New toolkit helps clinicians navigate perimenopause hormone choices

Clinical takeaway: Do not wait for menopause confirmation or rely on routine hormone testing. Treat clinically significant perimenopausal symptoms now, choosing ovarian suppression when contraception and cycle control are priorities or menopausal hormone therapy (MHT) when estrogen supplementation is the primary goal.

Perimenopause is marked by erratic hormonal fluctuations rather than simple estrogen deficiency. Follicle-stimulating hormone and estradiol levels vary substantially, so serum, salivary, urine, and anti-müllerian hormone testing should not routinely guide diagnosis or treatment.

Combined hormonal contraceptives can suppress ovarian fluctuations, provide contraception, and improve abnormal bleeding, menstrual migraine, and vasomotor symptoms. Lower-dose ethinyl estradiol formulations (10–20 micrograms) and extended or continuous regimens are generally preferred; estetrol, estradiol valerate, or transdermal combined contraceptives may help when vasomotor symptoms persist.

Avoid combined hormonal contraceptives in patients with major cardiovascular or thrombotic risks, including smoking after age 35, uncontrolled hypertension, migraine with aura, prior venous thromboembolism, ischemic heart disease, stroke, or current breast cancer.

MHT is reasonable off label for symptomatic patients who are still cycling, particularly in late perimenopause, but it neither reliably suppresses ovulation nor provides contraception. Transdermal estradiol is generally preferred because of its favorable thromboembolic profile, and standard or occasionally higher doses may be needed during pronounced hormonal fluctuations or when transitioning from combined contraception.

Patients with a uterus who use systemic estrogen need endometrial protection. Options include micronized progesterone, synthetic progestogens, or a 52-mg levonorgestrel intrauterine system, which can also provide contraception and control bleeding.

“We argue that clinicians should understand the full landscape of hormonal management options,” authors Jaclyn Piasta, DNP, WHNP-BC, and Amani Zewail, MD, write, emphasizing individualized shared decision-making.

Key Recommendations

• Evaluate and offer treatment when symptoms begin rather than waiting until menopause is confirmed.
• Reserve laboratory testing for selected situations, such as suspected ovarian insufficiency before age 40, early menopause before age 45, or an obscured menstrual history.
• Match treatment to the primary goal: ovarian suppression and contraception versus systemic estrogen supplementation.
• Consider high-dose oral micronized progesterone, medroxyprogesterone acetate, or norethindrone acetate when estrogen is contraindicated or undesired.
• Do not use lower-dose levonorgestrel intrauterine systems or the etonogestrel implant as endometrial protection with systemic estrogen.
• Evaluate abnormal uterine bleeding before treatment and investigate persistent unscheduled bleeding.

Source: Piasta J, Zewail A. (2026 Sep 15) Obstet Gynecol. Hormonal Options for Perimenopause: A Clinician Toolkit