Re: Clearing confusion about perimenopause

I must take issue with Dr J.C. Prior’s statement in her article [BCMJ 2005;47(10):538-542] that “one randomized controlled trial of 20 µg ethinyl estradiol-containing oral contraceptive in perimenopausal women with heavy flow showed some benefit for menorrhagia, but no significant improvement in hot flushes or quality of life.” To the contrary, the study[1] (which was Canadian) showed that the oral contraceptive-treated women had an approximately 50% reduction in hot flash frequency and severity compared with placebo. In addition, the study showed a significant improvement in quality of life in the oral contraceptive-treated women in comparison with the placebo-treated group.

The use of low-dose oral contraceptives to control perimenopausal symptoms in women remains a very important and effective treatment. I disagree with Dr Prior that micronized progesterone is a preferred treatment because I can find no evidence from randomized controlled trials to support it.

—Timothy Rowe, MB
Head, Division of Reproductive Endocrinology and Infertility, UBC

See responses to this letter

Dr Prior should be lauded for her attempts to proffer some sense to the confusion surrounding perimenopause (BCMJ 2005;47[10]:538-542). However, apart from showing us that nobody knows what is going on, and that there is no consistent or optimum therapy for this undefined disorder, she could only offer us an opportunity to refer our patients to a specialist—who it appears knows no more than the family doctor anyway. Prescribing “lifestyle changes, diet, and exercise” along with giving them instruments to tabulate their grief, is another way of telling them, “you’re getting old, so get used to it.” Such advice to age gracefully is not popular with the public. Dr Prior might have really excited our interest in perimenopause if she had teased us with the use of the king of the female replacement hormones, testosterone. Or elucidated us on the role of sex hormone binding globulins (SHBG), which tie up the bioavailability of estrogens and testosterone. And what can we do to reduce the effect of SHBG that starts to rise at the perimenopause-periandropause phase of life? Should we try to bypass the liver’s proclivity to produce SHBG by using transdermal delivery methods for hormone replacement, or maybe zinc supplements? These are some of the approaches that are coming out of the male gender medicine movement, which learned about the value of hormone replacement therapy from women. Maybe women can learn a few things from the men? Ultimately, Mother Nature is trying to kill us off after we’ve passed our genes on to a successful next generation—less hindrance to the struggling tribe. Should we accept what Mother Nature designed for us, or should we try to cheat her out of our graceful aging?

Murray Allen, MD
North Vancouver


1. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 µg ethinyl estradiol/1 mg norethindrone acetate (Minestrin), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997;4:139-147. 

Timothy C. Rowe, MBBS, FRCSC, FRCOG. Re: Clearing confusion about perimenopause. BCMJ, Vol. 46, No. 2, March, 2006, Page(s) 66 - Letters.

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