Considerations for systemic MHT in perimenopause
Perimenopause is the 4- to 8-year transitional stage of increasingly irregular menstrual cycles leading up to the final menstrual period, and the first 12 months following the final period. In addition to management of menopausal symptoms, perimenopausal individuals may have specific needs for contraception and management of heavy menstrual bleeding.
Options for systemic hormonal therapies for perimenopausal individuals that provide contraception and regulate bleeding include:
- combined hormonal contraception (CHC) (except if 50 years or older)—a combined oral contraceptive or the contraceptive vaginal ring.
- continuous estrogen-only systemic menopausal hormone therapy (MHT)] plus the 52 mg levonorgestrel-releasing intrauterine device1.
If a perimenopausal individual does not require contraception, additional options include:
- cyclical combined systemic MHT with estrogen and cyclical progestogen
- estrogen-only systemic MHT if the individual has had a total hysterectomy2.
Estrogen-only MHT can be used by most individuals who have had a total hysterectomy. Addition of a progestogen is required for individuals with endometrial tissue. This may include individuals who have had a total hysterectomy, but who have significant endometriosis, to prevent stimulation of endometrial deposits and malignant transformation; seek specialist advice. See also Systemic MHT in individuals with endometriosis.
Combined continuous MHT, tibolone and conjugated estrogens+bazedoxifene are not advised in the perimenopause because they can cause breakthrough bleeding. However, combined continuous MHT can be considered after 1 year of cyclical MHT if withdrawal bleeding is becoming lighter.
Mood swings, depressive symptoms and major depression become more prevalent in perimenopause; risk factors include a past psychiatric history, younger age, adverse life events and socioeconomic factors. Treat depressive symptoms or depression as for depression in adults. Continuous or extended use of CHC may benefit premenstrual syndrome and premenstrual dysphoric disorder. Systemic MHT has not demonstrated consistent benefit for mood.