What is the treatment for irregular menstrual cycles during perimenopause in a 50-year-old woman?

From the Guidelines

To treat irregular menstrual cycles during perimenopause in a 50-year-old woman, hormone therapy is the most effective intervention, and estrogen therapy alone is recommended for women who have had a hysterectomy, as it has a more beneficial risk/benefit profile 1. When considering treatment options, it's essential to evaluate the patient's specific symptoms, medical history, and whether they need contraception.

• Low-dose combination hormonal contraceptives (containing estrogen and progestin) can regulate cycles and manage heavy bleeding; options include pills like Loestrin or Yasmin, taken daily.
• Alternatively, progestin-only treatments such as medroxyprogesterone acetate (Provera) 5-10mg daily for 10-14 days each month or the levonorgestrel IUD (Mirena) can effectively control heavy or irregular bleeding.
• Non-hormonal options include tranexamic acid (Lysteda) 1300mg three times daily during heavy bleeding days or nonsteroidal anti-inflammatory drugs like ibuprofen 600mg every 6 hours during menses.
• Lifestyle modifications that may help include maintaining a healthy weight, regular exercise, stress management techniques, and avoiding excessive caffeine and alcohol. It's crucial to note that hormone-sensitive breast cancer is a contraindication to using systemic hormone therapy 1.
• Psychosocial counseling (cognitive behavioral therapy) and/or clinical hypnosis may provide a benefit and reduce vasomotor symptoms 1. Regular follow-up is important as perimenopausal symptoms typically last 4-8 years before menopause occurs.
• The benefits of estrogen include inhibition of hepatic stellate cell activity and fibrogenesis as well as broader benefits on metabolic health, making hormone replacement therapy a viable option for managing menopausal symptoms and bone health 1.

From the FDA Drug Label

Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind In undiagnosed persistent or recurrent abnormal bleeding from the vagina, adequate diagnostic measures are indicated to rule out pregnancy or malignancy. If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease

The treatment for irregular menstrual cycles during perimenopause in a 50-year-old woman may involve ruling out pregnancy or malignancy through adequate diagnostic measures. If both are excluded, time or a change to another preparation may help solve the problem. Additionally, changing to an oral contraceptive with a higher estrogen content may be considered to minimize menstrual irregularity, but this should be done with caution due to the potential increased risk of thromboembolic disease 2.

• Key considerations include ruling out underlying causes and weighing the potential benefits and risks of treatment options.
• Important factors to consider are the patient's overall health and medical history.

From the Research

Treatment Options for Irregular Menstrual Cycles during Perimenopause

The treatment for irregular menstrual cycles during perimenopause in a 50-year-old woman can include:

• Hormonal contraceptives, which can help regulate menstrual cycles and provide non-contraceptive benefits such as relief from vasomotor symptoms and endometrial protection 3, 4
• Oral contraceptives, which can decrease the risk of postmenopausal hip fractures, regularize menses, and reduce the need for surgical intervention for benign menstrual conditions 4
• The levonorgestrel intrauterine system (LNG-IUS), which is safe for use in nearly all women and has particular benefits during perimenopause, including treatment of heavy menstrual bleeding and endometrial protection 5
• Medical therapies such as intrauterine levonorgestrel, oral progestogens, the combined oral contraceptive pill, tranexamic acid, mefenamic acid, danazol, and gonadotrophin-releasing hormone (GnRH) analogues, which can be effective in managing heavy menstrual bleeding 6

Considerations for Treatment

When selecting a treatment option, it is essential to consider the individual woman's risk factors, comorbidities, and lifestyle, as well as the possibility of continuing contraception until reaching menopause and beyond 3, 5. Reliable contraception should be used until menopause is confirmed, and sterility cannot be assumed until at least age 60 5.

Evaluation and Management

The evaluation and evidence-based management of women in the perimenopause transition should take into account the complex management decisions and the significant impact of symptoms on quality of life 7. A multidisciplinary approach, considering lifestyle and food habits as part of general good health, is recommended for correct perimenopause management 3.