This article is the second of a four-part series in partnership with MHealthy and the U-M Menopause Clinic to further awareness about menopause and U-M benefits that assist in treating symptoms and health risks.

Decades before they hit perimenopause, some women thought they would embrace the day their periods started to wane. Menopause, they figured (because perimenopause was mostly unknown), would be freedom. 

No more bleeding. No more contraception. No more cramps, migraines, stashing extra clothing in case they bled through, fatigue, bloating, and – before tampons, menstrual cups and period underwear – no more skipping beach days and wearing dark pants. 

When they became acquainted with perimenopause years later, that freedom seemed more like, as one woman described it, a freight train slamming into her, day after day. 

“Patients in my care for perimenopause have a spectrum of reactions. Some are thrilled that they are liberated from periods,” said Shubham Kalwani, DO, assistant professor in the U-M Department of Family Medicine and Department of Obstetrics and Gynecology. “Others are debilitated by symptoms and demoralized because they are unheard, without answers or relief.

“To patients who feel like they’ve been hit by a train, it’s no comfort that perimenopause is different for each individual.” 

In an effort to elevate awareness about menopause and encourage support, Kalwani will host a free webinar, “Navigating Menopause Together,” with Natalie Saunders, MD, associate professor of obstetrics and gynecology at Michigan Medicine. Kalwani and Saunders are Menopause Society-certified practitioners.

Answers and Treatment

Fortunately, doctors can offer safe, effective treatment for many perimenopausal symptoms, especially those that most interfere with quality of life. 

“Hormone therapy is the most effective treatment for the more interruptive symptoms, such as hot flashes and night sweats,” Kalwani said. 

Hormone therapy, also called hormone replacement therapy (HRT), delivers medicine through pills, patches, rings and gels. Localized, vaginal hormone options also can be delivered through creams, suppositories, rings and pills. 

Depending on several factors, patients may receive estrogen-only therapy, or estrogen in combination with progestins, which reduces the risk of developing uterine and colon cancers. 

Millennial Shift

In the early 2000s, doctors treating women, especially those younger than 50, for perimenopause may have balked at prescribing hormones. A landmark study in 2002 had linked estrogen and progestin to an increase in serious health conditions, including heart disease and cancer. In turn, the U.S. Food and Drug Administration (FDA) mandated that a “black box” warning be placed on hormone prescription packaging. 

“I wasn’t practicing when the study was released, but I’ve heard it was like a bomb went off for practitioners treating perimenopause and menopause,” Kalwani said. 

Hormone therapy prescriptions plummeted for decades afterward. 

“The FDA just removed the black box warning from prescriptions last year,” Kalwani noted.  

Time, perspective and additional research have moved the conversation about hormones into a more positive direction. 

“Hormone therapy is safe and effective when prescribed appropriately,” Kalwani said. “There are specific risk factors that need to be considered and discussed, such as previous health history and tobacco use. Best practices for treatment begin with an honest doctor-patient conversation.”

Patients may not be good candidates for hormone therapy if they:

• Have been treated for estrogen-dependent cancers, including breast, ovarian and uterine

• Have active liver disease and/or clotting disorders

• Are at high risk for stroke and/or heart disease

• Have a strong family history of estrogen-dependent cancers

• Use tobacco products, including cigarettes and cigars; vaping products; and smokeless tobacco

“Every medicine, even over-the-counter (OTC) drugs, has some health risk,” Kalwani noted. “The key is to create a treatment plan that has the most benefit with the least amount of risk. Hormone therapy can relieve many of the perimenopausal symptoms that debilitate, giving them a better quality of life.”

Additional Treatments

If a patient or their doctor are not certain about trying traditional hormone therapy, other treatments are available, including OTC lubricants; antidepressants; selective estrogen receptor modulators; and medications that calm overactive nerves. 

“There’s some excitement about a new class of medications called neurokinin receptor antagonists, which work directly on the source of specific symptoms,” Kalwani said. “Neurokinin receptor antagonists reduce menopausal hot flashes and night sweats by blocking brain signals that disrupt the body’s temperature-control center when estrogen levels fall.”

Fresh or Fad?

It’s difficult to graze social media or television without seeing ads for “natural treatments” that promise favorable results. These treatments feature plants, and are used in the forms of teas, capsules, tablets, tinctures, and powders. 

Herbal medicine falls under the umbrella of alternative medicine, most of which is unregulated by the FDA. Research into botanicals for perimenopause relief are scant and generally show mixed results. The effectiveness of such supplements also can depend on the severity of symptoms. 

“If a supplement is physically safe, we can discuss it,” Kalwani said. “Soy foods, omega-3-rich foods and flaxseed are often promoted for perimenopausal symptoms, but evidence that they substantially relieve symptoms is limited or inconsistent. As components of a balanced diet, they may support cardiovascular health, which becomes increasingly important during and after the menopause transition.”

If a patient would rather try a supplement before a prescription, she added, the first step is to discuss it with their doctor so potential risks and benefits are clear.

Part three of this series, “Menopause and the Mind-Body Connection,” will be published on Tuesday, Oct. 20.