Perimenopause Symptom Management is Never One-Size-Fits-All, Says Menopause Expert

Unlike menopausal hot flashes and night sweats, which have well-established treatment protocols, perimenopausal symptom management requires a highly individualized approach, Marla Shapiro, CM, CCFP, MHSc, professor in the Department of Family and Community Medicine at the University of Toronto, said in a recent interview with Patient Care.^© Shapiro, who was presenting during The Menopause Society 2025 Annual Meeting, in October, explained that the fluctuating hormone levels and unpredictable symptoms that characterize this transition mean that treatment must be tailored to each woman's specific needs.

The first question she asks when considering pharmacotherapy for perimenopause symptoms is crucial to guiding the treatment decision, Shapiro emphasized. "'What is your most bothersome symptom? Is it the menstrual irregularity? Is it the hot flashes and night sweats?' In perimenopuase management, there is no one-size-fits-all." The well worn admonition to "meet the patient where they are" is idea in this situation.

In the segement above from our longer interview above, Shapiro discusses the range of options clinicians have to help meet each woman's particular needs.

The following transcript has been lightly edited for style and flow.

Patient Care: So how should perimenopause symptoms be managed? Is pharmacologic treatment at this stage recommended, or does it depend on the case?

Shapiro: So I think firstly, that you want to know, and I often will say to women, what is your most significant symptom? What is bothering you the most? Is it the menstrual irregularity? Is it the hot flashes and night sweats? On perimenopause, there is no one-size-fits-all.

It's not like hot flashes and night sweats in post-menopausal women where we're typically going to look at, for most women, menopausal hormone therapy. Management really has to focus on that primary symptom relief. So the first thing that I'll say is, please tell me what is your most significant symptom. If there was one thing that we're going to work on today, what is it?

Certainly it's a great time to talk about lifestyle adjustment, and it's a "never too late" mentality, as far as I'm concerned.

So what are the options? The options can be a low-dose birth control pill if there's menstrual irregularity and contraception is still an issue. Remember, we can use menopausal hormone therapy, but that sometimes can make the bleeding profile even worse. It won't suppress the woman's own estrogen. So sometimes you're adding estrogen onto very irregular, fluctuating estrogen, and you get what are called luteal out-of-phase cycles—these loop cycles—and you can make things completely worse. So that can be an issue.

SSRIs, SNRIs, low-dose antidepressants, are used off-label for the management of hot flashes and night sweats in some women. But in terms of perimenopausal management, there is no definitive pathway that we use.

If you're going to use menopausal hormone therapy, then typically we'll use cyclical, combined menopausal hormone therapy. But you have to keep at the back of your mind that contraception is still an issue for these women, so you're going to have to individualize what you do.

But often the mainstay will be low-dose contraception in a woman up until the average age of menopause, or it may be using cyclical hormones. It really is going to be very individualized in this particular phase of a woman's life.