Management of Perimenopause Symptoms

Introduction to Perimenopause Management

The American College of Obstetricians and Gynecologists recommends that women with perimenopause symptoms, such as hot flashes and night sweats, be treated with cyclic oral micronized progesterone 300 mg at bedtime on cycle days 14-27, as this addresses the underlying pathophysiology of progesterone deficiency with estrogen excess 3, 4
The North American Menopause Society suggests that hormone therapy should not be initiated for chronic disease prevention in asymptomatic women, as the risks outweigh the benefits 6, 4

The use of transdermal estradiol 50 μg daily, in combination with micronized progesterone 200 mg at bedtime, is recommended for women with moderate-to-severe symptoms who are under 60 or within 10 years of menopause onset 3, 4
The transdermal route is preferred over oral due to lower thrombotic and cardiovascular risk 3, 4
Micronized progesterone has a superior safety profile compared to medroxyprogesterone acetate, with lower rates of venous thromboembolism and breast cancer risk 3, 4

Serial estradiol levels can help determine return of ovarian function if amenorrhea develops then bleeding resumes 1, 2
FSH is not reliable for determining menopausal status during perimenopause, especially in women on hormone therapy 1, 2
The duration of therapy should be discussed every 3-6 months, with the goal of using the lowest effective dose for the shortest duration needed 4, 5

Women with Hashimoto's thyroiditis can be treated with hormone therapy, but thyroid function should be monitored closely to ensure TSH remains in normal range 1, 2