How pharmacists can help patients navigate perimenopause

In this article:

• Common perimenopause symptoms
• Nonpharmacologic options
• Complementary treatments
• Prescripton options
• Helping patients

In this article

• Common perimenopause symptoms
• Nonpharmacologic options
• Complementary treatments
• Prescripton options
• Helping patients

Most women transition into natural menopause between the ages of 45 and 56, but it rarely happens quickly. Menstrual cycle changes, night sweats, and other symptoms may appear in your 30s or 40s and continue for years before your period stops for good. During this phase, called perimenopause, declining estrogen can contribute to symptoms that affect sleep, mood, and quality of life. 

Around 90% of women seek medical care for perimenopausal symptoms. Pharmacists can help reassure women that this is a normal life stage and does not always require treatment, yet effective options are available when symptoms are bothersome.

Understanding common perimenopause symptoms

During perimenopause, fluctuating estrogen levels can drive a wide range of symptoms that affect daily life. Common symptoms patients ask pharmacists about are:

Vasomotor symptoms (hot flashes and night sweats)

Hot flashes are sudden episodes of warmth, often affecting the chest, neck, and face. The flushed sensation may be followed by sweating or other symptoms such as headache or anxiety. 

During perimenopause, many women experience intense sweating at night that soaks clothing or bedding and interrupts sleep. Night sweats (with or without daytime hot flashes) can take a real toll on your mood and energy. 

Mental health symptoms

Patients may describe “brain fog,” forgetfulness, trouble concentrating, or feeling “off.” Declines in estrogen around menopause have been linked to depression and mood disorders, along with memory and concentration issues.

Sleep problems are common during perimenopause and early menopause, particularly in patients with hot flashes, though they can also occur independently. Poor sleep can worsen fatigue, mood changes, and cognitive fogginess.

Genitourinary symptoms

Vaginal dryness often appears later in the transition and can significantly negatively affect quality of life. Patients may also report pain with intercourse (dyspareunia), urinary urgency, or recurrent urinary tract infections.

Medication-induced symptoms

Pharmacists can review patient profiles for any prescribed medications that could be contributing to hot flashes or making them worse. Drugs associated with hot flashes may include:

• Chemotherapy
• Calcium channel blockers
• Clomiphene
• Leuprolide
• Monoamine oxidase inhibitors (MAOIs)
• Raloxifene
• Tamoxifen
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)

Some SSRIs are also used to manage vasomotor symptoms, so patients may be confused about what is helping versus making things worse. Reviewing recent dose changes and timing can help clarify if symptoms may be drug-related and if prescriber follow-up is needed.

Nonpharmacologic strategies for perimenopause

Many women prefer nonpharmacologic options. Research supports lifestyle-based approaches to help reduce vasomotor symptoms and support overall well-being.

Pharmacists can emphasize that healthy lifestyle changes are worth trying and may improve sleep, mood, and well-being for some people. At the same time, it’s important to set realistic expectations, as relief is often modest and may be due to the placebo effect.

Lifestyle strategies for coping with perimenopause symptoms include:

• Healthy eating and physical activity are linked to improvements in vasomotor symptoms, sleep quality, weight regulation, bone health, and cardiometabolic health.
• Weight loss may help reduce hot flashes in overweight or obese women, according to a study involving an intensive behavioral weight loss program.
• Sleep hygiene, including consistent bedtimes and a cool sleep environment, can be beneficial.
• Warm environments, hot drinks, and emotional stress can trigger hot flashes. Stress management approaches such as relaxation, stress reduction, and mindfulness, which may reduce symptom bother even if hot flash frequency does not change.

Complementary treatments

Many people seek natural options for perimenopause. Evidence for plant-based “hormone” supplements is inconsistent and may pose safety concerns in patients with hormone-sensitive cancers or other chronic health problems. Supplements can also interact with many medications. Pharmacists can help guide patients on any supplements they should avoid or use with caution. 

