What are the management options for dysfunctional uterine bleeding in perimenopausal women?

From the Guidelines

The most effective management option for dysfunctional uterine bleeding in perimenopausal women is a personalized approach that considers the woman's reproductive goals, bleeding severity, and underlying causes, with first-line medical therapy typically involving hormonal treatments such as combined oral contraceptives or the levonorgestrel intrauterine system, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. Management options for dysfunctional uterine bleeding in perimenopausal women include both medical and surgical approaches.

• Medical treatments for abnormal uterine bleeding associated with ovulatory dysfunction include progestin-only contraception and combined hormonal contraception, as outlined in the ACOG guidelines 1.
• If medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery, including endometrial ablation and hysterectomy, may be an option, with treatment decisions based on therapeutic goals such as stopping acute bleeding, avoiding heavy bleeding, and preventing complications 1. Key considerations in managing dysfunctional uterine bleeding in perimenopausal women include:
• Ruling out structural abnormalities, malignancy, and coagulopathies through appropriate evaluation, including pelvic examination, imaging, and sometimes endometrial sampling.
• Individualizing treatment based on the woman's age, bleeding severity, comorbidities, and future fertility desires.
• Providing informed consent and counseling for women considering endometrial ablation, including discussion of possible long-term complications such as postablation Asherman syndrome, synechiae, and delayed endometrial cancer diagnosis 1.

From the Research

Management Options for Dysfunctional Uterine Bleeding in Perimenopausal Women

The management of dysfunctional uterine bleeding (DUB) in perimenopausal women involves various medical and surgical approaches. The following are some of the options:

• Medical treatment:
  • Cyclic progestin or cyclic conjugated equine estrogens for 25 days with the concomitant administration of medroxyprogesterone acetate for days 18 to 25 2
  • Low-dose combination oral contraceptives for nonsmokers without evidence of vascular disease 2
  • Nonsteroidal anti-inflammatory drugs, antifibrinolytic agents, danazol, and gonadotropin-releasing hormone agonists 2, 3, 4
• Surgical treatment:
  • Endometrial ablation 3, 4, 5
  • Hysterectomy 2, 3, 4, 5

Considerations for Treatment

When selecting a treatment option, it is essential to consider the individual patient's needs and medical history. For example:

• Patients with risk factors for endometrial cancer should undergo endometrial biopsy 5
• Patients with hyperplasia without atypia may be treated with cyclic or continuous progestin 5
• Patients with von Willebrand's disease may require specific treatment, such as high-concentration desmopressin acetate nasal spray 2

Effectiveness of Treatment Options

The effectiveness of different treatment options varies:

• Antifibrinolytic tranexamic acid is the most effective medical therapy for DUB 4
• The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia 4, 5
• Hysterectomy is the most definitive treatment, but it has a relatively high complication rate 4, 5