Perimenopause Symptoms And Treatment

Understanding perimenopause 

Definition 

Perimenopause, also called the menopausal transition, is a phase when there is a transition from fertile years to menopause. It starts when there are fewer eggs in the ovaries, causing changes in hormones and periods. This can lead to irregular periods until they stop completely, marking the end of this phase.^1,4 On average, the menopause transition lasts 4 years most of the time.⁴

Stages of perimenopause

During perimenopause or the menopausal transition, there are two main stages– the early stage and the late stage.^1,3 

• In the early stage, periods are mostly regular with few interruptions 
• In the late stage, periods may stop for longer periods, sometimes lasting at least 60 days, until the final menstrual period occurs

Perimenopause symptoms and treatment

Symptoms of menopause usually start sparingly and then become more common as time goes on. As one goes through longer periods without menstruation and lower oestrogen levels, symptoms like irregular periods and changes in bleeding patterns may show up early. These symptoms are usually most noticeable and intense during the first 1 to 2 years after the final menstrual period.⁴ Mental health issues like depression are typically linked with severe hot flashes and worse sleep due to these common symptoms interacting with each other.³

Hot flashes

• Hot flashes, also known as vasomotor symptoms (VMS), affect the majority of those undergoing the menopause transition and can significantly impair their quality of life
• They typically last a few minutes and start with a warm feeling that spreads across the upper body. These symptoms happen because the body's temperature suddenly rises, causing blood vessels to widen
• On average, hot flashes stick around for about 4 to 5 years, but for some, they can last as long as 10 years ^1,2,3,4 

Treatment of hot flashes

Hormonal treatment

Hormone replacement therapy (oestrogen) is the most effective and first-line treatment for the management of hot flashes not associated with a mood disorder.^2,4 

Non-hormonal treatment

The only FDA-approved non-hormonal treatment for moderate to severe vasomotor symptoms is the selective serotonin reuptake inhibitor (SSRI) namely paroxetine. 

Other options include:²

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) 
• Clonidine 
• Gabapentinoids 
• Oxybutynin

Sleep disorder

• Poor sleep becomes more common during perimenopause, not only in association with the menopausal transition but also with ageing.³ Sleep disturbances have been associated with hot flashes. The more severe the hot flashes, the more likely it may lead to insomnia (sleeplessness)¹ 

Treatment of sleep disorder

Hormonal treatment

Patients starting hormone therapy and experiencing sleep disturbances may find bedtime micronised progesterone preferable due to its sedative effects from its binding to γ-aminobutyric acid (GABA) receptors.² 

Non-hormonal treatment

GABA agonists such as zolpidem, certain benzodiazepines, and dual orexin receptor antagonists are the first-line drugs for sleep disorders.² Melatonin is also used for sleep disorders.

Genitourinary syndrome of menopause (GSM)

• Genitourinary syndrome of menopause (GSM) encompasses the gradual impact of oestrogen decline on the genitourinary system. Manifestations include vaginal dryness, itching, inadequate vaginal lubrication, discomfort during intercourse, urinary urgency, painful urination, and urinary tract infections (UTIs)
• Alterations in hormonal levels lead to elevated vaginal pH and changes in the microbiome, increasing the susceptibility to urinary and vaginal infections.^2,3

Treatment of GSM

Unlike hot flashes and adverse mood, which tend to improve over time, vaginal dryness, similar to sleep difficulties, does not get better without specific ongoing treatment.¹ 

Hormonal treatment

Vaginal oestrogen products are the most effective at treating GSM, surpassing vaginal lubricants and moisturisers. Another viable option is dehydroepiandrosterone, which is converted to oestradiol and testosterone within the vaginal mucosa. Those experiencing moderate to severe GSM, along with concurrent vasomotor symptoms or osteopenia, may opt for hormone therapy supplemented with additional localised treatment as required.²

Non-hormonal treatment

Lubricants for sexual activity and moisturisers for regular use are considered first-line GSM treatments.²

Mood disorder

• Depressive symptoms are more likely to be reported by those in the perimenopausal phase. This may be due to the changes in oestrogen and progesterone levels during the menopause transition and an increase in life stressors.^1,2 

Treatment for mood disorders

As mood symptoms are related to hormonal fluctuations and symptoms of low oestrogen in perimenopause, hormone therapy improves mood with or without antidepressant therapy.²

Cognitive changes

• Cognitive changes are seen early in the menopause transition. These include challenges with recalling new information, learning and completing complicated tasks, and a shortened attention span.^2,4

Treatment of cognitive changes

Hormonal treatment

When oestrogen hormone therapy was initiated in perimenopause, it was found to protect cognitive performance.⁴

