If an ultrasound (ultrasound) is negative, how is perimenopause uterine bleeding treated?

From the Guidelines

Treatment for perimenopausal uterine bleeding with a negative ultrasound typically begins with medical treatments, including progestin-only contraception and combined hormonal contraception, as these have been shown to be effective in managing abnormal uterine bleeding associated with ovulatory dysfunction. According to the American College of Obstetricians and Gynecologists (ACOG) guidelines, as outlined in the study published in the American Family Physician in 2014 1, medical treatments such as progestin-only contraception and combined hormonal contraception are recommended for abnormal uterine bleeding associated with ovulatory dysfunction.

Some key points to consider in the treatment of perimenopausal uterine bleeding include:

• The use of progestin-only contraception, which can help regulate the menstrual cycle and reduce bleeding
• The use of combined hormonal contraception, which can also help regulate the menstrual cycle and reduce bleeding
• The consideration of surgery, including endometrial ablation and hysterectomy, if medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, as noted in the study 1.

It is essential to note that the PALM-COEIN classification system, developed to describe uterine bleeding abnormalities in women of reproductive age, includes both structural and nonstructural causes of bleeding, and each potential cause is linked with at least one letter qualifier specifying its etiologies, as described in the study 1.

In terms of specific treatment options, combined hormonal contraceptives and progestin-only contraception are considered first-line treatments for perimenopausal uterine bleeding with a negative ultrasound, as they have been shown to be effective in managing abnormal uterine bleeding associated with ovulatory dysfunction, as noted in the study 1.

From the FDA Drug Label

Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. Secondary amenorrhea, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen. Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.

If an ultrasound is negative, abnormal uterine bleeding due to hormonal imbalance in perimenopause can be treated with norethindrone acetate tablets. The dosage is 2.5 to 10 mg daily for 5 to 10 days to produce secretory transformation of the endometrium.

• Key points:
  • Dosage: 2.5 to 10 mg daily
  • Duration: 5 to 10 days
  • Indication: abnormal uterine bleeding due to hormonal imbalance
• Reference: 2, 2

From the Research

Treatment Options for Perimenopause Uterine Bleeding

If an ultrasound is negative, the treatment for perimenopause uterine bleeding depends on the underlying cause of the bleeding. The following are some possible treatment options:

• Hormonal treatment, such as oral progestogens, combined oral contraceptives, or insertion of the levonorgestrel intrauterine system, may be used to regulate menstrual cycles and reduce bleeding 3.
• Antifibrinolytic and non-steroidal anti-inflammatory drugs can be used to reduce the amount of bleeding 3, 4.
• Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures 3, 5.
• Endometrial ablation or endometrial resection are good choices in selected cases, but some women may need a hysterectomy to treat their abnormal uterine bleeding in perimenopause 3, 4, 5.

Medical Management

Medical management is the preferred initial approach for hemodynamically stable patients with severe bleeding 4. Treatment options include:

• Oral estrogen
• High-dose estrogen-progestin oral contraceptives
• Oral progestins
• Intravenous tranexamic acid
• The levonorgestrel-releasing intrauterine system is the most effective long-term medical treatment for heavy menstrual bleeding 6, 4.

Surgical Options

Surgical options are available for women with abnormal uterine bleeding who do not respond to medical management or have a structural cause for their bleeding 6, 3, 4, 5. These options include:

• Hysterectomy
• Endometrial ablation
• Myomectomy
• Polypectomy
• Uterine artery embolization