begin with lifestyle modifications including weight loss (if overweight), smoking cessation, and environmental adjustments, then escalate to non-hormonal pharmacotherapy (SNRIs, SSRIs, or gabapentin) or hormone replacement therapy based on symptom severity and contraindications. 1

Vasomotor Symptoms (Hot Flashes/Night Sweats)

First-Line: Lifestyle Modifications

• Weight management is critical: Women who lose ≥10% of body weight are significantly more likely to eliminate hot flash symptoms compared to those maintaining weight, making this the primary recommendation for overweight women 1
• Smoking cessation substantially improves both frequency and severity of hot flushes compared to continued smoking 1
• Environmental modifications include dressing in layers for quick cooling, maintaining cool room temperatures, and avoiding spicy foods and caffeine that trigger symptoms 1
• Alcohol limitation is recommended if it triggers hot flushes in individual women, as responses vary 1

Second-Line: Mind-Body Approaches

• Acupuncture is safe and effective, with multiple studies showing equivalence to or superiority over pharmacological treatments like venlafaxine or gabapentin 1
• Cognitive Behavioral Therapy (CBT) reduces the perceived burden of hot flushes and significantly improves problem ratings for both hot flashes and night sweats 1
• Yoga improves quality of life associated with menopause, including vasomotor symptom domains, though effects on frequency may be limited 1

Third-Line: Pharmacological Management

Hormone Replacement Therapy (HRT)

• HRT remains the most effective treatment for vasomotor symptoms in eligible women 1
• Long-term use is controversial due to increased risks of stroke, pulmonary embolism, and invasive breast cancer with estrogen plus progestin 1
• Reserve for moderate-to-severe symptoms in women without contraindications 1

Non-Hormonal Medications

• SNRIs (venlafaxine) are first-choice non-hormonal agents, proven safe and effective for reducing hot flashes 2
• SSRIs can decrease intensity and severity of vasomotor symptoms, though not FDA-approved for this indication 2
• Avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition potentially reducing tamoxifen efficacy, though negative breast cancer outcomes have not been conclusively demonstrated 2, 1
• Gabapentin is effective for reducing hot flashes 2, 1
• Clonidine has been used in clinical practice but is no longer recommended by The Menopause Society 3

Important caveat: Do not screen patients for CYP2D6 genotype, consistent with ASCO and NCCN recommendations 2

Genitourinary Symptoms

Vaginal Dryness and Dyspareunia

• Non-hormonal, water-based lubricants and moisturizers are primary treatment 2, 1
• Silicone-based products last longer than water-based or glycerin-based alternatives 2
• Combination therapies provide additional short-term comfort 2
• Low-dose vaginal estrogen (tablets or ring) may be considered for urogenital atrophy, though results take 6-12 weeks and safety in breast cancer survivors is not well established 2
• Vaginal dilators or pelvic floor relaxation techniques help treat dyspareunia secondary to vaginal atrophy and stenosis 2

Critical point: Unlike hot flashes, vaginal symptoms will not resolve without treatment 4

Sexual Dysfunction

• Assess for signs and symptoms of sexual dysfunction and problems with sexual intimacy 2
• Identify and treat reversible contributing factors including anxiety, stress, mood changes, and physical discomfort 2
• Refer for psychoeducational support, group therapy, sexual counseling, or marital counseling when appropriate 2, 1

Mood and Sleep Disturbances

• Depressed mood and anxiety increase during perimenopause, with abrupt rise in prevalence during later stages with longer amenorrhea 4
• Poor sleep becomes more common in association with both menopausal transition and aging 4
• These symptoms often interact: depressed women experience worse hot flashes and worse sleep 4
• Neurokinin B antagonists show promise for addressing vasomotor symptoms, sleep, and mood issues 3

Fertility and Contraception

• Do not assume amenorrheic survivors are infertile, as menses may resume 2
• Unintended pregnancy incidence is approximately 3 times higher in perimenopausal women than the general population 2
• Contraception should continue until menopause is confirmed (12 months of amenorrhea) 5
• Refer women experiencing infertility to reproductive endocrinology specialists as soon as possible 2

Health Promotion During Perimenopause

• Achieve and maintain healthy weight through limiting high-calorie foods and increasing physical activity 2
• Engage in regular physical activity: at least 150 minutes of moderate or 75 minutes of vigorous aerobic exercise per week, plus strength training at least 2 days per week 2
• Follow dietary pattern high in vegetables, fruits, whole grains, and legumes; low in saturated fats; and limited in alcohol 2
• Avoid smoking and refer smokers to cessation counseling 2

What NOT to Use

• Soy isoflavones are not recommended as primary treatment for vasomotor symptoms, as clinical evidence shows minimal to no benefit compared to placebo, with substantial placebo effect (40-60% reduction) observed in control groups 1
• Pregabalin is no longer recommended per updated Menopause Society guidelines 3
• Clonidine is no longer recommended per updated Menopause Society guidelines 3