What's in the Menopause Toolbox?

When considering hormone regimens for perimenopause and menopause, many of us think of the combination that is most commonly prescribed: estrogen plus progesterone. This combination serves many women well, but there are several different ways to take hormones, and there are also nonhormonal ways to relieve many midlife symptoms. Your practitioner should have the equivalent of a “toolbox” to utilize so that if one recommended or prescribed treatment does not seem to be working, something else can be added or substituted.

First, when considering a perimenopause or menopause treatment plan, there are two major questions to answer:

1. Am I in perimenopause or menopause? Plans for each phase of life will be slightly different, with different expectations.
2. What is the end goal for our hormonal or non-hormonal therapy plan?

In perimenopause, your ovaries may still be functioning, producing some of the hormones that they were meant to produce during the reproductive years: estrogen, progesterone, and testosterone.

If the end goal for seeking treatment is symptom relief, we need to look at the list of symptoms that are likely to present themselves at midlife.

Hot flashes and night sweats, together known as vasomotor symptoms, can usually be treated safely with estrogen. The most common estrogen treatment is either a pill or a transdermal patch or gel. These are all prescribed as estradiol, which is the type of estrogen that is produced in abundance by the ovaries from the teenage years until your forties. So, taking or using this form of estrogen is considered a “bioidentical” form of estrogen, as it is identical in chemical formula to the type of estrogen naturally produced in the body. Estrogen can also alleviate brain fog, insomnia, mood swings, and fatigue. It protects the bones from thinning and can reduce vaginal dryness.

While estrogen has many benefits, its use should be personalized and individualized. There are many different doses, and they should be prescribed depending on your age, preferences, and severity of symptoms. Estrogen is also responsible for causing growth and thickening of the lining inside the uterus (the endometrium). This is the lining that sheds when you have a menstrual period. In perimenopause, this lining often sheds irregularly, so instead of having a monthly period, there may be skipped, heavier, lighter, or unexpected bleeding as the lining builds and sheds randomly in response to hormonal swings. In menopause, the endometrial lining should not be shedding at all, but estrogen can still cause a buildup if taken by itself (also called “unopposed” estrogen). This is the reason that almost all hormone plans that include estrogen also include progesterone.

The most commonly used progesterone is called micronized progesterone, an oral tablet taken at night before bed. Progesterone helps with sleep and moods, but its most important job is to make sure that the lining of the uterus does not build up too much; it stabilizes and keeps the endometrial lining thin. Women who do not have a uterus, such as those who have had a hysterectomy, need not add progesterone to their hormone plan since they do not need uterine-lining protection. However, some women find the other benefits of progesterone, such as improved sleep and stable moods, appealing and choose to take it alone or in combination with estrogen.

One of the most under-discussed and undertreated symptoms of menopause is vaginal dryness. Now called GSM, or genitourinary syndrome of menopause, this can be chronic and progressive. If it is the only symptom of menopause that you feel, the toolbox contains various ways to offer relief. The standard of care for symptoms of vaginal dryness, irritation, lack of lubrication, itching, and burning that are not related to infection is to use some form of vaginal estrogen. This is also prescribed as estradiol, most commonly in the form of a cream, vaginal insert, or suppository used regularly—usually two to three times a week—at bedtime on an ongoing basis. It can relieve common GSM symptoms in as little as two weeks. It may still be recommended to use a lubricant or moisturizer for sexual activity, but vaginal estrogen will actually change the tissues in the genital area, making them thicker, more elastic, and more comfortable when estrogen is used regularly and continuously.

What About Non-hormonal Options?

Not every woman wants to or is a candidate for hormonal therapy, and this is one area where the personalization of treatment becomes especially important. Depending on your medical history and symptoms, sometimes specific medications designed to treat mood swings, depression, and anxiety are indicated. Some of these medications have also been shown to treat hot flashes, night sweats, and low energy. If the main symptoms that have plagued you since entering perimenopause seem like an exacerbation of earlier mental health issues, such as PMS (premenstrual syndrome) or PMDD (premenstrual dysphoric disorder), hormones may not be the recommended treatment pathway. In this case, medications such as SSRIs or SNRIs, both serotonin medications, might offer the most benefit while possibly treating some menopausal symptoms as well. Also, if your history contains certain cancers or blood-clotting abnormalities, specific hormones may be considered to have more risk than benefit—you may want to try the non-hormonal route. A personalized approach is best and safest.

You do not need to start the conversation knowing which, if any, hormone therapy is right for you; you just need to know that you have options. It is a clue that you are in the right place if the practitioner asks a lot of detailed questions during your intake to consider your individual symptoms, history, and needs. Then they can take out their toolbox. The art is knowing which tools to use to offer you the right treatment or combination of treatments that make the most sense for you.