What are the symptoms and treatment options for perimenopause (perimenopausal transition)?

From the Guidelines

Perimenopause symptoms can be effectively managed with lifestyle modifications and medical treatments, prioritizing the use of non-hormonal medications like SSRIs, such as paroxetine 7.5-20mg daily, to mitigate vasomotor symptoms and improve quality of life. During perimenopause, women experience a range of symptoms due to fluctuating hormone levels, including irregular periods, hot flashes, night sweats, sleep disturbances, mood changes, vaginal dryness, and decreased fertility 1. For symptom management, lifestyle modifications like regular exercise, stress reduction techniques, and avoiding triggers like caffeine, alcohol, and spicy foods can help alleviate symptoms. Medical treatments include low-dose birth control pills to regulate hormones, hormone replacement therapy (estrogen with progesterone if you have a uterus), or specific medications like SSRIs for hot flashes. Vaginal moisturizers, lubricants, or low-dose vaginal estrogen products can address vaginal dryness. Regular healthcare visits are important during this transition to monitor symptoms and discuss treatment options. Some studies have shown that non-hormonal medications like SNRIs and SSRIs can decrease the intensity and severity of vasomotor symptoms, although they are not approved by the US Food and Drug Administration for this indication 1. The American Heart Association and the American Congress of Obstetricians and Gynecologists recommend against the use of menopausal hormone therapy for the primary or secondary prevention of cardiovascular disease 1. Key considerations for managing perimenopause symptoms include:

• Lifestyle modifications to alleviate symptoms
• Medical treatments, such as low-dose birth control pills or hormone replacement therapy, to regulate hormones
• Non-hormonal medications, like SSRIs, to mitigate vasomotor symptoms
• Vaginal moisturizers, lubricants, or low-dose vaginal estrogen products to address vaginal dryness
• Regular healthcare visits to monitor symptoms and discuss treatment options.

From the FDA Drug Label

Between ages 45 and 55, the ovaries normally stop making estrogens. This leads to a drop in body estrogen levels which causes the “change of life” or menopause (the end of monthly menstrual periods). Sometimes, both ovaries are removed during an operation before natural menopause takes place. The sudden drop in estrogen levels causes “surgical menopause. ” When the estrogen levels begin dropping, some women develop very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden strong feelings of heat and sweating (“hot flashes” or “hot flushes”). Perimenopause is not explicitly mentioned in the provided drug labels, but it can be inferred that the symptoms and conditions described are related to the transition period leading up to menopause, which is often referred to as perimenopause.

• The drug labels discuss the use of estradiol to treat symptoms associated with menopause, such as hot flashes and vaginal dryness.
• The labels also mention the importance of talking to a healthcare provider about whether treatment with estradiol is still needed, and about the potential risks and benefits of using estrogen therapy 2, 2, 2.

From the Research

Definition and Symptoms of Perimenopause

• Perimenopause, or the menopausal transition, is a period of time during which newly arising symptoms can present complex management decisions for providers 3.
• Many women present to care with complaints of hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns 3.
• The effect of these symptoms on quality of life, even before a woman enters menopause, can be significant 3.

Management and Treatment of Perimenopause

• The appropriate evaluation and evidence-based management of women in this transition is reviewed in the literature 3.
• Progesterone is commonly prescribed in combination with estrogen therapy, but monotherapy with progestins has been used as treatment of menopausal symptoms in women with contraindications to estrogens 4.
• A systematic review found that progestin therapy led to an improvement of vasomotor symptoms in postmenopausal women, but the optimal route and dosage of progestin monotherapy has not been established 4.
• Guidelines for the evaluation and treatment of perimenopausal depression have been developed, which include the use of antidepressants, psychotherapy, and hormone therapy 5.

Diagnosis and Interventions

• An interdisciplinary S3-guideline provides help to physicians as they inform women about the physiological changes which occur at this stage of life and the treatment options 6.
• The guideline includes recommendations for diagnosis and therapeutic interventions for perimenopausal and postmenopausal women, urogynecology, cardiovascular disease, osteoporosis, dementia, depression, mood swings, hormone therapy and cancer risk, as well as primary ovarian insufficiency 6.
• Hormone therapy is recommended for first-line management of menopausal symptoms, particularly for women younger than 60 years or who initiate hormone therapy within 10 years of menopause onset 7.

Hormone Therapy

• Hormone therapy use has undergone dramatic changes over the past 20 years, and there is general agreement that women who initiate hormone therapy within 10 years of menopause onset gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases 7.
• Despite accumulating evidence in support of hormone therapy for symptomatic menopausal women, the slow response by the medical community has led to a 'large and unnecessary burden of suffering' by women worldwide 7.