How to manage irregular bleeding during perimenopause?

Management of Irregular Bleeding in Perimenopause

The levonorgestrel intrauterine system (LNG-IUD) is the most effective treatment for managing irregular bleeding during perimenopause, followed by oral progestogens, combined oral contraceptives, and non-hormonal options like tranexamic acid. 1, 2

Diagnostic Approach

Before initiating treatment, it's essential to rule out serious underlying conditions:

1. Exclude malignancy: Adequate diagnostic measures, including directed or random endometrial sampling, should be undertaken to rule out malignancy in women with undiagnosed persistent or recurring abnormal genital bleeding 3

2. Initial evaluation:

   • Transvaginal ultrasound as first-line assessment
   • Saline or gel contrast sonohysterography if needed for better diagnostic accuracy
   • Endometrial biopsy or hysteroscopy based on ultrasound findings 1
   • Rule out pregnancy with hCG testing
   • Check hemoglobin and iron levels if heavy bleeding is present

3. Common causes in perimenopause:

   • Anovulatory cycles due to declining ovarian function
   • Uterine fibroids (increase with age)
   • Endometrial polyps
   • Endometrial hyperplasia 1, 4

Treatment Algorithm

First-line options:

1. Levonorgestrel intrauterine system (LNG-IUD):

   • Most effective medical treatment for heavy menstrual bleeding
   • Provides contraception with >99% efficacy (typical failure rate 0.1-0.2%)
   • Reduces menstrual blood loss significantly 1, 2, 5

2. Hormonal options:

   • Combined oral contraceptives:

     • Effective for decreasing blood loss and improving cycle regularity
     • Typical failure rate 5-9%
     • Contraindicated in women with high risk of thromboembolic events 6, 5

   • Oral progestogens:

     • Effective for anovulatory bleeding
     • Can be used cyclically (10-12 days per month) or continuously
     • Cancels proliferative effects of estrogen, reducing endometrial cancer risk 4
     • Typical failure rate 5-9% 5

   • Depot medroxyprogesterone acetate (DMPA):

     • Efficacy 94-97% (typical failure rate 0.3-6%)
     • May reduce vasomotor symptoms
     • Potential risk of decreased bone mineral density 5

3. Non-hormonal options:

   • Tranexamic acid:

     • Antifibrinolytic that reduces menstrual blood loss
     • Take only during days of heavy bleeding 1, 2

   • Non-steroidal anti-inflammatory drugs (e.g., mefenamic acid):

     • Reduces menstrual blood loss
     • Take during days of bleeding 1, 2

For focal lesions:

• Hysteroscopic procedures for endometrial polyps or submucous fibroids 1
• Endometrial ablation/resection for selected cases without desire for future fertility 1

Last resort:

• Hysterectomy for severe, treatment-resistant cases 1

Special Considerations

1. Severity assessment:

   • Heavy bleeding causing anemia requires immediate treatment
   • Less severe cases may be managed expectantly 1

2. Contraception needs:

   • Contraception should be maintained until menopause is confirmed (usually around age 51) 5
   • When using estrogen therapy in postmenopausal women with a uterus, progestin should also be initiated to reduce endometrial cancer risk 3

3. Warning signs requiring further investigation:

   • Persistent or recurring abnormal bleeding
   • Postmenopausal bleeding
   • Rapid growth of fibroids
   • Severe anemia 7, 3

4. Follow-up:

   • Regular assessment at 3-6 month intervals to determine if treatment is still necessary 3
   • Reevaluate if bleeding patterns change or worsen

Pitfalls to Avoid

1. Missing endometrial cancer: Irregular bleeding in perimenopause can mask symptoms of underlying pathology. Always consider endometrial sampling in persistent cases 3

2. Underestimating blood loss: Perimenopausal women often underreport the severity of bleeding; assess for anemia and impact on quality of life 1

3. Inappropriate hormonal therapy: Use the lowest effective dose for the shortest duration consistent with treatment goals and risks 3

4. Neglecting structural causes: Fibroids and polyps increase with age and are common causes of abnormal bleeding in perimenopause 1, 7