Perimenopausal women need advice tailored to their symptoms and situations.

Introduction

Perimenopause is defined as the time from when symptoms and signs of approaching menopause begin until 12 months after the final period.

It is characterised by irregular cycles (length, volume + pattern of flow) and is the result of erratic hormone secretion by the hypothalamus, pituitary and the ovaries.

Many women experience symptoms of perimenopause and typically present with vasomotor symptoms, a change in their cycles and / or mood disturbance. 

The median age of perimenopause in longitudinal studies is between 45.5 and 47.5 years, and the mean duration estimated at between 3.8 and 6.25 years ^{1, 2}. Early perimenopause is
characterised hormonally by a fall in inhibin B and clinically by a change in cycle frequency. 

By late perimenopause further hormonal changes include a rise in FSH levels and falls in oestradiol and inhibin A, and clinically women have skipped cycles and extended lengths of
amenorrhoea ^{3, 4}.

Diagnosis

Diagnosis is a clinical one, based on a change in cycles (frequency, length, amount of flow), the presence of vasomotor or genito-urinary symptoms, and a lack of other pathology (e.g. thyroid disease). 

Other clinical features may include low mood, anxiety, irritability, poor memory or concentration, ‘foggy’ thoughts, fatigue, sleep disturbance, migraine, joint aches and pains, headache, mastalgia and sexual dysfunction.

Diagnosis of perimenopause does not rely on measurement of levels of oestradiol or FSH, as these will continue to fluctuate throughout perimenopause.

Symptom Management

Symptom management will depend on the woman’s past medical history, the symptoms experienced by the individual and how these affect their sleep, general functioning and quality of life.

In non-smokers the combined oral contraceptive pill may be used until the age of 50 years, with the transition to a low-dose pill being a reasonable approach in the mid to late 40s.

Hormone replacement therapy in any form is also an option, and for women with an intact uterus this should consist of continuous oestrogen and sequential progestogen administration, aiming for a regular withdrawal bleed.

If a continuous delivery of progestogen is given, erratic bleeding will probably ensue.

Similarly Tibolone should be avoided until women have extended amenorrhoea after menopause.

Mirena is a good option for women who require contraception and / or have menorrhagia; systemic oestrogen may be easily added to this treatment. 

In women in whom hormonal treatment is contra-indicated or if mood disturbance is prominent, several of the SSRI or SNRI agents may be beneficial for control of vasomotor symptoms ⁵.

Other non-hormonal alternatives for vaso-motor symptom control are clonidine or gabapentin ⁶.

Black cohosh may also be a short-term option for vasomotor symptom control.

Where genito-urinary symptoms predominate, regular use of vaginal oestrogens or alternatively vaginal moisturisers such as Replens may be useful.

Contraception

Approximately one third of cycles remain ovulatory in perimenopausal women, so contraception is still an issue.

For those who do not desire pregnancy contraception should be advised for women younger than 50 years until they have been amenorrhoeic for 2 years, and for women 50 years and over, for 12 months after their last period.

Options for contraception will vary with the individual situation but include barrier methods, the combined oral contraceptive pill, Mirena, Implanon, NuvaRing or permanent measures such as tubal ligation or vasectomy.

Disease Prevention

Disease prevention is an important future goal, as postmenopausal women are at increased risk of lipid abnormalities, weight gain, cardiovascular disease, osteoporosis and cognitive decline.

Perimenopause is an excellent opportunity to address these issues as women often present to medical practitioners for advice about symptoms.  Regular screening investigations such as Pap smear and mammogram should be advised, it is also a good opportunity to check blood pressure and look at lipid profile. 

The importance of maintaining a healthy diet, to do regular weight bearing exercise and to avoid excessive weight gain, alcohol excess and cigarette smoking should be discussed.

Another important part of the management of perimenopausal women is providing advice about where to seek further help, and a number of websites with links to excellent references for peri- and menopausal women are provided below.

Resources/Websites

www.jeanhailes.org.au
www.healthforwomen.org.au
www.managingmenopause.org.au
www.menopause.org.au - Australasian Menopause Society
www.menopause.org – North American Menopause Society  

 Talking Women Perimenopause  166.50 Kb

References

1. Treloar AE. Menstrual cyclicity and the pre-menopause. Maturitas. 1981 Dec;3(3-4):249-64

2. McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas. 1992 Jan;14(2):103-15

3. Burger HG, Dudley EC, Hopper JL, Shelley JM, Green A, Smith A, et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab. 1995 Dec;80(12):3537-45

4. Soules MR, Sherman S, Parrott E, Rebar R, Santoro N, Utian W, et al. Stages of Reproductive Aging Workshop (STRAW). J Womens Health Gend Based Med. 2001 Nov;10(9):843-8.

5. Stearns V. Serotonergic agents as an alternative to hormonal therapy for the treatment of menopausal vasomotor symptoms. Treat Endocrinol. 2006;5(2):83-7.

6. Rada G, Capurro D, Pantoja T, Corbalan J, Moreno G, Letelier LM, et al. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane database of systematic reviews (Online). 2010(9):CD004923.

Content Updated 19 July 2011