Editing Menopause (section)

== Management ==
Perimenopause is a natural stage of life. It is not a disease or a disorder. Therefore, it does not automatically require any kind of medical treatment. However, in those cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the life of the woman experiencing them, palliative medical therapy may sometimes be appropriate.

=== Menopausal hormone therapy ===
{{Main|Hormone replacement therapy}}
In the context of the menopause, [[menopausal hormone therapy]] (MHT) is the use of [[estrogen]] in women without a uterus and estrogen plus [[progestogen]] in women who have an intact uterus.<ref>The Woman's Health Program Monash University, [http://med.monash.edu.au/sphpm/womenshealth/docs/postmenopausal-hormone-therapy.pdf Oestrogen and Progestin as Hormone Therapy] {{webarchive|url=https://web.archive.org/web/20120711003526/http://med.monash.edu.au/sphpm/womenshealth/docs/postmenopausal-hormone-therapy.pdf|date=11 July 2012}}</ref>

MHT may be reasonable for the treatment of menopausal symptoms, such as hot flashes.<ref>{{cite journal |author=North American Menopause Society |date=March 2010 |title=Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society |journal=Menopause |volume=17 |issue=2 |pages=242–255 |doi=10.1097/gme.0b013e3181d0f6b9 |pmid=20154637 |s2cid=24806751}}</ref> It is the most effective treatment option, especially when delivered as a skin patch.<ref name="HRT20172">{{cite journal |author1=North American Menopause Society |date=March 2012 |title=The 2012 hormone therapy position statement of: The North American Menopause Society |journal=Menopause |volume=19 |issue=3 |pages=257–71 |doi=10.1097/GME.0000000000000921 |pmc=3443956 |pmid=22367731}}</ref><ref>{{cite journal |vauthors=Sarri G, Pedder H, Dias S, Guo Y, Lumsden MA |date=September 2017 |title=Vasomotor symptoms resulting from natural menopause: a systematic review and network meta-analysis of treatment effects from the National Institute for Health and Care Excellence guideline on menopause |url=http://eprints.gla.ac.uk/138525/7/138525.pdf |journal=BJOG |volume=124 |issue=10 |pages=1514–1523 |doi=10.1111/1471-0528.14619 |pmid=28276200 |s2cid=206909766}}</ref> Its use, however, appears to increase the risk of [[stroke]]s and [[blood clots]].<ref name="boardman20152">{{cite journal |vauthors=Boardman HM, Hartley L, Eisinga A, Main C, Roqué i Figuls M, Bonfill Cosp X, Gabriel Sanchez R, Knight B |date=March 2015 |title=Hormone therapy for preventing cardiovascular disease in post-menopausal women |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=3 |pages=CD002229 |doi=10.1002/14651858.CD002229.pub4 |pmid=25754617 |pmc=10183715 |hdl-access=free |hdl=20.500.12105/9999}}</ref> When used for menopausal symptoms the global recommendation is MHT should be prescribed for a long as there are defined treatment effects and goals for the individual woman.<ref name="auto2" />

MHT is also effective for preventing bone loss and [[Osteoporosis|osteoporotic]] fracture,<ref>{{cite journal |vauthors=de Villiers TJ, Stevenson JC |date=June 2012 |title=The WHI: the effect of hormone replacement therapy on fracture prevention |journal=Climacteric |volume=15 |issue=3 |pages=263–6 |doi=10.3109/13697137.2012.659975 |pmid=22612613 |s2cid=40340985}}</ref> but it is generally recommended only for women at significant risk for whom other therapies are unsuitable.<ref name=":22">{{cite journal |vauthors=Marjoribanks J, Farquhar C, Roberts H, Lethaby A, Lee J |date=January 2017 |title=Long-term hormone therapy for perimenopausal and postmenopausal women |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD004143 |doi=10.1002/14651858.CD004143.pub5 |pmc=6465148 |pmid=28093732}}</ref>

