It’s Perimenopause. What Are Ya Gonna Do About It?

Medically reviewed by Dr. Tamara Neuhaus MD

You're sitting in a staff meeting, sweating bullets. You're not the one giving the presentation. It's mid-winter and you're wearing a sleeveless dress. Three months ago you were the person who kept a space heater on under her desk, year-round. What on earth is happening? 

More importantly, is there anything you can do about it? 

The answers are: Perimenopause, and (thankfully) Yes.

In fact, there’s a plethora of treatment options out there for you. But one of the biggest barriers to comprehensive perimenopause care is that many women—and doctors—aren’t aware of all the effective treatment tools available to you. At The Cusp, we’ve assembled a clinical team of menopause experts representing diverse medical disciplines. From Gynecology to Psychiatry to Naturopathy, we know every evidence-based trick in the book for treating perimenopause symptoms, and some that seem effective and need more research. The bottom line is that whether you’re medication-averse or you pop a pill at the first sign of discomfort, you don't have to be relegated to a lower quality of life; your symptoms can be managed. 

Let’s start with a few examples that help show how one symptom—hot flashes—can be treated differently for different women.

Angela explains, "I'm starting to get hot flashes. They're uncomfortable and embarrassing, especially at work. And I'm finding it a bit stressful." She could start with modest lifestyle changes—increase her vegetable intake, eliminate caffeine, alcohol and spicy foods, start meditation or yoga, dial-up her exercise routine slightly—and possibly add an herbal treatment like black cohosh. 

Shondra shares, "I'm having some hot flashes, too. But I also find myself crying for no reason. The things that used to give me joy don't anymore, and I'm struggling to sleep." Her hot flashes aren’t really that bothersome, so she could follow the same course as Angela. But her emotional state and sleeplessness are weighing heavily on her. In Shondra’s case, a prescription for a mood stabilizer like an SSRI or SNRI could be added to her treatment plan. 

Preeti says, "My hot flashes are wreaking havoc on my work life and sleep. I have to excuse myself from meetings to cool off. I’m constantly waking up to kick off my covers or pull them back on. Sometimes I even have to change my sheets in the middle of the night. It's stressing me out and I feel exhausted and depressed most days." Preeti’s actually experiencing hot flashes AND night sweats. The latter can be even more disruptive than the former because they interrupt your sleep, which can have a negative impact on all aspects of your life. Her cocktail of symptoms and their severity have her near the end of her rope. Presuming she doesn't have a history of breast cancer, liver disease or blood clots, hormone therapy might be her most efficient path to relief.

You can see how, depending on the severity of your symptom, the impact it’s having on your life, which other symptoms are at play, and even your personal preferences, your treatment approach could change. You also probably noticed four distinct avenues for treatment: lifestyle changes, herbal remedies, prescription medications, and hormone therapy. Let’s unpack each of those to get a better understanding of what they are and how they work.

Lifestyle Changes

What are these?

These are modifications you can make with your diet, exercise or sleep routine; and can include incorporating practices like mindfulness and meditation into your day.

How do they work?

These kinds of lifestyle changes can stimulate systems and organs in your body that are being impacted by fluctuating, and eventually decreasing estrogen levels—think slowing metabolism, stiffening joints and muscles, brain fog. They’re basically stepping in when estrogen leaves the building.

Upside?

Your physical and mental health, overall, will likely benefit from these new habits. And you don’t have to worry about any adverse side effects or drug interactions. 

Downside?

Anyone who has ever made and abandoned a New Year’s resolution (i.e.: all of us) knows that lifestyle changes are really hard to make. Baby steps are the name of the game here. Go to bed at the same time each night for a couple of weeks and see how it feels. Get off the bus a few stops early or park at a less convenient parking lot to get more steps in every day. Eat your favorite meals, just dial up the veggie portion and dial down the meat portion. The more you can incorporate your new habits into your daily rituals, the easier it will be to stick with them. Beyond that, it can take time for the benefits of lifestyle changes to kick in. So you don’t get that immediate gratification you may experience with a prescription med. Then there’s the tendency for certain friends to give you grief about giving up alcohol or trading the hangout for a workout. So your social life can suffer.

Herbal Remedies & Supplements

What are these?

Plants, minerals and other organic compounds have been used to treat human ailments for centuries. And there’s evidence that they work to alleviate many of the symptoms associated with perimenopause.

How do they work?

You take them like you’d take a vitamin. Some restore restful sleep patterns, some relieve mood swings, others prevent hot flashes, headaches, or joint pain. There’s a vast apothecary of supplements and herbs that have proven to have positive effects on perimenopause symptoms. 

Upside?

They’re easily accessible, with no prescription required. And the fact that they’re plant or mineral-based is comforting to women who are medicine—or Big Pharma—averse.

Downside?