Examples of common supplements marketed for perimenopause support but have limited evidence of benefit include:

• Phytoestrogens, such as soy isoflavones and those found in red clover, have not consistently shown a meaningful benefit for hot flashes in clinical trials.
• Black cohosh is widely used, but its effectiveness in treating hot flashes has not been proven to be better than a placebo. 
• Evening primrose oil and flaxseed, both of which have not shown benefit over placebo in randomized trials.

Bioidentical hormone products

Patients may ask about “bioidentical hormones,” often referring to compounded preparations marketed as safer or more natural options. Experts at the American College of Obstetricians and Gynecologists (ACOG) caution against routine use of compounded bioidentical hormone therapy, citing a lack of evidence supporting safety and effectiveness and a lack of regulation.

It can help to clarify that estradiol and micronized progesterone can be bioidentical and are available in FDA-approved forms. Compounded products may carry added risks related to dosing variability and quality control; therefore, patients should be encouraged to discuss these choices with their prescriber.

Over-the-counter treatments

Some patients turn to over-the-counter products for symptom relief, often in conjunction with lifestyle changes or medical therapies. Pharmacists can advise patients on safe selection and appropriate use of OTCs.

Nonprescription options may offer symptom relief:

• Melatonin may help patients sleep better and is safe for most people.
• NSAIDs or acetaminophen may help relieve headaches, joint pain, or discomfort. 
• Vaginal moisturizers are intended for regular use to improve baseline moisture, while lubricants are used as needed for sexual activity.

Prescription options

Pharmacists can answer patients’ questions about prescribed medications for menopause symptoms. 

Menopausal hormone therapy

Menopausal hormone therapy (MHT) refers to estrogen alone or estrogen combined with progestin to relieve bothersome menopausal symptoms. Estrogen is the primary hormone for symptom relief, and patients with a uterus generally require progestin to reduce the risk of uterine cancer from unopposed estrogen.

Estrogen is prescribed in several forms, including oral tablets, transdermal patches, vaginal rings or tablets, gels, and sprays. Estradiol, which is identical to endogenous estrogen, is commonly used.

Low-dose vaginal estrogen is a highly effective option for vaginal dryness and painful intercourse. Because systemic absorption is minimal, it does not treat hot flashes and does not require added progestin. Patient counseling should distinguish this local therapy from systemic estrogen, especially for patients concerned about safety. 

Low-dose birth control pills may help some premenopausal women manage hot flashes and irregular bleeding while also providing contraception. 

Be prepared to answer questions about changes to hormone therapy warnings

Some patients may ask about recent changes to hormone therapy labeling. The FDA, in coordination with the Department of Health and Human Services, has announced the removal of the boxed warnings on menopausal hormone therapy to better reflect current evidence.

FDA-reviewed evidence shows that starting systemic hormone therapy before age 60 or within 10 years of menopause is associated with a more favorable balance of benefits and risks, without the higher rates of cardiovascular events, stroke, and blood clots seen when therapy is started later.

Expert organizations, including the ACOG, have welcomed these changes, noting that boxed warnings created unnecessary fear and barriers to care, especially for low-dose vaginal estrogen. Awareness of this update can help pharmacists address safety concerns and reinforce shared decision-making with prescribers.

Non-estrogen options for hot flashes

Non-estrogen therapies can reduce hot flashes for many patients, though they are generally less effective than MHT. Options described in medical literature include certain antidepressants (including paroxetine, an SSRI approved for hot flashes), gabapentin, oxybutynin, and newer drugs such as Veozah (fezolinetant). 

Helping patients navigate perimenopause

Perimenopause conversations often start in the pharmacy. For instance, patients may ask for natural remedies for hot flashes or sleep problems, or want to know if any of their medications could cause irregular cycles.

Pharmacists can support patients by listening for symptom patterns, setting realistic expectations for supplements and OTC products, and helping patients evaluate social media trends and “all-natural” claims through an evidence-based lens. When patients are overwhelmed or confused, a few clear counseling points can help them feel more confident about their next step.