MHT may be unsuitable for some women, including those at increased risk of cardiovascular disease, increased risk of thromboembolic disease (such as those with obesity or a history of venous thrombosis) or increased risk of some types of cancer.<ref name=":22" /> There is some concern that this treatment increases the risk of breast cancer.<ref name="ChlebowskiAnderson20152">{{cite journal |vauthors=Chlebowski RT, Anderson GL |date=April 2015 |title=Menopausal hormone therapy and breast cancer mortality: clinical implications |journal=Therapeutic Advances in Drug Safety |volume=6 |issue=2 |pages=45–56 |doi=10.1177/2042098614568300 |pmc=4406918 |pmid=25922653}}</ref> Women at increased risk of cardiometabolic disease and VTE may be able to use transdermal estradiol which does not appear to increase risks in low to moderate doses.<ref name="auto2" />

Adding [[testosterone]] to hormone therapy has a positive effect on sexual function in postmenopausal women, although it may be accompanied by hair growth or acne if used in excess. Transdermal testosterone therapy in appropriate dosing is generally safe.<ref>{{cite journal |display-authors=6 |vauthors=Davis SR, Baber R, Panay N, Bitzer J, Cerdas Perez S, Islam RM, Kaunitz AM, Kingsberg SA, Lambrinoudaki I, Liu J, Parish SJ, Pinkerton J, Rymer J, Simon JA, Vignozzi L, Wierman ME |date=October 2019 |title=Global Consensus Position Statement on the Use of Testosterone Therapy for Women |journal=Climacteric |volume=22 |issue=5 |pages=429–434 |doi=10.1080/13697137.2019.1637079 |pmid=31474158 |s2cid=201713094 |doi-access=free|hdl=2158/1176450 |hdl-access=free }}</ref>

=== Selective estrogen receptor modulators ===
[[Selective estrogen receptor modulator|SERMs]] are a category of drugs, either synthetically produced or derived from a botanical source, that act selectively as agonists or antagonists on the [[estrogen receptor]]s throughout the body. The most commonly prescribed SERMs are [[raloxifene]] and [[tamoxifen]]. Raloxifene exhibits oestrogen agonist activity on bone and lipids, and antagonist activity on breast and the endometrium.<ref>{{cite journal |vauthors=Davis SR, Dinatale I, Rivera-Woll L, Davison S |date=May 2005 |title=Postmenopausal hormone therapy: from monkey glands to transdermal patches |journal=The Journal of Endocrinology |volume=185 |issue=2 |pages=207–22 |doi=10.1677/joe.1.05847 |pmid=15845914 |doi-access=free}}</ref> Tamoxifen is in widespread use for treatment of hormone sensitive breast cancer. Raloxifene prevents vertebral fractures in postmenopausal, osteoporotic women and reduces the risk of invasive breast cancer.<ref>{{cite journal |vauthors=Bevers TB |date=September 2007 |title=The STAR trial: evidence for raloxifene as a breast cancer risk reduction agent for postmenopausal women |journal=Journal of the National Comprehensive Cancer Network |volume=5 |issue=8 |pages=719–24 |doi=10.6004/jnccn.2007.0073 |pmid=17927929 |doi-access=free}}</ref>

=== Other medications ===
Some of the [[SSRIs]] and [[SNRIs]] appear to provide some relief from vasomotor symptoms.<ref name="Kra20152" /><ref name=":62" /> The most effective SSRIs and SNRIs are [[paroxetine]], [[escitalopram]], [[citalopram]], [[venlafaxine]], and [[desvenlafaxine]].<ref name=":62" /> They may, however, be associated with appetite and sleeping problems, constipation and nausea.<ref name="Kra20152" /><ref name=":52">{{cite journal |vauthors=Potter B, Schrager S, Dalby J, Torell E, Hampton A |date=December 2018 |title=Menopause |journal=Primary Care |series=Women's Health |volume=45 |issue=4 |pages=625–641 |doi=10.1016/j.pop.2018.08.001 |pmid=30401346 |s2cid=239485855}}</ref>

