Perimenopausal Abnormal Uterine Bleeding

Perimenopausal abnormal uterine bleeding is abnormal bleeding (heavy, prolonged, frequent or irregular) in women aged 40 to 55 years in the transition to menopause. It results from irregular ovulation and unopposed oestrogen (anovulatory bleeding), and from structural disease such as endometrial polyps, fibroids, adenomyosis, hyperplasia and cancer. It matters because it is a common reason for gynaecology visits, it causes anaemia, and endometrial cancer must be excluded.

• Risk factors: age 40 to 55 years, obesity, diabetes, polycystic ovary syndrome, nulliparity, tamoxifen use, family history of endometrial or colon cancer, fibroids.
• Most perimenopausal bleeding is from anovulation, but persistent bleeding needs endometrial assessment.
• The levonorgestrel intrauterine system is an effective first-line treatment.

Women have irregular periods with heavy or prolonged bleeding, short or long cycles, flooding, spotting between periods, hot flushes, night sweats and vaginal dryness. Anaemia causes tiredness and breathlessness.

• Variable cycle length, with gaps of 60 days or more followed by heavy bleeding.
• Enlarged uterus or pelvic mass in fibroids and adenomyosis.
• Differential diagnosis: anovulatory bleeding, endometrial polyp, fibroids, adenomyosis, endometrial hyperplasia, endometrial cancer, cervical cancer, thyroid disease, bleeding disorder, pregnancy complication, hormone therapy effect.
• Complications: iron deficiency anaemia, endometrial hyperplasia and cancer, reduced quality of life, hospital admission, hysterectomy.

The approach is to exclude pregnancy and cancer and to measure haemoglobin.

• Urine hCG; menstrual diary; speculum and bimanual examination; cervical screening if due.
• Full blood count and ferritin; thyroid stimulating hormone; coagulation screen if heavy bleeding since menarche; follicle stimulating hormone is not needed to diagnose perimenopause at age 45 years or above.
• Transvaginal ultrasound for endometrial thickness (above 12 mm needs sampling), polyps, fibroids and adenomyosis; hysteroscopy and biopsy for persistent bleeding.
• Endometrial sampling for women aged 45 years or above, or younger women with obesity, persistent bleeding or treatment failure.

The principle is to exclude cancer, then to control bleeding with the levonorgestrel intrauterine system or other drugs, and to correct anaemia.

• Supportive: menstrual diary; weight loss; stop smoking; iron rich diet; counselling about the menopause transition and contraception until 1 year after the last period (2 years if age under 50 years).
• Pharmacological: levonorgestrel intrauterine system 52 mg for 5 years (also provides endometrial protection and contraception); tranexamic acid 1 g oral 8-hourly for up to 4 days during bleeding (maximum 4 g daily); mefenamic acid 500 mg oral 8-hourly with food for up to 5 days; norethisterone 5 mg oral 8-hourly on days 5 to 26 of the cycle, or medroxyprogesterone 10 mg oral once daily for 12 to 14 days each month; combined oral contraceptive pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms oral once daily for 21 days then 7 days free in healthy nonsmoking women under 50 years; ferrous sulphate 200 mg oral 12-hourly for 3 to 6 months; endometrial hyperplasia without atypia: levonorgestrel intrauterine system 52 mg for 6 months or more or medroxyprogesterone 10 mg oral once daily for 12 to 14 days each month for 3 to 6 months.
• Procedures: hysteroscopic polypectomy or fibroid resection; endometrial ablation after childbearing; uterine artery embolisation or myomectomy; hysterectomy for atypical hyperplasia, cancer, or failure of other treatment; transfusion for haemoglobin below 7 g/dL or instability.
• Special groups: women with obesity, diabetes or tamoxifen use have a low threshold for endometrial sampling; women who smoke above age 35 years, have hypertension, migraine with aura or previous clot avoid combined pills and use the levonorgestrel intrauterine system; women with atypical hyperplasia have hysterectomy.
• Red flags: postmenopausal bleeding, endometrial thickness above 12 mm, atypical hyperplasia, haemoglobin below 8 g/dL, intermenstrual or postcoital bleeding, pelvic mass, weight loss.
• Follow-up: review at 3 months with diary and haemoglobin; endometrial biopsy review at 6 months for hyperplasia on treatment; ferritin at 3 months; yearly review while on drug treatment.