Although The Menopause Society refers to perimenopause as a “transition” between normal menstruation and menopause, not necessarily a medical condition, the demand for perimenopause treatment is increasing.

A study published last year in Nature found that 4432 US women aged 30-45 years who were surveyed reported experiencing perimenopause-related symptoms, with severity increasing as they aged. The Women Living Better Survey found that women in this age group reported “not feeling helped” by their doctor for their chief complaints.

“Menopause and perimenopause seem to be having a moment, and that really hasn't happened in past generations,” JoAnne Manson, MD, MPH, DrPH, told Medscape Medical News.

Manson is a professor of medicine and the Michael and Lee Bell Professor of Women’s Health at Harvard Medical School in Boston, where she is also chief of preventive medicine. In addition, Manson is a professor of epidemiology at the Harvard T.H. Chan School of Public Health in Boston and a past president of The Menopause Society.

In this Q&A, Manson shares her thoughts on why perimenopause is so hot now and how she recommends clinicians counsel patients who want remedies for it.

The following interview has been edited for length and clarity.

To what do you attribute the rise of the idea of perimenopause in women’s health?

I think it’s a cultural moment happening at the intersection of women’s health and advocacy. The Millennials are a fairly large group of women who are reaching the age where they’re thinking about these issues. It’s because this generation has way more data available to it than there would have been for Boomers when they were going through it.

Could social media and the rise of influencers also contribute to perimenopause’s ascendency?

I do think that’s an important factor. Information is more accessible, and it’s so much easier now to go online and search for answers. But I also think that women being in the workplace is different from previous generations. Because there are more women, there is more awareness. There are more discussions about the topic than in the past.

Are advertisers helping to create this moment, leveraging it to sell women treatments they don’t need or that may be contraindicated?

Absolutely, that’s a risk. That is why clinicians can play a big role in helping patients understand that they should be cautious about some of the messages they’re getting online. Some of these treatments are just not effective, and many can have risks. In fact, there actually aren’t really good treatments for perimenopause.

Clinicians can help by having a discussion about perimenopause with the patient instead of waiting for the patient to bring it up. Start by asking patients whether they’ve had any changes to their periods recently. This gives the message to patients that they can talk openly with their doctor about the subject.

What are some of the most common types of misinformation about perimenopause?

A really key myth is around hormones. Once your periods are becoming irregular, that is associated with fluctuation in hormones. It doesn’t mean that your hormones are dropping precipitously. In fact, they fluctuate widely during the 5-7 years of perimenopause, and many, many women will experience the onset of irregular periods 5-7 years before their final menstrual period. But a key myth is that there are reliable blood tests for perimenopause. They are not reliable. These tests can give you a guide, but they’re not really recommended clinically because of all the hormone fluctuations. After menopause, there are the very clear rises in the follicle-stimulating hormone and declines in the estradiol that stay much more stable. There’s not much clinical utility in offering these blood tests during perimenopause. Most clinicians will not recommend them.

Another one is that once your periods become irregular, and you begin perimenopause, you can’t become pregnant. That is a myth. Women are intermittently ovulating during this time, leaving open the potential for an unplanned pregnancy. It’s important that women understand they will still need contraception during this time.

Another myth is that just about any symptoms a woman has in her mid-forties are perimenopause symptoms. That isn’t true because women are also at a high risk for other health conditions with similar symptoms. This is why it’s really important for clinicians to know what the patient’s symptoms are, whether there is new onset, and to describe them at length, because sometimes it’s an indication that she has a thyroid problem. The patient might have an underactive or an overactive thyroid, which is very common in midlife women, as are autoimmune diseases. So we shouldn’t jump to conclusions and automatically assume everything is perimenopause.

Finally, though much touted, it’s just not well demonstrated that compounded hormone therapy is effective. There are a lot of problems, and the efficacy and safety data are very, very limited. Also, the FDA has done quality control audits that have shown there is a lot of inconsistency in the dosages. What you’re told is the correct dose for you might actually be quite different from what you’re receiving. They’ve found contaminants and impurities.

In that case, are there any clinical data for hormone therapy in perimenopausal women?

Manson: The only randomized trials of transdermal estradiol — the various patches that you get through regular pharmacies that are FDA-approved medications — were in women who were postmenopausal. We don’t have the data on women in the perimenopausal years.

It sounds like what you’re saying is that there is no gold standard perimenopause treatment?

Perimenopause is more of a clinical diagnosis based on whether a woman is close to 45 or her periods are becoming irregular. Clinicians treat perimenopause symptoms such as hot flashes and night sweats with a low-dose oral contraceptive. Oral contraceptives are used rather than starting menopausal hormone therapy because they are a form of contraception, so they suppress the intermittent ovulation. The low dose addresses the hot flashes, night sweats, and irregular menses.

There are many other treatments to use such as selective serotonin reuptake inhibitor and selective norepinephrine reuptake inhibitor antidepressants and gabapentin — these could all be chosen as various treatments for different symptoms, but it’s not like there is a gold standard.

It needs to be an individualized decision, and importantly, a prescription medication or pharmacologic treatment is not always needed. Some women just do not require it. Sometimes the symptoms are really not bothering the woman’s quality of life. That’s key. They just do some lifestyle modifications such as trying to be more physically active, eating healthily, minimizing alcohol, or maybe having some cognitive-behavioral therapy if there is a disruption in sleep.

Last year, the FDA removed the black box warning from menopause hormone therapies. Before that, the number of women receiving these treatments was fairly low. Have you noticed a change in prescribing behavior since the label was removed?

Some of the companies making the transdermal estradiol patches have been running out of their supply, which is a sign that the demand has increased, but I have not seen a formal analysis of how prescription writing has gained. It’s too early to know what the impact will be because it just happened.

But I think that the removal of the black box warning will lead to more personalized decision-making about hormone therapy and, hopefully, more appropriate decision-making. I mean, the black box warning was very much a one-size-fits-all kind of approach, so it scared away a lot of women. Even women who wanted to use a low dose for painful sex or vaginal dryness saw this very alarming, frightening black box warning, even though we’re not talking about the higher hormone levels that are seen with systemic hormone therapy.

So I think if women aren’t alarmed and clinicians aren’t alarmed, it gives them a chance to really carefully consider the benefits and risks of hormone therapy for the individual patient and to make decisions about different formulations.

But I do want to comment that I think it is still important that women receive information about what the randomized trials have found, and that information is still in the package insert. It’s just not in a frightening black box. The Women’s Health Initiative findings about stroke and blood clots are still in there, but they are in a more appropriate place.

What are the best websites for clinicians and their patients to visit for accurate perimenopause information?

I do have a bias in this area as past president of The Menopause Society, but clinicians should be recommending menopause.org because that’s where all of the clinically tested information is going to be. Patients don’t need to surf around. There is a huge amount of information on the site about what perimenopause is, what menopause is, what the risks and benefits of hormone therapy are, and decision-making information about hormone therapy and nonhormonal treatment options. I would say it’s a treasure trove.

Manson had no relevant financial disclosures.