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A case vignette describing management of menopausal symptoms and migraine in the perimenopause
  1. Katherine Louise Gilmore,
  2. Diana Mansour
  1. Newcastle Hospitals NHS Foundation Trust, Newcroft House, Newcroft Centre, Newcastle, UK
  1. Correspondence to Dr Katherine Louise Gilmore, Sexual health, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK; katherinegilmore{at}

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Michelle, a 49-year-old nurse, attends your clinic for a discussion about the menopause. She describes having hot flushes and night sweats, frequent migraines, disturbed sleep, anxiety and poor memory. She is using a 52 mg levonorgestrel-releasing intrauterine system (LNG IUS 52 mg) to control her heavy menstrual bleeding and has not had a ‘period’ for several years. Her mother was diagnosed with breast cancer when she was 55.


Michelle is keen to explore HRT.


She has tried sage (over the counter) with little benefit and is interested in knowing more about alternative therapies such as bioidentical hormone replacement therapy (HRT) as well as standard HRT.


Improvement in vasomotor symptoms and migraines.

Key messages

  • Migraine can be triggered in the perimenopause by fluctuating oestrogen levels and vasomotor symptoms. Migraine with aura is not a contraindication to transdermal HRT and may reduce headache frequency.

  • Many women enquire about alternative therapies including compounded ‘bio-identical’ HRT. These products are unlicensed, unregulated with limited evidence supporting efficacy and safety. ‘Body-identical’ HRT however, (transdermal oestradiol and oral micronised progesterone) can be prescribed and effectively treats menopausal symptoms.

  • NICE guideline on familial breast cancer outlines situations where women with a positive family history but without a personal history of breast cancer, can be cared for in primary care and receive HRT.


This case vignette illustrates a common presentation of perimenopausal women demonstrating the importance of individualising care to meet each woman’s needs. All women experience menopause, yet symptoms vary and making a diagnosis is challenging, particularly if they are using progestogen-only contraception. The average age of the menopause in Europe is 51 years, but this may be influenced by genetic, medical and environmental factors.1

The perimenopause is a time of transition, with menopausal symptoms (see figure 1) often starting 1–2 years prior to the last menstrual period. Symptoms may last …

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  • Editor's note The details of this case are fictitious. Any resemblance to actual persons, living or dead, or actual events is coincidental.

  • Contributors KG wrote the paper. DM helped revise the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.