What is the evaluation and management approach for abnormal uterine bleeding in a perimenopausal patient?

Evaluation and Management of Abnormal Uterine Bleeding in Perimenopausal Patients

Perimenopausal women with abnormal uterine bleeding should undergo immediate evaluation with transvaginal ultrasound and endometrial biopsy due to the high risk of endometrial cancer, regardless of endometrial thickness. 1

Initial Evaluation

History and Physical Examination

• Assess bleeding pattern: frequency, duration, amount, and associated symptoms
• Evaluate for cardiovascular risk factors, smoking status, and medication use
• Perform speculum examination to exclude cervical and vaginal causes 2
• Consider the PALM-COEIN classification system:
  • Structural causes (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified 3

Laboratory Testing

• Pregnancy test (β-hCG) to rule out pregnancy-related bleeding
• Complete blood count to assess for anemia
• Thyroid-stimulating hormone and prolactin levels to rule out endocrine causes
• Consider coagulation studies if heavy bleeding is present 3, 2

Imaging and Tissue Sampling

First-Line Imaging

• Transvaginal ultrasound (TVUS) combined with transabdominal ultrasound and Doppler is the most appropriate initial imaging study 1
• Assess endometrial thickness, texture, and potential structural abnormalities

Advanced Imaging

• Sonohysterography (saline infusion sonography) if focal abnormalities are suspected:
  • 97% accuracy in distinguishing between polyps and submucosal fibroids 1
• MRI with contrast and diffusion-weighted imaging when endometrium is obscured by leiomyomas or adenomyosis:
  • Sensitivity up to 79% and specificity up to 89% for endometrial cancer 1

Tissue Sampling

• Endometrial biopsy is mandatory even if imaging appears normal
• Consider hysteroscopy for direct visualization of the uterine cavity, especially if focal lesions are suspected 2, 4

Management Approach

Acute Heavy Bleeding

• Intravenous conjugated estrogen for hemodynamically unstable patients 1
• Tranexamic acid: reduces menstrual blood loss by approximately 50%, used for 4-5 days starting from first day of menstrual cycle 1
  • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis

Medical Management Options

1. Hormonal options:

   • Levonorgestrel-releasing intrauterine device (LNG-IUD): first-line option with failure rate of 0.1-0.2% 1, 2
   • Low-dose combined oral contraceptives (≤35 μg ethinyl estradiol): regularize cycles with typical failure rate of 5-9% 1
   • Oral progestins: effective for anovulatory bleeding 2

2. Non-hormonal options:

   • Nonsteroidal anti-inflammatory drugs (NSAIDs): reduce menstrual blood loss by 25-39% 1, 5
   • Tranexamic acid: can be used in combination with hormonal methods 5

Surgical Management

• Consider when medical management fails or is contraindicated 3
• Options include:
  • Hysteroscopic procedures for focal lesions (polyps, submucosal fibroids) 2, 4
  • Endometrial ablation/resection for selected cases 2
  • Hysterectomy for definitive treatment 4

Special Considerations and Follow-up

Monitoring

• Follow-up in 4-6 weeks if bleeding persists despite treatment
• Monitor hemoglobin/hematocrit if heavy bleeding continues 1
• Blood pressure measurement required before initiating combined hormonal contraceptives 1

Risk Factors to Consider

• Smoking is not a contraindication to COC use in women younger than 35 years
• Women with cardiovascular risk factors should consider progestin-only methods like LNG-IUD 1

Common Pitfalls and Caveats

• Never dismiss abnormal bleeding in perimenopausal women as "normal perimenopause" without thorough evaluation
• Endometrial cancer risk increases significantly in the perimenopausal period; biopsy is essential even with normal imaging
• Focal lesions may be missed with blind endometrial sampling; consider hysteroscopy when suspicion is high
• While hysteroscopic treatments have high patient satisfaction, they don't eliminate the risk of AUB recurrence or need for further intervention 4
• Consider the impact of different treatment options on quality of life and sexuality during shared decision making 4