Perimenopause is a distinct physiological stage, not early menopause, and it has no dedicated practice recommendation to lean on. Women arrive with abnormal uterine bleeding, vasomotor symptoms, disturbed sleep, mood and cognitive change and sexual concerns in almost any combination, while still needing contraception and while their cardiometabolic risk is shifting.
This clinical perspective sets out the hormonal options in that setting: where combined hormonal contraceptives do the work of both contraception and symptom control, where they are inadequate or unwanted, and what the alternative hormonal strategies are. It is a framework for shared decision making rather than a trial readout, and it is honest that the evidence underneath much of this is thin.
For Indian practice, the gap it names is familiar. Perimenopausal women are commonly managed either as contraception patients or as menopause patients, and the overlap — where bleeding, symptoms and contraceptive need have to be solved with one prescription — is where the consultation usually goes wrong. Having an explicit order in which to ask the questions is most of the value.
- Establish contraceptive need before choosing between a contraceptive and menopausal hormone therapy
- Take a bleeding history that distinguishes cycle shortening from genuinely abnormal bleeding needing assessment
- Record blood pressure, weight and lipid or glucose status before starting oestrogen-containing options
- Ask about sleep and mood directly — these are often what the woman came about
- Set a review date: perimenopausal needs change within months, not years
Why it matters
The commonest perimenopausal prescribing error is treating the stage as either contraception or menopause, when it is both.
Don't overread it
This is a clinical perspective and a toolkit, not a guideline or new evidence.
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