Rethinking Perimenopause: Common Clinical Mistakes and Better Strategies

Perimenopause has become one of the fastest-growing areas of women’s health, accompanied by increasing use of hormone replacement therapy (HRT). While HRT is well supported for menopause, applying the same treatment strategies to perimenopause is far more nuanced. Rather than a simple hormone deficiency, perimenopause is a dynamic neuroendocrine transition with multiple underlying physiological patterns. Changes in communication between the hypothalamus, pituitary, and ovaries may present as altered GnRH signaling, follicle offloading, intermittent anovulation, exaggerated hormone fluctuations, or declining ovarian reserve. Although these patterns often produce similar symptoms, they require different clinical approaches. This session introduces a practical framework for identifying the physiological drivers of perimenopausal symptoms and demonstrates how they influence assessment, treatment selection, and the appropriate use of HRT. Drawing on current research and extensive clinical experience, participants will learn to distinguish common perimenopausal patterns, determine when HRT is appropriate, when alternative strategies should be prioritized, and develop individualized treatment plans that improve patient outcomes.

Learning Objectives

• Differentiate the physiological differences between menopause and perimenopause and explain why management strategies cannot be directly extrapolated between the two
• Recognize the major biological patterns contributing to perimenopausal symptoms, including hypothalamic-pituitary-ovarian communication changes, GnRH dysregulation, follicle offloading, hormonal fluctuation, intermittent anovulation, and declining ovarian reserve
• Interpret clinical history, symptom patterns, and laboratory findings to distinguish common perimenopausal phenotypes and identify the most likely underlying mechanisms
• Apply an evidence-informed framework to determine when hormone replacement therapy is indicated, when it may be ineffective or inappropriate, and when alternative therapeutic strategies should be prioritized
• Develop individualized treatment plans that combine current research with practical clinical decision-making for patients experiencing the perimenopausal transition