Perimenopause Patient Guide

Perimenopause vs Menopause

Perimenopause is the transitionary period leading up to menopause (when periods stop). Perimenopause can start as early as the 30’s and last until the 50’s. During the peri stage, estrogen and progesterone levels steadily decline, leading to bothersome symptoms. During menopause, the ovaries stop egg production and hormone secretion and periods stop. Symptoms in menopause tend to be more severe. Menopausal symptoms can last around 7-10 years and then symptoms typically subside. 

Hormonal Changes

Estrogen

Created by the adrenal glands, the ovaries and fatty tissue, estrogen’s function ranges from controlling menstrual cycles, aids in breast development during puberty, maintains bone density, protects the heart, hydrates the skin and promotes healthy hair, and keeps the urinary tract and pelvic muscles functional.

Dips in estrogen can lead to:

• Difficulty losing weight

• Fatigue

• Infertility

• Thinning of hair/skin/nails

• Vaginal dryness and atrophy

• Weight gain around the midsection

• Increased risk of cardiovascular disease, elevated cholesterol

Progesterone

Progesterone is a steroid hormone produced in the ovaries after ovulation. It balances estrogen and prepares the uterus for implantation. 

Decreases in progesterone can lead to:

• Irregular periods

• Hot flashes

• Night sweats

• Increased risk of osteoporosis

• Mood changes

Testosterone

Produced in the ovaries and adrenal glands, testosterone plays many important roles in women. Testosterone helps with libido, muscle mass, bone strength, brain health and memory, and energy. 

Low testosterone can cause:

• Fatigue

• Low libido

• Brain fog/difficulty focusing

• Low bone mass

• Decreased muscle mass/strength

Diagnosing Peri/Menopause

Many individuals have inadequate hormone levels despite technically “normal “blood tests. The diagnosis and treatment will involve many components including your symptoms, confounding medical issues or medications, blood levels, physical exam, response to therapy, possible side effects, individual reaction/response to therapy, and other information. Your blood levels may fall into “normal” lab reference ranges, which may not in our opinion, reflect your deficiency.

Main Hormones Tested

FSH: Follicular stimulating hormone. This hormone is released from the pituitary and 

increases dramatically during menopause. During perimenopause, this hormone can fluctuate and is not usually high.

DHEA-S: Produced by the adrenal glands, this hormone is a precursor to estrogen and testosterone and supports sexual desire and arousal. 

Estradiol & Progesterone: Fluctuations throughout the cycle during perimenopause, low during menopause.

Testosterone Total & Free: The total amount of testosterone that is produced and the free testosterone that is not bound by proteins (free to be used).

Vitamin B12 & D: Common deficiencies that can cause fatigue and brain fog.

Other Tests

Mammogram: To screen for abnormalities and cancer prior to starting hormone 

replacement.

Bone Density Test: Also known as a DEXA scan to check for osteopenia and 

Osteoporosis.

Pap/pelvic exam: Not required but we recommend completing to stay up-to-date on regular screenings.

Hormone Treatment 

There are many treatment options for peri/menopause. Whether a woman has an intact uterus or has had a hysterectomy (non-intact uterus) is key to medication management. 

Combined Therapy (Intact Uterus) 

If a woman is still having periods, even if irregular, cyclic combined therapy is recommended. This means estrogen is taken constantly and progesterone is taken on days 16-28. Progesterone is administered on certain days to prevent the uterine lining from growing too much (endometrial hyperplasia). This mimics a natural cycle. 

If a woman’s periods have stopped, progesterone can be taken daily without breaks. This is called continuous combined therapy.

We prefer bioidentical estrogen and progesterone products. These types of products are chemically similar to the hormones women naturally produce and tend to be better tolerated. Biological products are made from plants. 

Combined therapy can look like:

Combipatch (combined estradiol and progestin) placed on the skin twice weekly

Estradiol patch & micronized progesterone oral capsules 

Estradiol oral pill & micronized progesterone oral capsules

Estrogen-Only (Non-Intact Uterus) 

For a woman that has had a hysterectomy, estrogen-only therapy may be used. Some women may still be prescribed progesterone for symptom-management.

Estrogen-only therapy can look like:

Estradiol oral tablets

Estradiol patches

Hormone Contraindications & Side Effects

Contraindications

• History or suspected breast cancer

• Estrogen-based cancer (uterine), women with hysterectomy and no remaining evidence of cancer are eligible

• DVT (active or history), PE (pulmonary embolism)

• Clotting disorder

• MI, stroke

• Chronic liver disease or dysfunction

• Pregnancy

Side Effects

• Vaginal spotting/bleeding (usually stops within 6 months)

• Breast tenderness (temporary)

• Bloating

• Abdominal pain

• Estrogen specific: nausea, dizziness, mood changes, headache. Topicals cause less nausea- no effect on cholesterol

• Progestin specific: mood disturbances, spotting