[[Gabapentin]] or [[fezolinetant]] can also improve the frequency and severity of vasomotor symptoms.<ref name="Kra20152" /><ref name=":62" /> Side effects of using gabapentin include drowsiness and headaches.<ref name="Kra20152" /><ref name=":52" />

=== Therapy ===
[[Cognitive behavioural therapy]] and [[Hypnotherapy|clinical hypnosis]] can decrease the amount women are affected by hot flashes.<ref name=":62" /> [[Mindfulness]] is not yet proven to be effective in easing vasomotor symptoms.<ref>{{cite journal |display-authors=6 |vauthors=Goldstein KM, Shepherd-Banigan M, Coeytaux RR, McDuffie JR, Adam S, Befus D, Goode AP, Kosinski AS, Masilamani V, Williams JW |date=April 2017 |title=Use of mindfulness, meditation and relaxation to treat vasomotor symptoms |journal=Climacteric |volume=20 |issue=2 |pages=178–182 |doi=10.1080/13697137.2017.1283685 |pmid=28286985 |s2cid=10446084}}</ref><ref>{{cite journal |vauthors=van Driel CM, Stuursma A, Schroevers MJ, Mourits MJ, de Bock GH |date=February 2019 |title=Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis |journal=BJOG |volume=126 |issue=3 |pages=330–339 |doi=10.1111/1471-0528.15153 |pmc=6585818 |pmid=29542222}}</ref><ref name=":62" />

=== Lifestyle and exercise ===
Exercise has been thought to reduce postmenopausal symptoms through the increase of endorphin levels, which decrease as estrogen production decreases.<ref name=":32">{{cite journal |vauthors=Hickey M, Szabo RA, Hunter MS |date=November 2017 |title=Non-hormonal treatments for menopausal symptoms |journal=BMJ |volume=359 |pages=j5101 |doi=10.1136/bmj.j5101 |pmid=29170264 |s2cid=46856968}}</ref> However, there is insufficient evidence to suggest that exercise helps with the symptoms of menopause.<ref name=":62" /> Similarly, yoga has not been shown to be useful as a treatment for vasomotor symptoms.<ref name=":62" />

However a high [[Body mass index|BMI]] is a risk factor for vasomotor symptoms in particular. Weight loss may help with symptom management.<ref>{{cite journal |vauthors=Moore TR, Franks RB, Fox C |date=May 2017 |title=Review of Efficacy of Complementary and Alternative Medicine Treatments for Menopausal Symptoms |journal=Journal of Midwifery & Women's Health |volume=62 |issue=3 |pages=286–297 |doi=10.1111/jmwh.12628 |pmid=28561959 |s2cid=4756342}}</ref><ref name=":62" />

There is no strong evidence that cooling techniques such as using specific clothing or environment control tools (for example fans) help with symptoms.<ref name=":62" /> Paced breathing and [[Relaxation technique|relaxation]] are not effective in easing symptoms.<ref name=":62" />

=== Dietary supplements ===
There is no evidence of consistent benefit of taking any [[dietary supplement]]s or [[Herbal medicine|herbal products]] for menopausal symptoms.<ref name=":62" /><ref>{{cite journal |vauthors=Clement YN, Onakpoya I, Hung SK, Ernst E |date=March 2011 |title=Effects of herbal and dietary supplements on cognition in menopause: a systematic review |journal=Maturitas |volume=68 |issue=3 |pages=256–63 |doi=10.1016/j.maturitas.2010.12.005 |pmid=21237589}}</ref><ref name="ReferenceA2">{{cite journal |vauthors=Nedrow A, Miller J, Walker M, Nygren P, Huffman LH, Nelson HD |date=July 2006 |title=Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review |journal=Archives of Internal Medicine |volume=166 |issue=14 |pages=1453–65 |doi=10.1001/archinte.166.14.1453 |pmid=16864755 |doi-access=free}}</ref> These widely marketed but ineffective supplements include [[soy isoflavones]], [[Pollen|pollen extracts]], [[Actaea racemosa|black cohosh]], [[Omega-3 fatty acid|omega-3]] among many others.<ref name=":62" /><ref name="Franco20162">{{cite journal |display-authors=6 |vauthors=Franco OH, Chowdhury R, Troup J, Voortman T, Kunutsor S, Kavousi M, Oliver-Williams C, Muka T |date=June 2016 |title=Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis |journal=JAMA |volume=315 |issue=23 |pages=2554–2563 |doi=10.1001/jama.2016.8012 |pmid=27327802 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Leach MJ, Moore V |date=September 2012 |title=Black cohosh (Cimicifuga spp.) for menopausal symptoms |journal=The Cochrane Database of Systematic Reviews |volume=9 |issue=9 |pages=CD007244 |doi=10.1002/14651858.CD007244.pub2 |pmc=6599854 |pmid=22972105}}</ref>

