Perimenopause is one of the most undertreated conditions I see. A generation of women was told hormone therapy is dangerous, and too many doctors still wave off the symptoms as just getting older. Most of it doesn’t need a blood test to diagnose, and for many women the treatments are both effective and safer than their reputation. Here’s how I’d think about it: treat the symptoms that are bothering you, skip low-value hormone testing, and be wary of hormone products that aren’t regulated like real medications.
Do you need a blood test?
Usually not. I diagnose perimenopause mostly from your story: your age (typically your 40s), periods getting irregular, hot flashes and night sweats, and the sleep and mood changes that ride along with them. Choosing Wisely, a clinician-led campaign against low-value testing, discourages FSH testing here because FSH swings month to month during the menopause transition and doesn’t settle until years after your last period. It can’t time where you are or set a dose.1
The main exception: if you’re under 40 with these symptoms, that warrants a workup for early menopause. Hormone levels can also matter if you’re being evaluated for fertility. Otherwise, your story is the test.
Decision table: test, treat, or skip
| Situation | What usually helps | What to skip |
|---|---|---|
| Irregular periods plus hot flashes in your 40s or 50s | Clinical diagnosis and symptom-based treatment | Routine FSH testing |
| Similar symptoms before age 40 | Workup for early menopause | Dismissing it as normal perimenopause |
| Bothersome hot flashes or night sweats | Estrogen, with progesterone if you still have a uterus | Waiting years because of outdated WHI fear |
| Vaginal dryness or painful sex | Low-dose vaginal estrogen | Systemic hormone therapy if local treatment is enough |
| Hormones are not an option | NK3 blockers, SSRIs/SNRIs, gabapentin, or CBT | Supplements as the main plan |
| Clinic offers pellets or compounded optimization | FDA-approved body-identical prescriptions instead | Saliva testing, pellets, and dose chasing |
What hormone therapy actually does, and who it’s for
Estrogen, paired with progesterone or another progestogen if you still have a uterus, is the most effective treatment we have for hot flashes and night sweats. It cuts them by about 75 percent, usually within two weeks.1 It also treats vaginal dryness and painful sex, and it protects against fractures.2
The big shift in thinking is about timing. For women under 60 or within 10 years of their last period, with bothersome symptoms and no clear reason to avoid hormones, the benefits generally outweigh the risks (the Menopause Society’s 2022 position).3 Started much later, the balance tips the other way. Clear reasons to avoid systemic hormones include a history of breast cancer, blood clots, stroke, or active liver disease.3
The route matters too. A patch or gel (transdermal estrogen) doesn’t carry the clot risk that the older oral pills do.4 And the safety story is more reassuring than its reputation: the famous WHI trial that scared a generation off hormones enrolled mostly women well past menopause, and the absolute risks for women in their 50s starting near menopause were far smaller than the headlines suggested5 (the full breakdown is here).
If you can’t or don’t want hormones
There are good non-hormonal options now. Two newer non-hormonal drugs, fezolinetant and elinzanetant (the latter approved in late 2025), target the brain pathway behind hot flashes directly and work well, though fezolinetant requires liver monitoring.6 Older options have real evidence too: low-dose paroxetine and other SSRIs or SNRIs, gabapentin for nighttime symptoms, and cognitive behavioral therapy for the sleep and distress.6
For vaginal dryness and painful sex specifically, low-dose vaginal estrogen works locally with almost no absorption into the rest of the body, and it’s generally considered safe for long-term use, including for many breast cancer survivors.1
The limits of hormones, and what to skip
You may have heard that starting hormone therapy near menopause protects the heart. Maybe, but that claim is not as well proven as the evidence for treating hot flashes and protecting bone. The cardiovascular upside comes mostly from re-analyses of older trials, not a fresh study built to test it, so treat the “heart benefit” as suggestive rather than proven.7 Symptom relief and bone protection are the better-supported reasons to use it.
The practical thing to skip is “hormone optimization” clinics. Compounded “bioidentical” hormones and hormone pellets aren’t FDA-reviewed, deliver unpredictable doses, and pellets can’t be removed once they’re placed. ACOG recommends against them when FDA-approved options exist,8 and those approved options contain the same body-identical estradiol and progesterone, usually for less money. Saliva hormone testing to “customize” your dose isn’t validated.8 The legitimate version of this care comes from a regular doctor.
Treat the symptoms, skip hormone optimization
If you’re in your 40s or 50s with irregular periods and symptoms that bother you, you don’t need a blood test to start the conversation. You need a doctor willing to have it. If hot flashes, sleep, or mood are the main problem, hormone therapy is the most effective option. That is especially true if you’re within about 10 years of menopause and have no clear reason to avoid hormones. A transdermal patch or gel is usually the version worth asking about.
If hormones are off the table, the non-hormonal drugs are much better than they used to be. For vaginal symptoms, ask specifically about local vaginal estrogen. And skip the pellets and the compounded “optimization.” The real treatments are well understood, and most women have been undersold on them.