Don’t ignore perimenopause

We agree with Lega and colleagues1 that menopausal hormone therapy (MHT) has been shown in randomized controlled trials (RCTs) to be effective and safe for treating problematic vasomotor symptoms related to menopause. We also agree that treating menopausal vasomotor symptoms is important to decrease later life risks for heart disease and osteoporotic fracture. For women or people born with ovaries who do not wish to, or cannot, take estrogen-based therapy for vasomotor symptoms, oral micronized progesterone has been shown to be both effective and safe in menopause in an RCT, but this practical information was not provided in Lega and colleagues’ review.1^,2

Perimenopause is hormonally and experientially different than both premenopause and menopause. Those experiencing perimenopause have higher, and more erratic and unpredictable, estrogen levels3 and lower progesterone levels,4 compared with the premenopausal period. Symptoms associated with perimenopause often include heavy or frequent menstrual flow, sore breasts and migraine headaches that are likely related to these hormonal changes.

Estrogen (in MHT) will not reliably suppress perimenopausal estrogen levels; no RCT data have shown that MHT is effective or safe for perimenopausal vasomotor symptoms. Yet, night sweats and sleep problems are major concerns among people in perimenopause, often start when cycles are still regular and should be appropriately treated.

A recently published RCT involving 189 perimenopausal participants from across Canada offers promising evidence; oral micronized progesterone (300 mg/d at bedtime) significantly decreased perceived perimenopausal night sweats and improved sleep quality, compared with placebo.5