What are the typical symptoms of perimenopause and how should they be evaluated and managed?

Perimenopause Symptoms: Recognition and Management

Core Symptom Profile

Perimenopausal women experience a constellation of symptoms driven by hormonal fluctuations, with vasomotor symptoms (hot flashes and night sweats), sleep disturbances, mood changes, vaginal dryness, and musculoskeletal complaints being the most consistently linked manifestations. 1, 2, 3

Primary Symptoms

• Vasomotor symptoms affect most women, with approximately one-third experiencing moderate to severe hot flashes that significantly impact quality of life 3
• Sleep disturbances increase during perimenopause due to both hormonal changes and aging, often interacting with vasomotor symptoms to worsen overall sleep quality 3, 4
• Mood disturbances including depression and anxiety show an abrupt rise in prevalence as women approach later stages of the menopausal transition with longer periods of amenorrhea 3
• Vaginal dryness and dyspareunia affect approximately one-third of women and, unlike hot flashes, will not resolve without treatment 3
• Arthralgias and myalgias occur consistently during the menopausal transition due to fluctuating estrogen levels affecting inflammatory pathways and joint tissues 2
• Cognitive changes including difficulty concentrating, memory problems, and mental cloudiness result from estrogen fluctuations affecting neurotransmitter systems and cerebral blood flow 2

Symptom Duration and Patterns

• Most women experience hot flashes for one to two years, though some endure them for a decade or more, and a small proportion never achieve complete resolution 3
• Symptoms often interact with one another—depressed women tend to experience worse hot flashes and worse sleep 3

Clinical Evaluation

Laboratory Assessment

When evaluating perimenopausal symptoms, obtain estradiol, FSH, LH, and prolactin levels as clinically indicated, but recognize that FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation, or those on tamoxifen. 1

• Serial estradiol levels are useful for perimenopausal women who become amenorrheic and later develop bleeding to determine return of ovarian function 1
• Anti-Müllerian hormone (AMH) and inhibin may provide additional information on ovarian status but alone are not reliable to ensure menopausal status 1
• Rule out medical causes of symptoms including thyroid disease and diabetes before attributing symptoms solely to perimenopause 1

Symptom-Specific Evaluation

• For vaginal dryness complaints, perform a pelvic evaluation to assess for vaginal atrophy, which can be accomplished by referral to an appropriate specialist 1
• Assess frequency and severity of vasomotor symptoms, symptoms of atrophic vaginitis (vaginal dryness, dyspareunia, urinary urgency, pruritis), and associated symptoms such as sexual dysfunction, reduced libido, and sleep disturbance 1
• Use standardized scales like the Greene Scale to establish the range and severity of symptoms, evaluate changes over time, and discriminate menopause symptoms from other pathologies 1

Management Approach

First-Line: Non-Hormonal Options

For women with perimenopausal symptoms disruptive to quality of life, initiate non-hormonal pharmacologic options as first-line therapy, reserving hormonal therapies for after consideration of individual risks and benefits. 1

Non-Hormonal Pharmacologic Treatment for Hot Flashes

• SSRIs and SNRIs reduce vasomotor symptoms, though the degree of symptom reduction may be smaller than with hormonal treatments 1
• Low-dose paroxetine specifically reduces the frequency and severity of hot flashes in postmenopausal women 1
• Other options include anticonvulsants, neuropathic pain relievers, and certain antihypertensives 1

Lifestyle and Integrative Approaches

• Plant-forward diets and phytoestrogens may alleviate vasomotor symptoms and support cardiovascular and bone health 5
• Yoga and resistance training improve physical and psychological well-being 5
• Exercise and health education offer benefits in managing perimenopausal symptoms 6

Hormonal Therapy

Menopausal hormone therapy (MHT) is the most effective therapy for management of vasomotor symptoms and genitourinary symptoms, but must be prescribed with careful consideration of contraindications. 1

Systemic Hormone Therapy Guidelines

• Use combination estrogen and progestins for women with an intact uterus 1
• Use estrogen alone for women without a uterus 1
• For young women experiencing menopause at an early age, consider oral contraceptives for symptom relief 1
• Appropriate specialist management of MHT dosing is recommended 1

Local Vaginal Estrogen

• Local estrogen treatments (rings, suppositories, creams) are appropriate for vaginal symptoms and are category 2B recommendations 1
• Consider appropriate specialist for management of local estrogen therapy 1

Absolute Contraindications to MHT

• History of hormone-related cancers 1
• History of abnormal vaginal bleeding 1
• Active or recent history of pregnancy 1
• Active liver disease 1

Special Considerations

• Custom-compounded bioidentical hormone therapy lacks data supporting claims that it is safer and more effective than standard hormone therapies 1
• For women with sexual dysfunction, address the complex origins including body image changes, psychosocial trauma, and vaginal dryness through direct questioning and potentially validated instruments like the Sexual Activity Questionnaire 1

Referral Indications

• Refer to endocrinology or gynecology for delayed puberty, persistently abnormal hormone levels, or hypogonadism 1
• Consider referral to specialist menopause service for complex symptom management 1
• Refer to appropriate specialist for management of vaginal atrophy and sexual dysfunction 1