What are the treatment options for perimenopause bleeding?

Treatment Options for Perimenopause Bleeding

The most effective treatment option for perimenopause bleeding is low-dose combined oral contraceptives (COCs) containing 30-35 μg of ethinyl estradiol, which can be used for both short-term management of acute bleeding episodes and long-term management of irregular bleeding patterns. 1, 2

First-Line Treatment Options

• NSAIDs (such as ibuprofen or naproxen) for 5-7 days during days of bleeding can effectively reduce blood flow and are recommended as initial treatment for mild to moderate bleeding 3, 1
• Low-dose COCs containing 30-35 μg of ethinyl estradiol for 10-20 days are recommended for short-term treatment of heavy or prolonged bleeding 3, 1
• For long-term management, monophasic COCs containing 30-35 μg of ethinyl estradiol provide both menstrual regulation and effective contraception 2
• The contraceptive vaginal ring (NuvaRing) can be an alternative to oral contraceptives, providing comparable effectiveness with a simpler regimen 2

Treatment Algorithm for Perimenopause Bleeding

Initial Assessment

• Rule out pregnancy, malignancy, and other underlying gynecological problems before starting treatment 3, 4
• If clinically indicated, consider transvaginal ultrasound as an ideal first step for evaluation 5

Treatment Based on Severity

1. For mild to moderate bleeding:

   • NSAIDs for 5-7 days during days of bleeding 3, 1

2. For heavy or prolonged bleeding:

   • Low-dose COCs containing 30-35 μg ethinyl estradiol for 10-20 days 3, 1
   • Consider levonorgestrel intrauterine system (LNG-IUS) as the most effective option for long-term management 6

3. For persistent bleeding despite treatment:

   • Consider endometrial biopsy or hysteroscopy to rule out endometrial pathology 5
   • For focal intrauterine lesions such as polyps or submucous fibroids, operative hysteroscopic procedures may be required 5

Specific Treatment Options

Hormonal Options

• Combined oral contraceptives (COCs): Provide both menstrual regulation and contraception 2, 7
• Levonorgestrel intrauterine system (LNG-IUS): Most effective medical therapy for heavy menstrual bleeding 6
• Oral progestogens: Can be used cyclically (10-14 days per month) or continuously 5, 6
• Depot medroxyprogesterone acetate (DMPA): Can be considered as a second-line treatment 2

Non-Hormonal Options

• NSAIDs: Reduce blood loss by 20-40% through inhibition of prostaglandin synthesis 6
• Tranexamic acid: Antifibrinolytic that reduces menstrual blood loss by approximately 50% 6

Important Considerations and Monitoring

• COCs increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years) 1, 2
• Blood pressure should be monitored at follow-up visits for patients on hormonal treatments 1, 2
• Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful has been shown to reduce method discontinuation 3, 1
• For breakthrough bleeding on COCs, consider NSAIDs for 5-7 days or a brief hormone-free interval if using extended regimen 2

Surgical Options (When Medical Management Fails)

• Hysteroscopic procedures for focal lesions such as endometrial polyps or submucous fibroids 5
• Endometrial ablation or resection for selected cases 5
• Hysterectomy may be necessary in cases where other treatments fail 5

Contraception During Perimenopause

• Contraception should continue until menopause is confirmed (12 months of amenorrhea) 8
• Hormonal contraceptives provide many non-contraceptive benefits including treatment of abnormal bleeding, relief from vasomotor symptoms, and endometrial protection 7