gynecology

Managing Menopause: Perimenopause, Symptoms, and Treatment Options

By Dr. Adeeb Alshahrour · January 30, 2023

Menopause is a single day; perimenopause is the years of change leading up to it, and it is where most symptoms actually happen. Understanding that distinction explains why you can feel awful while still having periods, and why a blood test in your forties often tells you nothing.

(Note: an earlier version of this article repeatedly spelled perimenopause as "per menopause." It is one word — perimenopause — and the error has been corrected throughout.)

The definitions

Perimenopause is the transition. Hormones fluctuate rather than declining smoothly, which is why symptoms can be more erratic and sometimes more severe than after menopause. It commonly lasts 4 to 8 years and can begin in the late 30s. You are still fertile — contraception is still needed.

Menopause is a point in time: 12 consecutive months without a period, diagnosed in retrospect. In the US it typically occurs between 45 and 55, averaging around 51.

Postmenopause is everything after. Vasomotor symptoms usually ease over several years; genitourinary symptoms do not — they progress without treatment.

Early menopause is before 45, and premature ovarian insufficiency before 40. Both warrant specific evaluation and, usually, hormone therapy at least until the average age of natural menopause, for bone and cardiovascular protection.

Surgical menopause, after removal of both ovaries, is abrupt and typically more severe.

Diagnosis

Over 45, with typical symptoms, this is a clinical diagnosis — no blood test required. FSH and estradiol swing so widely during perimenopause that a single measurement can be actively misleading, and a "normal" result does not mean you are not perimenopausal.

Testing is useful mainly under 45, or where the picture is unclear, and thyroid function is worth checking because it mimics much of this.

Symptoms

The well-known ones

Hot flushes and night sweats — the classic vasomotor symptoms, affecting up to 80%
Irregular periods — usually the first sign; often heavier and closer together before they space out
Sleep disruption, with or without night sweats
Mood changes — irritability, anxiety, low mood, tearfulness

The ones nobody warns you about

These are the symptoms people are most surprised by and least likely to raise:

Genitourinary syndrome of menopause — vaginal dryness, burning, pain with sex, urinary urgency, recurrent UTIs. Affects a majority, is progressive, and is the most treatable and least treated of all of them.
Joint and muscle aches — extremely common and usually blamed on age
Brain fog — difficulty with word-finding and concentration. Real, generally temporary, and frightening if you think it means something worse.
Palpitations
Skin and hair changes — dryness, thinning, and sometimes new facial hair
New or worsening migraine
Frozen shoulder, which has a genuine association with this transition
Loss of libido
Weight redistribution toward the abdomen — even when weight itself does not change

Treatment

Hormone therapy

The most effective treatment for hot flushes and night sweats, and it also prevents bone loss.

For healthy people under 60 or within 10 years of menopause, benefits generally outweigh risks. Transdermal estrogen (patch, gel, spray) avoids the clot risk that oral estrogen carries. If you have a uterus, a progestogen is required to protect the endometrium.

There is no fixed stopping date; the decision is reviewed at least annually. See the full practical guide to HRT for types, risks by age, and monitoring.

Vaginal estrogen — separately

If your symptoms are only genitourinary, low-dose vaginal estrogen is the treatment. Minimal systemic absorption, no progestogen needed, usually continued long-term, and appropriate for many people who cannot take systemic HRT — including many breast cancer survivors after discussion with their oncologist.

Vaginal DHEA (prasterone) and ospemifene are alternatives.

Non-hormonal prescription options

For people who cannot or prefer not to take hormones:

SSRIs and SNRIs — paroxetine, venlafaxine, escitalopram. Effective for hot flushes at doses lower than those used for depression. Avoid paroxetine and fluoxetine if you take tamoxifen, which they interfere with.
Gabapentin — useful particularly for night-time symptoms.
Oxybutynin.
Fezolinetant and other neurokinin-3 receptor antagonists — a newer non-hormonal class specifically for vasomotor symptoms, with liver monitoring requirements.
Clonidine — older, less effective, more side effects.

Non-drug approaches with real evidence

Cognitive behavioural therapy for hot flushes and sleep — genuinely effective, and recommended by menopause societies rather than offered as a consolation prize.
Clinical hypnosis has trial evidence for vasomotor symptoms.
Resistance training twice weekly — for bone, muscle, and body composition.
Weight loss, where relevant, reduces hot flush frequency.
Stopping smoking — smoking worsens hot flushes, accelerates bone loss, and brings menopause earlier.
Reducing alcohol — a trigger, a sleep disruptor, and a breast cancer risk factor.
Practical measures: layered clothing, a cool bedroom, a fan, identifying your own triggers.

On supplements and "alternative" therapies

Being honest about this is more useful than being encouraging:

Black cohosh — mixed evidence, mostly no better than placebo. Rare reports of liver injury.
Phytoestrogens and soy isoflavones — small effect at best; whole-food soy is safe.
Evening primrose oil, dong quai, wild yam cream — no good evidence of benefit.
"Bioidentical" compounded hormones and pellets — not FDA-approved, dose consistency not assured, and reviewed unfavourably by the National Academies. Salivary hormone testing to guide dosing is not valid.

Supplements are not regulated as medicines. Tell your clinician what you take — some interact with prescriptions.

When to seek care

Any bleeding after menopause — always, promptly
Periods becoming very heavy, or bleeding between periods
Symptoms disrupting work, relationships, or sleep
Menopause before 45
Low mood that is persistent rather than fluctuating

Talk to us

Menopause is roughly a third of your life. There is no prize for enduring it untreated.

Medical disclaimer

This article is general health information, not medical advice for any individual. Treatment depends on your age, time since menopause, symptoms, and medical history. Bleeding after menopause always needs evaluation before any hormone treatment begins.