Grand Rounds: The art and science of managing perimenopause

In the early days of daytime talk show television, Phil Donohue used to discuss menopause as if it were an overnight phenomenon: You go to bed premenopausal one night, and wake up the next morning postmenopausal. Unfortunately, it's not that easy. For many women, symptoms are the most annoying during those years surrounding the last menstrual period.

Adding insult to injury, patients often become frustrated because we can't even tell them they're perimenopausal. Menopause is itself a retrospective diagnosis. When a woman goes a year without a menstrual period, you can tell her she is now postmenopausal. Patients eagerly purchase home testing kits to check urinary or salivary FSH, and are disappointed when they find out that the test is meaningless: You don't need a significantly elevated FSH to say to a 53-year-old woman who hasn't had a period in 4 months and is having lots of hot flashes that she is perimenopausal. Similarly, elevated FSH will not tell her that she will have no more menstrual periods. Not until the STRAW study (Study of Reproductive Aging Workshop), in 2001, was an official nomenclature even established to define perimenopause. It was defined as the variable-length time frame during which menses become more erratic (greater than 7 days different from normal), and lasting through the 12 months of amenorrhea from the last menstrual period.¹

As you may already realize, perimenopausal management is significantly more complicated than postmenopausal management. With that in mind, we'll consider three different patients presenting during this time frame, and discuss approaches to the management of each.

Among the first questions I would ask this patient is, "Do you still plan to get pregnant?" Is her family complete, or is she just getting ready to start? I would also like to know for how long this menstrual pattern persisted, and is she charting her cycles? How heavy are the menses now, compared to her previous typical menses? Has she noted any other physical symptoms (fatigue, constipation, or hair loss) that might suggest other systemic disorders, such as hypothyroidism? Is she a high-risk candidate for endometrial cancer, i.e., is she obese, diabetic, hypertensive, or nulliparous?

My evaluation strategy is always based on Sutton's Law: Go where the money is.² After a thorough exam, I would check TSH levels to rule out hypothyroidism, and would check her endometrium to rule out pathology. (This can be done by your procedure of choice: sonohysterography, simple ultrasound, or biopsy.) I would obtain a day 3 FSH level if Ms. Abrams were hoping to conceive. If the level were elevated, I would have her see a reproductive endocrinologist and if FSH weren't elevated, strongly encourage her to accelerate her childbearing plans. If this patient were done with her childbearing, I wouldn't check FSH. Although 40 years of age is certainly a bit early for perimenopausal changes, it's not unusual; at least 1% of women are menopausal by age 40. Lastly, it's wise to run a CBC to make sure that this more frequent flow has not rendered her anemic.

If Ms. Abrams has a normal endometrium and normal thyroid function-the likely scenario-the next thing to do is to reassure her that she is indeed normal, and to discuss the physiology of perimenopause. Explain that declining levels of progesterone most likely account for her changing menstrual pattern. You then need to explore what she would like. For many women, just the reassurance that they are normal is sufficient, and they will not want medical intervention (i.e., they are happier having 21-day cycles than taking medication). For women who are annoyed by their cycles, low-dose OCs are usually the best tolerated and most successful approach to this problem. Obviously, smokers and women with a history of thrombophlebitis and certain rarer medical conditions are not candidates. But for the typical healthy 40-year-old, OCs are your best bet.