What are the diagnostic approaches for perimenopausal bleeding?

From the Guidelines

Diagnosing perimenopausal bleeding requires a comprehensive approach including medical history, physical examination, and appropriate testing, with a focus on ruling out structural and nonstructural causes of abnormal uterine bleeding, as outlined in the PALM-COEIN classification system 1. To diagnose perimenopausal bleeding, the following steps should be taken:

• Obtain a detailed menstrual history, noting changes in frequency, duration, and heaviness of bleeding, as well as associated symptoms like hot flashes, mood changes, and sleep disturbances.
• Perform a complete physical examination, including a pelvic examination, to check for anatomical causes.
• Laboratory tests should include a complete blood count to assess for anemia, thyroid function tests, and hormone levels including FSH, estradiol, and progesterone.
• Transvaginal ultrasound is essential to evaluate endometrial thickness and identify structural abnormalities like fibroids or polyps, as recommended by the American College of Radiology 1.
• If the endometrial thickness exceeds 4-5mm or bleeding is persistent, an endometrial biopsy should be performed to rule out hyperplasia or malignancy.
• Saline infusion sonography or hysteroscopy may be needed for further evaluation of intracavitary lesions. The goal of these diagnostic steps is to distinguish between normal perimenopausal changes and concerning pathology that requires intervention, and to identify the underlying cause of the bleeding, whether it be structural, such as polyps or fibroids, or nonstructural, such as ovulatory dysfunction or coagulopathy 1. The most recent and highest quality study, published in 2020, recommends a thorough history, physical examination, and appropriate laboratory tests, as well as imaging to assess for structural abnormalities, as the initial steps in the diagnosis of perimenopausal bleeding 1.

From the Research

Diagnostic Approach

To diagnose perimenopausal bleed, the following steps can be taken:

• A thorough medical history and physical examination should be conducted to identify any underlying causes of abnormal uterine bleeding 2, 3
• A speculum examination should be performed to exclude cervical and vaginal causes of abnormal uterine bleeding 2
• Laboratory tests such as measurement of haemoglobin and iron levels, human chorion gonadotropin, and thyroid hormones may be relevant in selected cases 2, 4
• Transvaginal ultrasound is an ideal first step for the evaluation of perimenopausal abnormal uterine bleeding, and saline or gel contrast sonohysterography can improve diagnostic accuracy 2, 3

Exclusion of Other Causes

The following causes should be excluded:

• Sexually transmitted diseases or pregnancy should be ruled out 2
• Thyroid disease, which can be challenging to diagnose in perimenopausal women, should be considered 4
• Bleeding disorders, such as von Willebrand's disease, should be investigated if suspected 5

Further Evaluation

Based on the initial evaluation, further testing may be necessary:

• Endometrial biopsy or hysteroscopy may be planned if premalignant or malignant causes are suspected 2, 6
• Endometrial tissue sampling may be necessary in women at high risk for endometrial cancer or in those who do not respond to medical treatment 6