Managing the transition without hormones

Perimenopause is a heterogeneous clinical transition characterized by fluctuating function of the hypothalamic-pituitary-ovarian axis and a broad range of symptoms that frequently occur in overlapping clusters. Although menopause hormone therapy (MHT) is effective, many women require or prefer non-hormonal approaches, and several clinically relevant symptoms are not adequately addressed by MHT alone. This review summarizes evidence-based non-hormonal strategies for the management of vasomotor symptoms, sleep disturbance and fatigue, psychological and cognitive concerns, musculoskeletal complaints, and sexual, vulvovaginal and urinary issues. The article also proposes a structured, symptom-oriented clinical framework based on assessment of symptom burden and consideration for functional impact, patient priorities, comorbidities, contraindications and differential diagnoses. Management options include cognitive behavioral therapy, neurokinin receptor antagonists, selected antidepressants and other targeted pharmacotherapies, pelvic floor therapy and individualized lifestyle interventions. Treatment should be selected through shared decision-making, reassessed after a defined interval, and combined or escalated when response is insufficient. A structured algorithm can support consistent clinical decision-making while preserving the individualized and multidimensional care required during the menopausal transition.