What treatment options are available for women experiencing perimenopausal symptoms?

Management of Perimenopausal Symptoms

Start with lifestyle modifications and non-hormonal approaches as first-line therapy for most women, reserving menopausal hormone therapy (MHT) for those with severe symptoms who lack contraindications and are within 10 years of menopause onset or under age 60. 1, 2

Initial Assessment

Before attributing symptoms to perimenopause, evaluate for alternative medical causes:

• Screen for thyroid disease and diabetes that can mimic perimenopausal symptoms 2
• Laboratory testing may include estradiol, FSH, LH, and prolactin as clinically indicated, though FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those on tamoxifen 2
• Perform pelvic examination if vaginal dryness is reported to assess for vaginal atrophy 2
• Assess symptom severity and impact on daily activities, particularly hot flashes and night sweats 2

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 1, 2

Smoking cessation substantially improves both frequency and severity of hot flushes 1, 2

Limit alcohol intake if it triggers hot flushes in individual women, as responses vary 1, 2

Environmental modifications include dressing in layers for quick cooling, maintaining cool room temperatures, and avoiding spicy foods and caffeine that trigger hot flushes 1

Second-Line: Mind-Body Approaches

Cognitive Behavioral Therapy (CBT) reduces the perceived burden of hot flushes and significantly improves problem ratings for both hot flashes and night sweats 1, 2

Acupuncture demonstrates efficacy equivalent to or better than pharmacological treatments like venlafaxine or gabapentin for vasomotor symptoms 1, 2

Yoga improves quality of life associated with menopause, including the vasomotor symptom domain, though effects on frequency may be limited 1

Third-Line: Non-Hormonal Pharmacologic Options

When lifestyle modifications and mind-body approaches prove insufficient:

Venlafaxine (SNRI) is the preferred first-line pharmacologic agent, reducing hot flashes by approximately 60% at doses lower than those used for depression, with faster onset of action than alternatives 2

Gabapentin decreases hot flash severity by 46% compared to 15% with placebo, and is particularly useful when given at bedtime due to sedating effects that help with sleep disruption from night sweats 2

Other SSRIs/SNRIs are effective alternatives, though avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition that affects tamoxifen metabolism 1, 2

Note that recent guidelines no longer recommend clonidine and pregabalin, which were previously suggested options 3

Neurokinin B antagonists (fezolinetant) represent a new class now available for vasomotor symptoms in postmenopausal women with contraindications or aversion to steroid hormones, modulating the thermoregulation center in the hypothalamus 3, 4

Fourth-Line: Menopausal Hormone Therapy (MHT)

MHT remains the most effective treatment for vasomotor symptoms but should be reserved for women with severe symptoms who have failed non-hormonal approaches 1, 2, 5

Use the lowest effective dose for the shortest duration necessary 2

Prescribe combination estrogen plus progestogen for women with intact uterus to protect the endometrium 2

Prescribe estrogen alone for women without a uterus 2

MHT is appropriate only for women under age 60 and within 10 years of menopause onset, as this population has a favorable benefit-to-risk ratio 5

Absolute Contraindications to MHT:

• History of hormone-related cancers 2
• History of abnormal vaginal bleeding 2
• Active liver disease 2
• Recent pregnancy 2

Important Caveats:

Long-term HRT use carries risks including increased stroke, pulmonary embolism, and invasive breast cancer with estrogen plus progestin 1

Custom-compounded bioidentical hormones have no data supporting claims of superior safety or efficacy compared to standard hormone therapies and should be avoided 2

Management of Genitourinary Symptoms

Low-dose estrogen vaginal tablets or estradiol vaginal rings are recommended for vaginal dryness due to urogenital atrophy, with results typically taking 6-12 weeks 2

Water-based lubricants and moisturizers are primary non-hormonal treatments for vaginal dryness, with silicone-based products lasting longer than water-based or glycerin-based options 1, 2

Vaginal dilators or pelvic floor relaxation techniques may help with dyspareunia 2

Note that genitourinary symptoms will not resolve without treatment, unlike hot flashes which may eventually subside 6

Special Populations

For breast cancer survivors, strongly prefer non-hormonal options including SNRIs, SSRIs, gabapentin, lifestyle modifications, and environmental modifications 1

For young women experiencing early perimenopause, oral contraceptives may provide symptom relief while also offering contraception 2

Women taking tamoxifen or aromatase inhibitors may experience worsened menopausal symptoms with limited treatment options - avoid vaginal estrogen in women on aromatase inhibitors 2

Common Pitfalls to Avoid

Do not delay treatment - menopausal symptoms remain substantially undertreated despite effective options that can significantly improve quality of life 2, 5

Do not rely on soy isoflavones for vasomotor symptom relief, as clinical evidence shows minimal to no benefit compared to placebo, with substantial placebo effects (40-60% reduction) observed in control groups 1

Do not use FSH levels to determine menopausal status in women with prior chemotherapy, pelvic radiation, or those on tamoxifen 2

Recognize that symptoms last longer than previously thought - median duration of 11.8 years for women affected in early perimenopause versus 3.4 years for those starting only after menopause 4