Perimenopause is a clinical diagnosis
According to the Stages of Reproductive Aging Workshop, perimenopause commences with persistent differences in menstrual cycle length by more than 7 days.1 Menopause begins after 12 months of amenorrhea. No laboratory or imaging tests are needed to diagnose perimenopause after age 40 years, given the variability of follicle-stimulating hormone levels during this time and lack of meaningful cut-off values.
Symptoms of hypoestrogenism can start during perimenopause
Fluctuating estrogen levels may cause heavy and irregular bleeding, vasomotor symptoms (i.e., hot flashes and night sweats), mood and memory changes, sleep disturbances, decreased libido, and genitourinary symptoms. These symptoms may precede the last menstrual period by up to 10 years.2
Hormone treatments in perimenopause should be guided by symptoms and need for contraception
Pregnancy can still occur during perimenopause, so contraceptive needs must be addressed. Menopausal hormonal therapy is recommended as the first-line treatment for vasomotor symptoms in perimenopause,3 but those with irregular bleeding or who require contraception may benefit from combined oral contraceptives. Mood disturbances may improve with menopausal hormonal therapy alone, or with serotonin–norepinephrine reuptake inhibitors or selective serotonin reuptake inhibitors. Strong evidence is lacking to support progestogens alone for treating perimenopausal symptoms.
People older than 40 years with new onset of frequent or heavy vaginal bleeding should have transvaginal ultrasonography with endometrial sampling, especially if there are risk factors for endometrial cancer4
Anovulation can cause irregular bleeding in perimenopause and is a risk factor for endometrial hyperplasia and cancer. Other risk factors for endometrial cancer include obesity, exogenous estrogen exposure, hypertension, diabetes, and some genetic predispositions like Lynch syndrome.
Metabolic parameters worsen faster, and more, during perimenopause than after menopause5
Optimizing lifestyle factors during perimenopause (i.e., healthy weight and physical activity) and screening for cardiovascular risk factors are important strategies for reducing the risk of cardiovascular disease in the period after menopause.
Footnotes
Competing interests: Michelle Jacobson sits on advisory boards for Astellas, BioSyent, Duchesnay, Eisai, Knight, Lupin, Pfizer, Canadian Menopause Society, and Menopause Foundation of Canada. She has received honoraria, consulting fees, or both, from Astellas, AbbVie, Bayer, BioSyent, Duchesnay, Knight, Lupin, Organon, Pfizer, and Searchlight, grants or contracts from Health Canada and the Canadian Institutes of Health Research, and support to attend meetings from The Society of Obstetricians and Gynaecologists of Canada. No other competing interests were declared.
This article has been peer reviewed.
References
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