Questions to ask your doctor about perimenopause

A perimenopause visit goes better when you arrive knowing what you want to find out. Appointments are short, the topic sits between specialties, and many clinicians received little training in it. The questions below are organized in the order a visit usually runs: is this perimenopause, what are my options, what are the risks for me, and what happens next. Pick the ones that matter to you and bring them written down.

Before you go

• Keep a two-week log of symptoms, sleep and hot flashes. Our symptom check produces a one-page summary.
• Write down your cycle history for the past 12 months: dates, flow, skipped periods, anything unusual.
• List every medication and supplement.
• Note your personal and family history of breast cancer, blood clots, stroke, heart disease and osteoporosis. These shape which treatments are appropriate.
• Decide your top three concerns and say them first.

Is this perimenopause?

“Do my symptoms and cycle changes fit perimenopause, or could something else explain them?” ACOG describes perimenopause as the years leading up to menopause when estrogen begins to fluctuate, usually in the 40s and sometimes the late 30s, with cycles that become longer or shorter, skipped periods, and lighter or heavier flow. The NIA notes that most women begin the transition between 45 and 55 and that it can last several years. The diagnosis is clinical. Thyroid disease, depression, iron deficiency and sleep apnea can mimic parts of it, so it is fair to ask what else is on the list.

“Do I need any blood tests?” Not to diagnose perimenopause. Hormone levels vary too much to be useful at this stage. Tests make sense to rule out other causes, or if your periods stopped before 40, which raises the question of premature ovarian insufficiency; see POI: menopause before 40.

“Is any of my bleeding abnormal?” ACOG lists bleeding between periods, after sex, heavier or longer than usual, and any bleeding after menopause as changes that should be evaluated. Say exactly what you have noticed. If the clinician does not ask about bleeding, raise it yourself.

What are my options?

“Do you prescribe menopausal hormone therapy? Do you also offer non-hormonal prescription options?” This is the single most useful question. If the answer to both is no, you are in the wrong office for this problem, and you can ask for a referral or look for a menopause specialist.

“Which of my symptoms would hormone therapy help, and which would it not?” The Menopause Society’s 2022 position statement describes hormone therapy as the most effective treatment for hot flashes and night sweats and for genitourinary symptoms (vaginal dryness, pain with sex, urinary irritation), and notes it prevents bone loss and fracture. Sleep and mood often improve when night sweats stop, but hormone therapy is not an antidepressant or a sleep medication.

“If I use hormone therapy, what type, dose and route would you suggest, and why?” Estrogen comes as pills, patches, gels and sprays; women with a uterus also need a progestogen to protect the uterine lining. ACOG notes that non-oral forms may carry less risk of deep vein thrombosis than pills. Women whose only problem is vaginal dryness can use low-dose vaginal estrogen, which acts locally. Ask the clinician to explain the choice for you specifically.

“What are my non-hormonal options?” The Menopause Society’s 2023 statement rates cognitive behavioral therapy, clinical hypnosis, certain SSRIs and SNRIs, gabapentin and fezolinetant as supported by good evidence for hot flashes (Level I), with oxybutynin close behind. Fezolinetant, approved by the FDA in May 2023, is a non-hormonal pill that blocks the brain pathway that triggers hot flashes; it requires liver blood tests before starting and periodically in the first months. The same statement does not recommend supplements and herbal remedies, soy products or acupuncture for hot flashes based on the evidence reviewed.

If your main problem is…	Ask about
Hot flashes and night sweats	Hormone therapy; fezolinetant; SSRI/SNRI; gabapentin; CBT or hypnosis
Waking at 3 a.m.	Night sweats as the cause; CBT for insomnia; see why perimenopause wakes you at 3 a.m.
Vaginal dryness, painful sex, urinary urgency	Low-dose vaginal estrogen; vaginal DHEA; moisturizers and lubricants
Low mood, anxiety, irritability	Screening for depression; therapy; SSRI/SNRI; whether hormone therapy fits
Heavy or erratic periods	Evaluation of the bleeding; hormonal IUD; cycle control options

What are the risks for me?

“Given my history, what are the risks of hormone therapy, and how do they compare with not treating?” The 2022 statement says that for women under 60 or within 10 years of menopause onset who have no contraindications, the benefit-risk ratio is favorable for treating bothersome hot flashes and preventing bone loss. Starting more than 10 years after menopause or after 60 carries higher absolute risks of heart disease, stroke, blood clots and dementia. ACOG lists small increased risks of stroke, deep vein thrombosis and, with combined therapy, breast cancer. The answer should be about your numbers, not a blanket yes or no.

“Does anything in my history rule out estrogen?” History of breast cancer, a prior blood clot or stroke, active liver disease, unexplained vaginal bleeding and migraine with aura on certain formulations all change the conversation; see perimenopause and migraine. If a contraindication applies, ask which non-hormonal options fit.

“Is what you are prescribing FDA-approved?” ACOG recommends FDA-approved hormone therapy over compounded preparations, which are not reviewed for safety, effectiveness or consistency. If you are offered compounded “bioidentical” hormones or pellets, ask why an approved product would not work.

What happens next?

“How will we know if it is working, and when do we follow up?” A follow-up two to three months after starting treatment is typical. Ask what improvement to expect, what side effects are common early on, and what should prompt an earlier call.

“What should I do about contraception?” You can still get pregnant during perimenopause. The NIA advises using contraception until 12 months after your last period. Hormone therapy is not contraception.

“What screening should I be doing at this age?” Mammograms, cervical screening, blood pressure, cholesterol, diabetes screening and, depending on risk, bone density. Midlife is when heart disease risk factors become more common, as ACOG notes, so this is a reasonable moment for a check.

“Can you send me a summary of today’s plan?” Most practices can post an after-visit summary in the patient portal. Having the plan written down prevents confusion about doses and follow-up.

If you feel dismissed

“That’s just your age” is a description, not a plan. You can respond: “What are my treatment options for these symptoms?” If the answer is none, ask for a referral to someone who treats menopause, or find one through our directory. Your records belong to you, and a second opinion is normal.