HRT in Perimenopause: Who’s a Candidate, Who Needs Contraception, and What to Avoid

Perimenopause basics
 

Perimenopause is the transition period—the months to years before menopause—when ovarian hormones fluctuate and cycles become irregular. During this time, many patients ask their primary care nurse practitioner (NP) about hormone therapy (HRT). For the right candidates, HRT is safe and highly effective for vasomotor and genitourinary symptoms.

The challenge: deciding who can use which therapy, whether contraception is still required, and what alternatives to consider if HRT is contraindicated.

This step-by-step workflow is designed for primary care NPs who want a clear, clinic-ready guide.

Step 1 — Do They Still Need Contraception?

• Most patients can stop contraception by ~age 51

• Ask about sexual activity, partner vasectomy, or tubal ligation.

• Important: HRT is not contraceptive. If pregnancy is possible, prioritize contraception first, then layer in symptom management as appropriate.

Best contraception options in perimenopause:

• Levonorgestrel IUD → excellent for bleeding control; can be paired with systemic estrogen (like the estradiol patch) if needed.

• Progestin-only methods → POP (Slynd or norethindrone) 

• Combined hormonal contraception (CHC) → if eligible; improves cycles and vasomotor symptoms.

Step 2 — Are They a Candidate?

A) Contraindications to Combined Hormonal Contraception (CHC)

(Pill, ring, patch)

• Age ≥35 + smoking ≥15 cigarettes/day

• Multiple major ASCVD risks (DM, HTN, smoking, older age)

• Uncontrolled hypertension

• History of VTE/DVT/PE

• Ischemic heart disease or stroke

• Complicated valvular disease

• Current or past breast cancer

• Severe liver disease/cirrhosis, hepatic tumors

• Migraine with aura

• Diabetes ≥20 years or with end-organ disease

👉 If CHC is contraindicated, choose non-estrogen contraception (IUD or progesterone only pill) and manage symptoms separately (e.g., transdermal estradiol + micronized progesterone if systemic estrogen is appropriate).

B) Contraindications / Cautions for Menopausal Hormone Therapy (HRT)

(Estradiol patch, gel, or tablet ± progestogen)

Absolute contraindications:

• Hormone receptor–positive breast cancer

• Active liver disease

• Prior stroke, VTE, or known thrombophilia

• Unexplained vaginal bleeding

• High-risk endometrial or ovarian cancer

• Recent MI

Use with caution / optimize first:

• High ASCVD risk → prefer transdermal estradiol (lower VTE risk than oral).

• Uncontrolled HTN, hyperlipidemia, or poorly controlled diabetes.

• Active smoking.

• Age ≥60 or >10 years post-menopause (initiation usually not preferred).

Decision Flow for NPs

1. Still need contraception?

   • If CHC eligible → consider CHC for both contraception + symptom relief. 

   • If CHC contraindicated → non-estrogen contraception (POP or IUD) + symptom treatment. Consider estradiol patch if appropriate. 

2. No contraception needed (post-menopause or permanent contraception):

   • If symptomatic and no contraindications → consider HRT (prefer transdermal estradiol + micronized progesterone if uterus present).

   • If high risk → non-hormonal therapies (SSRIs/SNRIs, gabapentin, fezolinetant) ± local vaginal estrogen for GSM.

Non-Hormonal & Alternative Options

• Vasomotor symptoms: SSRIs (paroxetine, escitalopram), SNRIs (venlafaxine), gabapentin, fezolinetant.

• Genitourinary syndrome of menopause (GSM): low-dose vaginal estrogen (tablet, cream, or ring)—minimal systemic absorption; progestogen not required.

• Cycle control + contraception when CHC not an option: IUD + transdermal estradiol.

Practical NP Pearls

• Transdermal estradiol → lower risk of VTE compared with oral.

• IUD provides endometrial protection if paired with systemic estrogen.

• Always start low, titrate to the lowest effective dose.

• Avoid starting systemic HRT for the first time in patients >60 or >10 years post-menopause.

• Reassess at 4–8 weeks, then annually (earlier if risks change).

Safety Checklist Before Starting

• Screen: BP, BMI, migraines with aura, VTE/stroke/MI history, breast/gyn history, liver disease, smoking, A1c/lipids.

• Confirm up-to-date breast, cervical, and colon cancer screening.

• Pregnancy test if cycles are present.

• Medication review for interactions (anticoagulants, enzyme inducers).

Final Takeaway for NPs

Perimenopause management is more than symptom control—it’s balancing contraception, HRT eligibility, comorbidities, and patient preferences. By following a structured workflow, NPs can confidently guide patients through this transition with safe, evidence-based options.

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