=== Alternative medicine ===
There is no evidence of consistent benefit of [[alternative therapies]] for menopausal symptoms despite their popularity.<ref name="ReferenceA2" /><ref name=":62" />

As of 2023, there is no evidence to support the efficacy of [[acupuncture]] as a management for menopausal symptoms.<ref name=":62" /><ref>{{cite journal |vauthors=Dodin S, Blanchet C, Marc I, Ernst E, Wu T, Vaillancourt C, Paquette J, Maunsell E |date=July 2013 |title=Acupuncture for menopausal hot flushes |journal=The Cochrane Database of Systematic Reviews |volume=7 |issue=7 |pages=CD007410 |doi=10.1002/14651858.CD007410.pub2 |pmc=6544807 |pmid=23897589}}</ref><ref name="ReferenceA2" /> The [[Cochrane review]] found not enough evidence in 2016 to show a difference between Chinese herbal medicine and placebo for the [[vasomotor]] symptoms.<ref name="Cochrane review 2016 on Chinese herbal medicine for menopausal symptoms2">{{cite journal |vauthors=Zhu X, Liew Y, Liu ZL |date=March 2016 |title=Chinese herbal medicine for menopausal symptoms |journal=The Cochrane Database of Systematic Reviews |volume=3 |issue=5 |pages=CD009023 |doi=10.1002/14651858.CD009023.pub2 |pmc=4951187 |pmid=26976671}}</ref>

=== Other efforts ===
* Lack of lubrication is a common problem during and after perimenopause. Vaginal moisturizers can help women with overall dryness, and lubricants can help with lubrication difficulties that may be present during intercourse. It is worth pointing out that moisturizers and lubricants are different products for different issues: some women complain that their genitalia are uncomfortably dry all the time, and they may do better with moisturizers. Those who need only lubricants do well using them only during intercourse.
* Low-dose prescription vaginal estrogen products such as estrogen creams are generally a safe way to use estrogen topically, to help vaginal thinning and dryness problems (see [[vaginal atrophy]]) while only minimally increasing the levels of estrogen in the bloodstream.
* Individual counseling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time.
* [[Osteoporosis]] can be minimized by [[smoking cessation]], adequate [[vitamin D]] intake and regular weight-bearing exercise. The bisphosphonate drug alendronate may decrease the risk of a fracture, in women that have both bone loss and a previous fracture and less so for those with just osteoporosis.<ref>{{cite journal |vauthors=Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P |date=January 2008 |title=Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women |journal=The Cochrane Database of Systematic Reviews |issue=1 |pages=CD001155 |doi=10.1002/14651858.CD001155.pub2 |pmid=18253985}}</ref>
* A surgical procedure where a part of one of the ovaries is removed earlier in life and frozen and then over time thawed and returned to the body ([[ovarian tissue cryopreservation]]) has been tried. While at least 11 women have undergone the procedure and paid over £6,000, there is no evidence it is safe or effective.<ref>{{Cite web |date=28 January 2020 |title=Concerns over new 'menopause delay' procedure |url=https://www.bbc.com/news/health-51269237 |website=BBC News}}</ref>