Care · 04

Perimenopause and menopause

Perimenopause starts years before anyone names it. The symptoms arrive one at a time and get sent to different people — sleep to one doctor, mood to another, joints to a third, and the whole thing to nobody. It can run a decade.

If your labs are in range and you still feel wrong, that is where we start. A normal result is information, not a conclusion, and it is not the end of the conversation. Symptoms are data too. We are not going to reach for an antidepressant as a first answer to perimenopause, and we are not going to tell you this is just your age.

What we can promise is the attempt: a full history, proper testing, and a plan we keep revising until something works or until we have honestly run out of things to try. Sometimes we do run out. We will tell you that rather than keep you coming back.

What that actually looks like

The approach is multimodal on purpose, because midlife rarely has one cause. Depending on what your history and your labs show, that can include:

• Transdermal estradiol — patch, gel or spray, which avoids the first-pass liver effect and carries a lower clot risk than oral
• Micronized progesterone for anyone with a uterus, dosed to the regimen rather than to a formula
• Vaginal estrogen for genitourinary symptoms — local, low dose, and safe for a great many women who have been told hormones are off the table entirely
• Testosterone where it is genuinely indicated, delivered in a form that can be stopped
• Non-hormonal options for women who can't or would rather not — there are more of these than there used to be, and they are not a consolation prize
• Sexual medicine — desire, arousal and comfort change in perimenopause and after, and this is medicine, so we treat it that way. Prescription options include compounded topicals and oxytocin, filled by a licensed compounding pharmacy and shipped to your door, inside the same visit as the hormone conversation — because it is the same conversation
• Sleep, thyroid, iron, metabolic and bone health worked up properly, because several of these masquerade as perimenopause and one or two of them are the actual answer
• The unglamorous ones — strength training, protein, alcohol, and what actually helps a hot flash at three in the morning. We'll talk about these even though nobody wants to hear it, because for some women they do more than the prescription

We don't do hormone pellets. ACOG recommends against them for testosterone delivery, on the grounds that the safety data isn't there and the pellet can't be removed once it's in. The comparative studies are not close: in one, 20% of pellet patients went on to a hysterectomy for bleeding, against 6% on conventional therapy. They are the most profitable thing we could sell you in this category, and that is part of why you should be careful who is offering them.

To be clear about what that isn't: it is not a position against hormones. We prescribe them, we think they are the right answer for a great many women, and the list above is what we use instead. The objection is to a delivery method you cannot take back out, not to the treatment.