What is the treatment for perimenopausal irregular bleeding in a 50-year-old woman?

From the Guidelines

For a 50-year-old woman experiencing perimenopausal irregular bleeding, the most effective treatment approach is often hormonal therapy, with options including combined hormonal contraceptives, cyclic progestin therapy, or continuous progestin options like the levonorgestrel IUD, as recommended by the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1. When considering treatment for perimenopausal irregular bleeding, it's crucial to explore patient goals and preferences, including continued method use or method discontinuation, as outlined in the 2024 guidelines 1.

Key Considerations

• Before initiating treatment, it's essential to rule out underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, as suggested by the 2024 guidelines 1.
• For women using contraceptive methods, such as the copper intrauterine device (Cu-IUD), levonorgestrel intrauterine device (LNG-IUD), implant, injectable (DMPA), or combined hormonal contraceptives (CHC), treatment options may vary depending on the patient's preferences, treatment goals, and medical history, as outlined in the 2024 guidelines 1.

Treatment Options

• Combined hormonal contraceptives can provide cycle control and contraception, with options including pills containing ethinyl estradiol 20-35 mcg with progestin.
• Cyclic progestin therapy using medroxyprogesterone acetate 10 mg daily for 10-14 days each month can regulate bleeding patterns.
• Continuous progestin options include the levonorgestrel IUD (Mirena), which provides both local hormonal effects and contraception for up to 7 years.
• Non-hormonal options include tranexamic acid 1300 mg three times daily during heavy bleeding days or nonsteroidal anti-inflammatory drugs like ibuprofen 600 mg three times daily during menses, as recommended by the 2024 guidelines 1.

Important Notes

• It's essential to consider the patient's individual needs and medical history when selecting a treatment option, as emphasized by the 2024 guidelines 1.
• Regular evaluation and follow-up are necessary to monitor the effectiveness of treatment and address any potential side effects or concerns, as suggested by the 2024 guidelines 1.

From the FDA Drug Label

3 Vaginal Bleeding In cases of breakthrough bleeding, as in all cases of irregular bleeding per vaginum, nonfunctional causes should be borne in mind and adequate diagnostic measures undertaken. 6. Use with Estrogen Studies of the addition of a progestin product to an estrogen replacement regimen for seven or more days of a cycle of estrogen administration have reported a lowered incidence of endometrial hyperplasia

The treatment for perimenopausal irregular bleeding in a 50-year-old woman may involve the use of progestin products, such as medroxyprogesterone acetate, in combination with estrogen to reduce the incidence of endometrial hyperplasia. However, it is essential to rule out nonfunctional causes of bleeding and undertake adequate diagnostic measures. 2

From the Research

Treatment Options for Perimenopausal Irregular Bleeding

• The treatment for perimenopausal irregular bleeding in a 50-year-old woman can vary depending on the cause and severity of the bleeding 3.
• Heavy menstrual bleeding causing anaemia will need immediate treatment, while less severe cases and intermenstrual bleeding may be managed expectantly 3.
• Hormonal treatment, such as oral progestogens, combined oral contraceptives, or insertion of the levonorgestrel intrauterine system, may be a possibility if anovulatory bleeding is interfering with quality of life 3, 4, 5.
• The amount of bleeding can be reduced by antifibrinolytic and non-steroidal anti-inflammatory drugs, progestogens, and the levonorgestrel intrauterine system 3, 4, 5.
• Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures 3, 4.
• Endometrial ablation or endometrial resection are good choices in selected cases, but some women will need a hysterectomy to treat their abnormal uterine bleeding in perimenopause 3, 4.

Medical Management

• Medical therapies suitable for perimenopausal women with heavy bleeding include intrauterine levonorgestrel, oral progestogens, the combined oral contraceptive pill, tranexamic acid, mefenamic acid, danazol, and gonadotrophin-releasing hormone (GnRH) analogues 5.
• Oral contraceptives can regularize menses, reduce the need for surgical intervention for benign menstrual conditions, and decrease the risk of postmenopausal hip fractures 6, 7.
• Combined oral contraceptives can help control menstrual irregularity, heavy menstrual bleeding, and vasomotor symptoms, and significantly reduce the risk of ovarian cancer, endometrial cancer, and colorectal cancer 7.

Diagnostic Evaluation

• Transvaginal ultrasound is an ideal first step for the evaluation of perimenopausal abnormal uterine bleeding, and saline or gel contrast sonohysterography can improve diagnostic accuracy 3.
• Measurement of haemoglobin and iron levels, human chorion gonadotropin, and thyroid hormones are relevant in selected cases, and endometrial biopsy or hysteroscopy can be planned based on ultrasound findings 3, 4.