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Perimenopausal Care

Providers should be able to offer basic guidance about what to expect during perimenopause, counsel on lifestyle changes to help mitigate symptoms, and therapeutic options, either directly or by referral. 

Providers should also advise patients that pregnancy can still occur during perimenopause; patients wishing to avoid pregnancy should be offered contraceptive counseling.94, 173 Laboratory testing, including testing for follicle-stimulating hormone (FSH) levels, is not helpful in diagnosing menopause or determining fertility and should be avoided. The North American Menopause Society (NAMS) offers position statements, questionnaires, and clinical guidance on this topic.174

Perimenopause lasts four years on average and is often associated with irregular menses, vaginal dryness, vasomotor instability, sleep disturbances, mood changes, and other symptoms.175 Symptom management includes lifestyle changes, hormone therapy, and other nontraditional treatment options.176 A shared decision-making approach to menopause therapy includes discussion of symptoms and a review of treatment options including the risks and benefits, and a discussion of the patient’s beliefs, preferences, and goals. 

Providers should be able to offer basic guidance about what to expect during perimenopause, counsel on lifestyle changes to help mitigate symptoms, and therapeutic options, either directly or by referral. 

  • Lifestyle changes include smoking cessation, sleep hygiene, maintaining a lower ambient temperature, and using non-estrogen water- or silicone-based vaginal lubricants.177 
  • Systemic hormone therapy with estrogen, with or without progestin, has been shown to be the most effective treatment for hot flashes and night sweats, as well as protecting against bone loss.178, 179 
  • Local estrogen is the most effective treatment for genitourinary symptoms of menopause, including vaginal dryness, pain with sex, and dysuria.177, 179 
  • Any patient with a uterus who uses systemic estrogen therapy should also use progestin to reduce the risk of endometrial hyperplasia and cancer.177, 180 Progestin can be administered continuously or intermittently through a variety of delivery systems, including orally or via intrauterine device.180
  • Consider non-hormonal medical management of vasomotor symptoms with medications like paroxetine and fezolinetant for patients who prefer non-hormonal management or those ineligible for hormone therapy.178

Both NAMS and ACOG also offer fact sheets and other information for patients.166, 181

Resources for Providers

North American Menopause Society
Management of Menopausal Symptoms
Source:
American College of Obstetricians and Gynecologists
  • 94

    Centers for Disease Control and Prevention. US Selected Practice Recommendations for Contraceptive Use, 2024 (US SPR).

  • 166

    Jodry D, Obedin-Maliver J, Flowers L, et al. Understanding sexual and gender minority populations and organ-based screening recommendations for human papillomavirus–related cancers. Journal of lower genital tract disease. 2023;27(4):307-321.

  • 173

    The North American Menopause Society. Contraception: You Need it Longer Than You May Think

  • 174

    The North American Menopause Society

  • 175

    Burger HG. Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications. Menopause international. 2011;17(4):153-154.

  • 176

    The North American Menopause Society. Perimenopause & Premature Menopause FAQs.

  • 177

    Furness S, Roberts H, Marjoribanks J, Lethaby A, Hickey M, Farquhar C. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database of Systematic Reviews. 2004;(3).

  • 177

    Furness S, Roberts H, Marjoribanks J, Lethaby A, Hickey M, Farquhar C. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database of Systematic Reviews. 2004;(3).

  • 177

    Furness S, Roberts H, Marjoribanks J, Lethaby A, Hickey M, Farquhar C. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database of Systematic Reviews. 2004;(3).

  • 178178

    Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstetrics & Gynecology. 2015;126(4):859-876.

  • 179179

    Duralde ER, Sobel TH, Manson JE. Management of perimenopausal and menopausal symptoms. BMJ. 2023;382.

  • 180180

    Faubion SS, Crandall CJ, Davis L, et al. The 2022 hormone therapy position statement of the North American Menopause Society. Menopause. 2022;29(7):767-794.

  • 181

    American College of Obstetricians and Gynecologists. Management of menopausal symptoms. Practice Bulletin No. 141. Obstet Gynecol. 2014;123(1):202-216.