From the Guidelines
Perimenopause treatment should prioritize nonhormonal medications like SNRIs and SSRIs, such as venlafaxine, to mitigate vasomotor symptoms, as recommended by the American Cancer Society and American Society of Clinical Oncology 1. Perimenopause treatment focuses on managing symptoms and maintaining health during the transition to menopause.
- For hot flashes and night sweats, starting with lifestyle changes like avoiding triggers (alcohol, caffeine, spicy foods), dressing in layers, and keeping the bedroom cool can help.
- If these aren't sufficient, medications like low-dose paroxetine or other SSRIs/SNRIs such as venlafaxine (37.5-75mg daily) can reduce hot flashes, as they have been found to be safe and effective in reducing vasomotor symptoms 1.
- The anticonvulsant gabapentin has also been shown to be effective in reducing hot flashes 1.
- Lifestyle interventions, including rhythmic breathing, vitamins, exercise, and avoiding spicy foods, caffeine, and alcohol, have had variable results, but may be beneficial in reducing menopausal symptoms 1.
- Environmental modifications, such as cool rooms and dressing in layers, can also be helpful in decreasing the intensity and severity of menopausal symptoms 1.
- It is essential to note that systemic hormone therapy is given rarely, if ever, to patients with breast cancer to control menopausal symptoms, and nonhormonal medications are preferred 1.
From the FDA Drug Label
When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. The usual initial dosage range is 1 to 2 mg daily of estradiol adjusted as necessary to control presenting symptoms.
The treatment for perimenopause is not directly addressed in the provided drug labels. However, the labels discuss the treatment of moderate to severe vasomotor symptoms and vulval and vaginal atrophy associated with the menopause using estradiol (PO). The recommended dosage is 1 to 2 mg daily, adjusted as necessary to control symptoms, and should be discontinued as promptly as possible 2.
- Key points:
- Lowest effective dose for the shortest duration
- Reevaluate patients periodically (e.g., 3-month to 6-month intervals)
- Consider progestin for women with a uterus to reduce the risk of endometrial cancer 2
From the Research
Perimenopause Treatment Options
- Hormone therapy (HT) is considered the most effective treatment for many perimenopausal symptoms, including vasomotor symptoms and genitourinary symptoms 3, 4, 5
- Estrogen-based hormonal therapies have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause 3
- Non-hormonal treatment options are also available, including selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs) 4
- Patient tailoring of treatment is key to managing symptoms of menopause, and physicians must have in-depth knowledge of the pharmacology of compounds to tailor therapy to the individual patient's characteristics and needs 4
Hormonal Treatment
- Hormonal contraceptives can confer many non-contraceptive benefits for women approaching menopause, including treatment of abnormal uterine bleeding, relief from vasomotor symptoms, and endometrial protection 6
- The main point remains selecting the most adequate contraceptive option for each woman, considering her risk factors, comorbidities, and keeping in mind the possibility of continuing contraception until reaching menopause and even further 6
Management of Perimenopause
- Correct perimenopause management should rely on individualized medical therapy and a multidisciplinary approach, considering lifestyle and food habits as part of general good health of a woman 6, 7
- The menopause transition is a disruptive process that can last for over a decade and causes symptoms in a majority of women, and it is important for clinicians to recognize early signs and symptoms of the transition and be prepared to offer treatment to mitigate these symptoms 5