What are the non-hormonal treatment options for a perimenopausal woman experiencing non-vasomotor symptoms such as mood changes, sleep disturbances, or vaginal dryness?

Non-Hormonal Treatment for Non-Vasomotor Perimenopausal Symptoms

For perimenopausal women with non-vasomotor symptoms, use water-based lubricants and moisturizers as first-line for vaginal dryness, SSRIs/SNRIs for mood disturbances, and psychoeducational interventions for sexual dysfunction, while addressing sleep issues with gabapentin when sedation is beneficial. 1, 2

Vaginal Dryness and Sexual Dysfunction

Water-based lubricants and moisturizers are the primary non-hormonal treatment for vaginal dryness. 1, 2 These remain first-line therapy before considering any hormonal options.

• Silicone-based products last longer than water-based or glycerin-based formulations and may provide superior duration of relief 1, 2
• Combination therapy using both types can provide additional short-term comfort 1
• Vaginal dilators or pelvic floor relaxation techniques help treat dyspareunia secondary to vaginal atrophy and stenosis 1, 2

Psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy should be offered to all women with sexual complaints. 1 These interventions specifically address anxiety, stress, sexual comfort, and mood changes that commonly accompany perimenopause. 1

Mood Disturbances

SSRIs and SNRIs effectively manage perimenopausal mood symptoms at doses typically lower than those used for depression. 2, 3

• Venlafaxine (SNRI) is a preferred first-line agent, reducing symptoms by approximately 60% with faster onset than alternatives 2
• Combined hormonal contraceptives containing drospirenone with 30 mcg ethinyl estradiol are particularly effective for mood symptoms in perimenopausal women who also need contraception 3
• Avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition affecting tamoxifen metabolism, though large database analyses have not shown increased cancer recurrence 1, 2, 3

Sleep Disturbances

Gabapentin is particularly useful for sleep disruption, especially when given at bedtime due to its sedating effects. 2 This decreases hot flash severity scores by 46% compared to 15% with placebo and simultaneously addresses night sweats that disrupt sleep. 2

• Cognitive behavioral therapy (CBT) reduces the perceived burden of symptoms and may help with concentration difficulties 2, 3
• Address medical causes of sleep disturbance including thyroid disease and diabetes before attributing symptoms solely to perimenopause 1, 2

Additional Non-Pharmacologic Interventions

Lifestyle modifications provide meaningful symptom relief without medication risks:

• Weight loss of ≥10% may eliminate symptoms in some women 2
• Smoking cessation improves frequency and severity of symptoms 2
• Limiting alcohol intake if it triggers symptoms in individual patients 2
• Physical activity is recommended for overall health benefits, though direct evidence for symptom improvement is limited 2

Acupuncture shows equivalence or superiority to venlafaxine or gabapentin for symptom management. 2 Yoga may improve quality of life, though evidence for direct symptom reduction is mixed. 2

Critical Assessment Before Treatment

Perform pelvic evaluation to assess for vaginal atrophy in women complaining of vaginal dryness. 1, 2 Laboratory evaluation including estradiol, FSH, LH, and prolactin should be obtained as clinically indicated, though FSH is unreliable in women with prior chemotherapy, pelvic radiation, or tamoxifen use. 1, 2, 3

Common Pitfalls

Do not delay treatment—menopausal symptoms remain substantially undertreated despite effective options that significantly improve quality of life. 2, 4 The trio of counseling, over-the-counter treatments, and pharmacologic interventions together provides comprehensive symptom management. 1

Avoid custom-compounded bioidentical hormones, as no data supports claims of superior safety or efficacy compared to standard therapies. 2, 3