Non-hormonal treatment

Antidepressant medications may result in improved cognition in the perimenopausal phase if one is also experiencing depression.⁵

Decreased sexual desire

• During the menopause transition, a decline in sexual desire is common, multifactorial, and can lead to distress ^2,4

Treatment of decreased sexual desire

Hormonal treatment

Estradiol can modulate central sexual desire and transdermal estradiol improves libido and sexual satisfaction in the perimenopausal phase.²

Non-hormonal treatment

Flibanserin, bremelanotide, and off-label bupropion can improve sex drive in this phase with or without depression.²

Behavioural treatments

Sex therapy consists of education about sexual response, communication and negotiation, cultural concerns, and exercises for individuals and couples.² 

Weight gain and metabolic syndrome 

• As menopause approaches, there is a tendency to gain more body fat, especially around the organs, whilst simultaneously losing muscle mass. This shift in body composition, along with problems like difficulty sleeping, stress, and mood changes, can lead to weight gain and even obesity ²

Treatment of weight gain and metabolic syndrome

Oral and transdermal hormone therapy has not been shown to affect weight in the menopausal stage but has been shown to decrease visceral fat and increase lean body mass. Oral hormone therapy showed significant advantages, while transdermal hormone therapy demonstrated modest benefits. Additionally, tailored dietary improvements, increased physical activity, stress management, and improved sleep can promote healthy weight and body composition on an individual basis.²

Irregular and abnormal uterine bleeding

• During perimenopause, experiencing frequent, heavy, prolonged, or irregular bleeding is not normal and should be checked by a doctor for further evaluation ²

• In the early menopause transition, short cycle intervals (fewer than 21 days) are more common, while long cycle intervals (more than 36 days) occur later in the transition ⁶

Treatment of irregular and abnormal uterine bleeding

Irregular bleeding can be troublesome and may result in low iron levels and anaemia. To address benign causes, hormone treatments like progestogen courses, combined hormonal contraceptives (CHC), progestin-only pills, and progestin intrauterine devices can be used. Non-hormonal treatments include nonsteroidal anti-inflammatories and tranexamic acid.² 

Headache 

• Perimenopause is often associated with frequent experiences with headaches, which could be caused by  hormonal fluctuations ³

Treatment of headache

Patch use may be a more effective treatment for headaches than oral formulation, because of the insurance of a more constant oestrogen level.³ 

Bone loss

• Oestrogen helps to keep our bones strong by slowing down the process of bone loss. When oestrogen levels drop during menopause, bone loss speeds up, which can lead to a condition called osteoporosis, where bones become weaker and more prone to fractures.^2,4

Treatment for osteoporosis

Different treatment options for osteoporosis include:

• Oestrogen 
• Raloxifene 
• Bisphosphonates 

Oestrogen is considered for prevention, but not for the treatment of osteoporosis as it is not as effective as other therapies for this degree of bone loss.² 

Frequently asked questions

What is the best treatment for perimenopause?

The most effective treatment for alleviating hot flashes and night sweats during perimenopause and menopause remains systemic oestrogen therapy. This treatment is available in various forms including pills, skin patches, sprays, gels, or creams.

What are some common symptoms of perimenopause?

Common symptoms include irregular periods, hot flashes, sleep disturbances, mood swings, vaginal dryness, decreased libido, weight gain, and cognitive changes.

How can sleep disturbances during perimenopause be managed?

Hormonal treatments such as bedtime micronized progesterone or non-hormonal options like GABA agonists (e.g., zolpidem), benzodiazepines, or melatonin can be used to manage sleep disorders.

What treatments are available for genitourinary syndrome of menopause (GSM)?

Hormonal treatments like vaginal oestrogen products or dehydroepiandrosterone can be effective for GSM. Non-hormonal options include lubricants and moisturisers for vaginal dryness.

Summary

Perimenopause, the transition to menopause, brings about various symptoms like hot flashes, sleep issues, mood swings, and more. Treatment includes hormonal therapies like oestrogen replacement and non-hormonal options such as SSRIs for hot flashes, and GABA agonists for sleep disorders. 

Vaginal oestrogen products and lubricants help manage genitourinary symptoms, while mood disorders may require hormone therapy and antidepressants. Cognitive changes can be addressed with hormone therapy or antidepressants, and sexual dysfunction with hormone treatments or therapy. Lifestyle adjustments like diet, exercise, and stress management can help with weight gain and metabolic issues. Irregular bleeding and headaches have hormonal treatment options, and osteoporosis can be managed with medications.