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11/1/2018

Evaluation and Management of Bleeding in Perimenopausal Women

The perimenopause is defined as the onset of intermenstrual cycle variability (±7 days) and/or classic menopausal symptoms through two years after the final menstrual period. Menopause is achieved after 12 completed months of amenorrhea. During the menopausal transition, menstrual cycle inconsistencies are a reflection of the decreasing number of ovarian follicles and the resulting variability of hormone secretion and oligoovulation. 

Abnormal uterine bleeding in perimenopausal women is generally caused by AUB-O (ovulatory dysfunction). In early perimenopause, elevated FSH levels lead to the development of multiple follicles.  Pregnancy is still possible, as a small portion of cycles may still be ovulatory. Endometrial hyperplasia should be considered in perimenopausal women with prolonged heavy bleeding or with risk factors such as obesity, family history, hypertension, diabetes, sources of unopposed estrogen, and nulliparity.

Evaluation begins with performing a focused history on menstrual patterns, vasomotor symptoms, and genitourinary syndrome of menopause (GSM).  Physical examination should evaluate for location of bleeding, assessment for structural causes, and GSM. A pregnancy test should be performed. Evaluation for structural causes of AUB, such as endometrial polyps, adenomyosis, and leiomyomas should be performed in women with persistent, heavy, or otherwise unexplained bleeding. AUB can be a sign of endometrial hyperplasia or cancer, so patients over 45 (or younger with coexistent risk factors) with suspected anovulatory bleeding, particularly if bleeding is very heavy, prolonged, or intermenstrual, should have an endometrial biopsy. Hysteroscopy may be necessary after a benign office biopsy if bleeding is persistent or imaging suggests a focal lesion.

Women over 45 with typical vasomotor symptoms of menopause and increasing length between bleeding and without intermenstrual bleeding should be offered anticipatory counseling on the menopause transition. No further hormonal testing is necessary, as changes in menstrual bleeding patterns are a better predictor of menopause than hormonal assays.  Early follicular FSH levels can fluctuate, from menopausal levels of 25 IU/L, to normal reproductive levels.  Because of the variability in FSH levels, it should not be used in the evaluation of the perimenopausal patient.

Several medical management modalities for AUB have added benefits of pregnancy prevention, control of vasomotor symptoms, and treatment of heavy vaginal bleeding associated with AUB-O.  The levonorgestrel IUD is an excellent option for the menopausal transition, protecting the endometrium, decreasing menstrual blood loss, and offering highly effective contraception.  Low dose combined oral contraceptive pills have these benefits while also relieving vasomotor symptoms and GSM.  Both treatment options can be continued long term based on the patient’s symptoms and need for further hormone therapy.  Cyclic oral progestin and cyclic combined hormone therapy are also options for cycle control and endometrial protection. However, neither of these options prevents pregnancy.

Acute heavy vaginal bleeding is a common problem in perimenopausal women. The likely etiology is irregular and incomplete shedding of proliferative endometrium as a result of anovulation.  Effective medical management includes use of high dose progestins, high dose estrogen, a combination oral contraceptive taper regimen, or tranexamic acid. When medical management fails, acute bleeding may be controlled with curettage or balloon tamponade.

Further Reading:

Committee on Practice Bulletins—Gynecology. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013 Jul;122(1):176-85. doi: 10.1097/01.AOG.0000431815.52679.bb.. Reaffirmed 2018

North American Menopause Society. (2019). Menopause Practice: A Clinician’s Guide (6th edition).

Initial Approval September 2018, Published November 2018; Revised September 2020, Minor Revision March 2022

 

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