Navigating Perimenopause: Understanding and Managing Symptoms
Perimenopause can be challenging to treat because, unlike the flat low estrogen levels that occur after menopause, hormone levels during perimenopause fluctuate significantly. This rollercoaster of hormones, with peaks sometimes higher than normal and troughs lower than normal, causes many of the symptoms associated with perimenopause.
The Hormonal Rollercoaster
Higher hormone levels may lead to symptoms like sore breasts, mood changes, and fatigue, while lower hormone levels often cause more traditional menopause symptoms such as hot flashes and poor sleep. These fluctuations occur because there are still egg reserves (follicles) in the ovaries. When hormone levels are low, the brain sends extra LH and FSH to the ovaries, which can result in higher hormone levels the following month, continuing the cycle of ups and downs.
Traditional HRT and Perimenopause
Traditional hormone replacement therapy (HRT) involves adding low-dose estrogen (and progesterone if the uterus is intact) and is highly effective for managing post-menopausal symptoms. However, in perimenopause, HRT may only slightly reduce the lows without affecting the peaks and fluctuating hormones. If symptoms persist despite HRT (e.g., topical estrogen and cyclical progesterone), my preference is to turn off ovulation completely. Once menopause occurs (with flat low hormones), I transition to traditional and safest HRT with topical estrogen.
Alternative Options for Perimenopause
A low-dose combined oral contraceptive pill is safe for most women, provided there are no risk factors for DVTs (smoking, obesity, past DVTs), migraines, or high risk for breast cancer. For those who cannot take the pill due to DVT or migraine risk, the progestogen-only pill Slinda, which contains Drospirenone, can turn off ovulation. This can be started with extra topical estrogen to provide the same perimenopause symptom relief.
When HRT Might Not Help
If HRT does not alleviate perimenopause symptoms, it may be because the symptoms are not actually caused by perimenopause. Perimenopause is often a clinical diagnosis, and some symptoms can be quite non-specific. If symptoms do not improve with HRT or the pill, other potential causes should be considered.
By understanding the complexities of perimenopause and exploring various treatment options, women can better manage their symptoms and improve their quality of life.