Perimenopause 101 for Primary Care NPs: Symptoms, Work-Up, and First-Line Treatment Options (Including HRT)

Perimenopause is getting the attention it deserves. Many patients want to talk hormone therapy (HRT)—and for the right candidates, it’s safe and very effective for symptom relief.

What Is Perimenopause?

The months–years before menopause (final menstrual period), when ovarian estrogen and progesterone decline and become erratic.

Common symptoms: hot flashes/night sweats, sleep problems, mood changes, vaginal dryness, decreased libido, weight gain/redistribution, cycle changes (length, flow, frequency).
Average duration 4–6 years (can be up to ~10). Average menopause age ~51 (range ~48–58). PMDD may flare.

Do We Need “Hormone Labs”?

Usually no. Ovarian hormones fluctuate wildly in perimenopause; a “normal” value doesn’t rule it out.

When to draw labs (targeted):

• To rule out other causes of symptoms or bleeding changes: TSH, prolactin, pregnancy test (still ovulating!).

• If considering other diagnoses or if the clinical picture is atypical.

Teach patients: symptoms can be perimenopause even if labs read “normal.”

Irregular or Heavy Bleeding—Don’t Skip the Work-Up

Bleeding changes are common, but heavy/prolonged bleeding needs evaluation:

• Pregnancy test, CBC, TSH ± prolactin

• Pelvic ultrasound

• Endometrial sampling if ≥45 years, or <45 with risk factors/persistent AUB

Who Might Benefit From HRT?

Best candidates are symptomatic, generally <60 years and within ~10 years of menopause, without contraindications. HRT is first-line for vasomotor symptoms and treats genitourinary syndrome of menopause (GSM).

Avoid / use with specialist input if: history of breast cancer or estrogen-dependent malignancy, unexplained vaginal bleeding, active/history of VTE/PE, stroke/MI, severe liver disease, or pregnancy.

If uterus present → add a progestogen with systemic estrogen to protect the endometrium.
No uterus → estrogen alone.

First-Line HRT Options (with practical starter doses)

Systemic estrogen (choose one; tailor to symptoms/coverage):

• Transdermal estradiol patch: 0.025–0.05 mg/day, change twice weekly

• Oral estradiol: 0.5–1 mg PO daily

• Topical gels/sprays: per product (nice for dose-flexing)

Endometrial protection (if uterus present):

• Micronized progesterone (100 mg PO nightly continuous) or

• Micronized progesterone 200 mg PO nightly for 12–14 days/month (cyclic regimen)

GSM (vaginal dryness, dyspareunia):

• Vaginal estradiol tablet 10 mcg twice weekly

• Estradiol ring or low-dose cream
  (Local vaginal estrogen = minimal systemic absorption; no progestogen needed.)

How to start: pick one systemic estrogen + appropriate progesterone (if uterus). Follow-up 4-8 weeks to assess symptom control and adjust.

Counsel: HRT isn’t meant for primary prevention of CVD or dementia; it does improve quality of life and helps bone while used.

Non-Hormonal Options (when HRT isn’t wanted or is contraindicated)

• SSRIs/SNRIs: paroxetine (including 7.5 mg), escitalopram, venlafaxine

• Gabapentin (helpful at night)

• Clonidine (less used due to side effects)

• Fezolinetant (non-hormonal NK3 receptor antagonist for vasomotor symptoms)
  Plus sleep hygiene/CBT-I, exercise, alcohol reduction, temperature layering.

Don’t Forget Contraception

Perimenopausal women can still conceive. Continue contraception until:

• ≥12 months of amenorrhea if ≥50 y (or 24 months if <50 y).
  Useful options that can also help symptoms/bleeding:

• Levonorgestrel IUD (bleeding control + endometrial protection if adding systemic estrogen)

• Progestin-only pill, implant, or copper IUD

• Combined hormonal contraception can help cycles and vasomotor symptoms if no CHC contraindications.

Safety Checklist Before Starting HRT

• BP, BMI, migraine with aura?

• Personal history: breast cancer, VTE/PE, stroke/MI, liver disease, unexplained bleeding

• Family history of early thrombosis or estrogen-dependent cancers

• Med list (enzyme inducers, anticoagulants, etc.)

• Ensure age-appropriate screening is up to date (breast/cervical, colon).

Sample Prescriptions (copy/paste; “may change per insurance formulary”)

Transdermal estrogen + nightly progesterone (continuous):

Vaginal estrogen for GSM:

Pearls (that actually help)

• Transdermal estradiol lowers VTE risk compared with oral—nice for patients with metabolic risk.

• Start low and titrate; the “right dose” is the lowest that controls symptoms.

• If bleeding on continuous therapy in the first 3–6 months, often settles; persistent or heavy bleeding warrants evaluation.

• Reassess 6–12 weeks after starting; then at least annually (or sooner if symptoms/risks change).

• Education beats lab chasing: normal hormones do not exclude perimenopause.

EMR SmartPhrase (paste & tweak)

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Education only; use clinical judgment and local guidelines.

Questions or tricky cases? [email protected]  or DM me on social.