What is the initial evaluation and management approach for perimenopausal women with prolonged menstrual bleeding?

Initial Evaluation and Management of Prolonged Menstrual Bleeding in Perimenopausal Women

The initial evaluation for perimenopausal women with prolonged menstrual bleeding should include transvaginal ultrasound as the first-line imaging study, followed by endometrial sampling if structural abnormalities are identified or if bleeding is severe or persistent.

Initial Assessment

History and Physical Examination Focus

• Determine bleeding pattern characteristics:
  • Duration of bleeding episodes
  • Frequency of bleeding
  • Severity (number of pads/tampons used)
  • Associated symptoms (pain, clots)
• Risk factors for endometrial cancer:
  • Obesity
  • Diabetes
  • Hypertension
  • Family history of endometrial or colon cancer
• Medication history:
  • Antiplatelet therapy
  • Anticoagulants
  • Hormone therapy

Laboratory Testing

• Complete blood count to assess for anemia
• Pregnancy test to exclude pregnancy-related bleeding
• Thyroid function tests if symptoms suggest thyroid dysfunction
• Coagulation studies if bleeding disorder is suspected

Diagnostic Approach

First-Line Imaging

• Transvaginal ultrasound (TVUS) to assess:
  • Endometrial thickness
  • Structural abnormalities (fibroids, polyps, adenomyosis)
  • Ovarian pathology 1

Additional Diagnostic Testing

• If TVUS is inconclusive or cannot fully visualize the endometrium:

  • Saline infusion sonohysterography to better evaluate endometrial cavity 1
  • MRI if adenomyosis or complex fibroids are suspected 1

• Endometrial sampling is indicated when:

  • Endometrial thickness >4mm in postmenopausal women
  • Persistent abnormal bleeding despite treatment
  • Risk factors for endometrial cancer present 2

• Hysteroscopy may be necessary for:

  • Direct visualization of endometrial cavity
  • Targeted biopsy of suspicious lesions
  • Removal of polyps or submucous fibroids 2

Management Approach

First-Line Treatment Options

1. Levonorgestrel-releasing intrauterine system (LNG-IUS):

   • Most effective medical therapy for heavy menstrual bleeding
   • Reduces menstrual blood loss by 71-95%
   • Provides contraception if needed 3, 4

2. Combined hormonal contraceptives:

   • Effective for regulating bleeding patterns
   • Good option for women without contraindications
   • Can be used cyclically or continuously 4

3. Cyclic oral progestogens:

   • Norethindrone acetate 5-10 mg daily for 5-10 days per month
   • Can help establish regular withdrawal bleeding 5
   • Less effective than LNG-IUS but suitable for women who cannot use intrauterine devices

Second-Line Treatment Options

1. Tranexamic acid:

   • Non-hormonal option
   • Taken during days of heavy bleeding
   • Contraindicated in women with history of thromboembolism 4, 2

2. Nonsteroidal anti-inflammatory drugs (NSAIDs):

   • Can reduce bleeding by inhibiting prostaglandin synthesis
   • Less effective than hormonal options but minimal side effects 1

3. Extended-cycle progestogens:

   • Norethindrone acetate 5 mg daily, increasing by 2.5 mg every two weeks up to 15 mg daily
   • Can be used for 6-9 months 5

Refractory Cases

For women with completed childbearing who fail medical management:

1. Endometrial ablation:

   • Destroys the endometrial lining
   • Effective for heavy bleeding without significant structural abnormalities
   • Contraindicated in women desiring future fertility 3

2. Hysteroscopic procedures:

   • For removal of polyps or submucous fibroids
   • Can be combined with endometrial sampling 2

3. Hysterectomy:

   • Definitive treatment for heavy bleeding
   • Consider when other treatments fail and fertility is not desired 2

Special Considerations

Women on Antiplatelet Therapy

• LNG-IUS is first-line treatment
• Endometrial ablation may be considered if LNG-IUS is insufficient 3
• Avoid tranexamic acid due to thrombosis risk 3

Women with Structural Abnormalities

• Fibroids: LNG-IUS may be effective for small intramural or subserosal fibroids
• Submucous fibroids: Consider hysteroscopic myomectomy
• Adenomyosis: LNG-IUS or extended hormonal therapy 2

Follow-up Recommendations

• Reassess bleeding pattern and treatment efficacy after 3 months
• If bleeding persists or worsens, consider advancing to next treatment option
• Monitor hemoglobin levels in women with severe bleeding
• Any postmenopausal bleeding requires immediate evaluation to exclude malignancy

Remember that perimenopausal bleeding often improves over time as women transition to menopause, but persistent heavy bleeding requires thorough evaluation and appropriate management to prevent complications such as anemia and to ensure serious pathology is not missed.