Lane 06 — Perimenopause.

Symptom log, lap 03 — three columns: hour, severity, what woke you.

Minute 03 — The window

Perimenopause — the menopausal transition — typically runs four to ten years before the final menstrual period and is defined retrospectively. The endocrine reality is messy: cycles become irregular, FSH bounces between menopausal and pre-menopausal values from one month to the next, and the symptoms most associated with the window — vasomotor flushes, sleep disruption, mood lability, joint pain, brain fog, urogenital atrophy — do not always travel together. The Menopause Society (formerly NAMS) frames this clearly in its 2022 hormone therapy position statement¹. We follow it.

The cultural problem is that primary care, in aggregate, has not been very good at this lane. The Lancet 2024 menopause series² made the case bluntly: most clinicians under-recognize perimenopausal symptoms, over-attribute them to depression or "stress," and either offer nothing or offer estrogen with insufficient counseling. We have tried to learn from that critique.

Week 02 — Tracking before treating

The first thing we do at a perimenopause visit is hand the member a paper tracker for the next six weeks: cycle (date, length, flow), sleep (bedtime, wake time, night wakings), hot flashes (count per day, severity 1–3), and mood (a single 0–10 daily check). The tracker is not a diagnostic instrument; it is a teaching instrument. By visit two we both know what the picture actually looks like, separated from the morning-of-visit recall problem.

We do not, by default, order a serum FSH on a 47-year-old member with cycle changes. The Menopause Society and the Endocrine Society both say plainly that FSH is unreliable in perimenopause³; the cycle-to-cycle variability of FSH within the menopausal transition makes a single value uninterpretable. The diagnosis is clinical.

Week 06 — Vasomotor symptoms

For moderate-to-severe vasomotor symptoms — hot flashes and night sweats — menopausal hormone therapy (MHT) remains the most effective treatment, and the 2022 Menopause Society statement supports its use in symptomatic women within ten years of menopause and under age 60 absent contraindications. Where MHT is declined or contraindicated, we use SSRIs/SNRIs (paroxetine 7.5 mg has the FDA indication; we more often use venlafaxine ER 75 mg or escitalopram 10–20 mg), gabapentin 300 mg at bedtime, or fezolinetant — the first FDA-approved selective NK3-receptor antagonist, marketed as Veozah and approved in May 2023⁴. Fezolinetant is expensive and does not cover under most high-deductible plans yet; we discuss the cost honestly.

Week 08 — Sleep

Perimenopausal sleep disruption is often a vasomotor problem dressed as an insomnia problem. Treat the night sweats and the sleep often follows. Where sleep stays broken after the flashes resolve, we work it as a primary insomnia: cognitive behavioral therapy for insomnia (CBT-I), sleep window restriction, stimulus control, and a clear-eyed conversation about the limits of pharmacotherapy. We avoid trazodone as a long-term sleep aid; we avoid benzodiazepines and z-drugs entirely for chronic perimenopausal insomnia. The American Academy of Sleep Medicine's 2021 clinical practice guideline on insomnia⁵ supports this stance.

Week 12 — Mood, separated from depression

Mood lability and irritability in the perimenopausal window are real, are common, and are not the same thing as a major depressive episode — though they can co-occur. We screen with the PHQ-9 and the GAD-7 at every visit, but we do not start an SSRI for perimenopausal mood lability alone if the depression score is low; we treat the underlying perimenopausal physiology first and watch what happens. Members with a true major depressive episode in the menopause transition follow Lane 03 management, and the two lanes share charting.

Year 01 — Menopausal hormone therapy, plainly

For members within ten years of their final menstrual period, under age 60, with moderate-to-severe vasomotor symptoms, MHT is first-line. The risk-benefit calculation reverses sharply outside that window — older or more time-distant initiation carries different risks⁶, and the conversation is different. We use estradiol transdermal patch (we like the 0.05 mg/day starting dose for most members) plus oral or vaginal progesterone; we use vaginal estrogen alone for genitourinary symptoms regardless of systemic MHT decisions. We follow the practice's lipid panel and BP at three months and six months after initiation, then yearly.

What we don't do: bioidentical-compounded MHT, salivary hormone testing, or "hormone optimization" pellet implants. Those are not evidence-based, and the Menopause Society explicitly warns against them. We will not write a letter of medical necessity for a compounded pellet, and we will not be polite about it.

Year 02 — Bone

We baseline bone-mineral density with a DEXA at the FMP (final menstrual period) for members with risk factors, and otherwise at age 65 per USPSTF recommendation. Calcium intake is dietary first; supplementation only when intake is below 1,000 mg/day. Vitamin D 800–1,000 IU/day for most members. The full-blown osteoporosis treatment conversation (bisphosphonates, denosumab, teriparatide, romosozumab) lives in the cardiometabolic-and-bone clinic with consulting endocrinology when a treatment decision is needed.

Cross-references: 04 · Reproductive for the IUD-as-progestin question during MHT; 03 · Mental health for the comorbid depressive episode; 01 · Cardiometabolic because the perimenopausal lipid trajectory deserves its own annual review. The transcript "Perimenopause as a data problem" is the longer essay version of this protocol.