What is the best approach to manage prolonged menstrual bleeding in perimenopausal women?

Management of Prolonged Menstrual Bleeding in Perimenopausal Women

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for prolonged menstrual bleeding in perimenopausal women, reducing menstrual blood loss by approximately 50% while providing effective contraception with a failure rate of only 0.1-0.2%. 1

Diagnostic Approach

Before initiating treatment, a thorough evaluation is essential to rule out underlying pathology:

1. Use the PALM-COEIN classification system to categorize potential causes:

   • Structural causes (PALM): Polyps, Adenomyosis, Leiomyomas, Malignancy
   • Non-structural causes (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified 1, 2

2. Initial imaging:

   • Transvaginal ultrasound combined with transabdominal ultrasound and Doppler as the first imaging study 1
   • Consider sonohysterography for detecting focal endometrial abnormalities with 97% accuracy 1
   • MRI with contrast for cases where endometrium is obscured by leiomyomas or adenomyosis 1

3. Laboratory testing:

   • Pregnancy test and complete blood count 2
   • Consider thyroid function tests and iron studies in selected cases 3

4. Endometrial sampling:

   • Mandatory in women with abnormal uterine bleeding, even if imaging appears normal 1
   • Particularly important in perimenopausal women due to increased risk of endometrial hyperplasia and malignancy 3

Treatment Algorithm

First-Line Treatments:

1. Levonorgestrel-releasing intrauterine device (LNG-IUD):

   • Most effective medical treatment for heavy menstrual bleeding 1, 2
   • Reduces menstrual blood loss by approximately 50% 1
   • Provides effective contraception (failure rate 0.1-0.2%) 1
   • Improves bleeding profile and quality of life 3

2. Tranexamic acid:

   • Reduces menstrual blood loss by approximately 50% 1
   • Use for 4-5 days starting from the first day of menstrual cycle 1
   • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1

3. NSAIDs (e.g., ibuprofen, mefenamic acid):

   • Reduces menstrual blood loss by 25-39% compared to placebo 1
   • Take during menstruation for 5-7 days 4
   • Less effective than LNG-IUD but fewer side effects than hormonal options 2

Second-Line Treatments:

1. Combined oral contraceptives (COCs):

   • Low-dose COCs (≤35 μg ethinyl estradiol) regularize cycles and provide contraception 1
   • Typical failure rate of 5-9% 1
   • Particularly useful for women who also need contraception 2, 5
   • Consider cardiovascular risk factors before prescribing 1

2. Oral progestins:

   • Effective for managing irregular menstrual bleeding 3
   • Can be used cyclically or continuously 6
   • Consider in women with contraindications to estrogen 2

For Acute Heavy Bleeding:

1. Intravenous conjugated estrogen:

   • For short-term use only in cases of acute abnormal uterine bleeding 1
   • Particularly for hemodynamically unstable patients 1, 2

2. High-dose estrogen-progestin oral contraceptives:

   • For initial treatment of severe bleeding in hemodynamically stable patients 2

Surgical Options (when medical management fails):

1. Endometrial ablation:

   • Performs as well as LNG-IUD for long-term management 2
   • Good choice for selected cases 3

2. Hysteroscopic procedures:

   • For focal intrauterine lesions such as endometrial polyps or submucous myomas 3
   • Hysteroscopic myomectomy for submucosal fibroids 4

3. Hysterectomy:

   • Definitive treatment when other options fail 2, 3

Follow-up and Monitoring

• Follow-up in 4-6 weeks if bleeding persists despite treatment 1
• Monitor hemoglobin/hematocrit if heavy bleeding continues 1
• Measure blood pressure before and during use of combined hormonal contraceptives 1
• Monitor for mood changes after initiating contraception, particularly during first 1-3 months 1

Important Considerations and Pitfalls

• Smoking is not a contraindication to COC use in women younger than 35 years, but women with cardiovascular risk factors should consider progestin-only methods like LNG-IUD 1
• Endometrial sampling is crucial in perimenopausal women with abnormal bleeding, as early malignancy may not be visible on imaging 1
• Continued fibroid growth or bleeding after menopause should raise suspicion for uterine sarcoma 4
• Patients with substance use, mental illness, or medication adherence difficulties may benefit from long-acting reversible contraceptives like the LNG-IUD 1
• In cases of acute severe bleeding causing hemodynamic instability, consider uterine tamponade, intravenous estrogen, dilation and curettage, or uterine artery embolization 2