COMMENTARY

When Menopause-Like Symptoms Start Early

Andrew M. Kaunitz, MD

Disclosures

August 26, 2021

This transcript has been edited for clarity.

Perimenopausal status (also known as entry into the menopausal transition) is defined by menstrual changes in age-appropriate women.

However, symptoms characteristic of perimenopause, including sleep disruption and hot flashes, often start prior to the occurrence of menstrual changes. This earlier time period is referred to as the late reproductive stage (LRS).

Starting in 2018, an evidence-based website has encouraged women aged 34-55 years who tracked their menses to contribute information regarding their symptoms by completing a detailed survey. Among all respondents, more than 900 met criteria for LRS and almost 600 for perimenopause. The mean age of LRS and perimenopausal respondents was 46 and 50 years, respectively. Overall, 80% of respondents had a college degree or had attended graduate school; 69% were White, 5% Hispanic, 3% Black, and 2% Asian.

For most of the symptoms assessed, including sleep disruption, mood changes, headaches, brain fog, and dizziness, the proportion of women in the LRS and perimenopause groups reporting these was similar. Among perimenopausal women reporting hot flashes, night sweats, palpitations, or mood symptoms, the daily frequency of these symptoms was higher than in LRS women. The only symptom rated by one group as significantly more bothersome was hot flashes, which caused more distress among perimenopausal women.

A limitation of this web-based survey is that few women from ethnic minorities or those with low educational attainment were included. Accordingly, it's not clear how generalizable these findings are. Nonetheless, this report suggests that symptoms we have previously attributed to perimenopause often occur prior to the onset of menstrual changes.

Let's turn to symptom management. In my experience, for many women, simply learning that their symptoms are common, even among women who have not yet experienced menstrual changes, may be reassuring and no pharmacologic treatment may be needed.

However, when symptoms are bothersome and cannot be attributed to another condition, such as thyroid disease, hormonal management should be considered.

If no contraindications are present, off-label use of combination estrogen-progestin contraceptives, including pills, patches, and rings, can reduce bothersome perimenopausal — and presumably LRS — symptoms. In women who are not candidates for combination contraceptives, off-label use of lower-dose estrogen-progestin formulations indicated for use in postmenopausal women may be helpful. Alternatively, placement of a progestin-releasing IUD combined with off-label estrogen therapy may reduce or eliminate perimenopausal symptoms.

Thank you for the honor of your time. I am Andrew Kaunitz.

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