A new clinical toolkit from the American College of Obstetricians and Gynecologists was designed to facilitate the management of perimenopause.

This reproductive stage in women, which typically begins at a median age of 47 years but can start before 45 years, is hormonally distinct from menopause and can be challenging to manage.

Unlike menopause, which is characterized by estrogen deficiency, this precursor stage involves a continuum of erratic hormonal fluctuations that produce symptoms ranging from long or short period cycles and mood or cognitive changes to abnormal bleeding, sleep disruption, and sexual problems.

“We have well-established guidance for menopause but far less for perimenopause, yet perimenopause is physiologically distinct and often more hormonally dynamic and clinically complex,” said Jaclyn Piasta, DNP, co-author of the new guidance document and founder of Monarch Health in Marietta, Georgia. “We wanted to give clinicians a practical framework for navigating that complexity,” she said.

Perimenopause should not be treated as a vague prelude to menopause. It has distinct physiology and distinct treatment challenges and deserves its own clinical framework, Piasta said.

The toolkit stands in contrast to the Stages of Reproductive Aging Workshop +10 staging system introduced in 2012 to standardize nomenclature for the menopause transition. This system describes discrete, stage-specific, and lab value-based hormonal patterns of early and late perimenopause, whereas the toolkit treats perimenopause as a continuum.

Published in Obstetrics & Gynecology, the toolkit, also co-authored by Amani Zewail, MD, gynecologist at Kaiser Permanente in Oakland, California, explores the therapeutic role of hormonal contraceptives and other hormonal strategies, as well as options for individualized care and shared decision-making.

No therapies have been specifically approved by the FDA for perimenopause; hence, much treatment is off-label. “Historically, patients have often been told to wait until their periods stop, offered only contraceptives, or reassured that symptoms are simply part of aging,” Piasta said. “Our manuscript is intentional about discussing off-label practice while outlining practical options clinicians can reasonably use in care.”

Recommendations for Care

First, according to the toolkit, anticipatory guidance should begin before symptoms become severe. Clinicians should ask about cycle changes, sleep, mood, vasomotor issues, sexual health, and bleeding patterns as part of routine midlife care.

“Start with the clinical picture: symptoms, bleeding pattern, contraceptive needs, and medical risk factors. Routine hormone testing is rarely helpful because hormone levels fluctuate substantially and don’t reliably correlate with symptoms,” Piasta said.

There are two main approaches: ovarian suppression with hormonal contraception or systemic estrogen supplementation with menopausal hormone therapy. “But there can also be a hybrid approach, where a contraceptive method is combined with menopausal hormone therapy,” said Piasta. “That’s really why we called this a toolkit. Clinicians have a broad range of options they can individualize based on symptoms, individual medical factors, and patient preference.”

“Keep an open mind to the range of presentations — do not dismiss perimenopause as a natural process of aging — and use the tools we have to build an individualized plan that best addresses that patient’s needs,” she said.

Ob/Gyns on the Toolkit

According to Stephanie Trentacoste McNally, MD, who was not involved in the guidance, “This outline is exactly what clinicians can and should use to start the patient on their midlife hormonal journey. Women should not wait until there are menstrual changes to seek care.”

The algorithm outlines clear interventions with proven benefits, added Trentacoste McNally, medical director of the Katz Institute for Women’s Health at Northwell Health and system director of the Center for Menopause and Midlife Health in Garden City, New York.

The guidance also highlights risk stratification and leverages existing models as part of care delivery, she pointed out. “It’s an individualized patient approach and emphasizes personalized care in real time.”

In other comments, menopause specialist Deborah Kwolek, MD, head of the Mass General Women’s Health and Sex and Gender Medicine Program in Boston, said the toolkit “pulls together things we’re already doing and gives us all the options. It’s likely more extensive than what people need to use, but it’s excellent.” 

Kwolek noted that while most care providers are unfamiliar with treating this reproductive stage, most would know to initially prescribe a hormonal contraceptive. But this toolkit distinguishes between women who need contraception or want to suppress ovulation and those who don’t and outlines other hormonal options going from there, including progesterone alone or progesterone supplemented with estrogen at the menopausal hormone treatment level. “This helpful article brings clinical rigor and guidance on options to providers starting to see patients with symptoms,” she said.

Looking ahead, Piasta stressed the need for better evidence specific to perimenopause. “I think important questions remain around optimal treatment strategies, the transition from contraception to menopausal hormone therapy, and how best to tailor therapy to different symptom patterns.”

The authors disclosed no specific funding for this article. Piasta reported advisory board consulting fees from Padagis and Amissa Health. Zewail reported no potential conflicts of interest. Trentacoste McNally and Kwolek had no conflicts of interest to declare.