It can be more difficult to find research on these treatments than pharmaceuticals. The sheer volume of options may be why these treatments haven’t been more thoroughly studied. And finding the right source can be tricky, too. The same remedy can be packaged a dozen different ways, by any number of brands. And some are more trustworthy than others. As with pharmaceuticals, you and your doctor need to be aware of any adverse interactions that a supplement may have with any prescription medications you’re taking.

Hormone Therapy

What is this?

Sometimes called hormone replacement therapy (HRT) or even menopause hormone therapy (MHT), this is the addition of hormones to the body to supplement fluctuating levels. For menstruating women in perimenopause, HT is often prescribed in the form of low-dose birth control pills. Once women reach menopause and no longer have menstrual cycles, HT is usually prescribed as pills, patches, creams, suppositories, and vaginal rings. 

How does it work?

Low-dose birth control pills prescribed during perimenopause help regulate hormone levels throughout the menstrual cycle. After a woman stops having periods, estrogen and progestin are typically prescribed in much lower amounts to relieve the symptoms a woman is experiencing. The delivery methods can be systemically via the bloodstream or directly to the vagina to relieve dryness, pain or urinary issues. 

Here at The Cusp, the hormones and birth control pills we prescribe are all FDA-approved. The HT we choose to prescribe is the FDA-approved bioidentical estrogen, Estradiol, which is synthesized from a chemical found in yams and soy and has a molecular structure identical to the estradiol women make in our bodies. It’s available in a range of products with a prescription. These stand in contrast to the first generation of hormone therapy that was (and still is) made with pregnant mares’ urine (Premarin) or other plants (Cenestin) that are not identical to human hormones. Aside from the obvious benefit of not contributing to animal cruelty, bioidentical hormone levels can be measured in standard lab tests, whereas Premarin cannot. So bioidentical estrogen can be monitored for more precise and individualized treatment. Bioidentical progesterone is synthesized from a plant source and chemically identical to the progesterone that human ovaries produce. 

Upside?

Hormone therapy is very effective in alleviating a broad range of perimenopause symptoms because it’s actually treating the cause—dwindling hormones.

Downside?

Women who have a history of breast cancer, liver problems, personal history of blood clot or abnormal vaginal bleeding are advised not to take hormones. That said, there are enough nuances to this advice that we could write an entire article about it. And in fact, we have. If you’re considering Hormone Therapy, you can dive deeper into your options and the data behind the largest HT study. And of course, our clinical team at The Cusp can answer any HT questions you may have.

Our position on HT is that it’s a great option when prescribed well, by a knowledgeable doctor who considers timing, hormone blend, delivery method, and the nuances of your personal health history.

Prescription Medications

What are these?

Okay, you know what these are. In fact, some of the medications used to treat perimenopause symptoms are commonly used to treat a variety of other health issues.

How do they work?

Antidepressants including SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Selective Norepinephrine Reuptake Inhibitors) work by affecting the system in our brain that regulates anxiety, happiness, and mood. Some of them have proven effective at relieving hot flashes, too. Some anti-seizure meds may be prescribed in very low doses as a treatment for night sweats. And blood pressure meds have shown some effectiveness in reducing hot flashes and migraines.

Upside?

Prescription meds have gone through rigorous trials to ensure their quality, and that their benefits outweigh any side effect risks for most people. They’re FDA approved, and they’re often covered by insurance.

Downside?

Most, if not all prescription meds, have side effects. And because everyone reacts differently to medications, it’s possible that you could be trading one discomfort for another one. But you won’t know that until you try one. The good news is that you have plenty of other options if a prescription isn’t working for you.

Making Sense of it All

Do you feel like suddenly you’ve gone from having nowhere to turn to having too many options? Well, not to worry: you don’t have to choose one route. The best treatment for you may involve a combination of approaches. You and your doctor can work together to suss that out based on your health history, your symptoms, and your personal preferences. Maybe you had a bad experience with hormonal birth control, and don't want to put any more hormones in your body. Or you may think lifestyle changes sound lovely but your schedule is wall-to-wall for the foreseeable future, so adding exercise or meditation into the mix just isn’t an option. If you’re up-front about your boundaries with your doctor, she or he can prescribe effective treatments that feel right for you.

Set Your Expectations

In a perfect world, you and your doctor will nail the exact treatment(s) and dosage(s) on the first try and you’ll be off to the races. In reality, it can take some time to dial in the perfect mix of treatments to alleviate your symptoms. Typically we give each treatment a few weeks to determine how it’s working and how your body is reacting, then we adjust accordingly. And because perimenopause is so dynamic, what’s working for you now could stop working a year from now. Or new symptoms might pop up at any time. So having a doctor to partner with is extremely important, and regular check-ins and treatment tweaks are par for the course.

By now your staff meeting—and hot flash—are probably over. Time to towel off and prepare for the next one. Because you know there will be a next one, of both. If only reducing meetings were as easy as reducing hot flashes.

About Us

The Cusp Team
The Cusp provides personalized menopause care. Our doctors have deep expertise and a broad treatment toolkit, offering natural and medical therapies to help you feel better.