What is the workup for prolonged vaginal bleeding in perimenopause (perimenopausal transition)?

From the Guidelines

The workup for prolonged vaginal bleeding in perimenopause should begin with a thorough history and physical examination, followed by laboratory tests including a complete blood count, thyroid function tests, and pregnancy test, as recommended by the American College of Radiology 1.

Initial Evaluation

The initial evaluation should focus on identifying the underlying cause of the bleeding, which can be due to hormonal fluctuations, structural abnormalities, or pathological conditions.

• A thorough history and physical examination are essential to identify any risk factors for endometrial cancer or other underlying conditions.
• Laboratory tests, such as a complete blood count, thyroid function tests, and pregnancy test, should be performed to rule out any underlying medical conditions that may be contributing to the bleeding.

Imaging Studies

Transvaginal ultrasound is essential to evaluate endometrial thickness and identify structural abnormalities like fibroids or polyps, as recommended by the American College of Radiology 1.

• Transvaginal ultrasound should be combined with transabdominal ultrasound to fully assess the pelvic structures.
• An endometrial thickness of 4 mm or more in a postmenopausal woman conveys a high risk for endometrial cancer, and an endometrial biopsy should be performed to rule out hyperplasia or malignancy.

Treatment Options

Treatment options depend on the underlying cause of the bleeding, but may include:

• Hormonal therapy, such as cyclic progestins (medroxyprogesterone acetate 10 mg daily for 10-14 days each month), combined hormonal contraceptives, or a levonorgestrel intrauterine system (Mirena) 1.
• Tranexamic acid (1000 mg three times daily for up to 5 days during bleeding) or high-dose estrogen therapy for acute heavy bleeding.
• Iron supplementation should be considered if anemia is present.
• Surgical options, such as endometrial ablation or hysterectomy, may be appropriate for women who have completed childbearing and have failed medical management.

Key Considerations

• The PALM-COEIN classification system can be used to describe uterine bleeding abnormalities in women of reproductive age, and includes structural causes (polyp, adenomyosis, leiomyoma, and malignancy and hyperplasia) and nonstructural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) 1.
• Medical treatments for abnormal uterine bleeding associated with ovulatory dysfunction include progestin-only contraception and combined hormonal contraception.
• If medical treatment fails, is contraindicated, or is not tolerated, or if the patient has concomitant significant intracavitary lesions, surgery, including endometrial ablation and hysterectomy, may be an option.

From the Research

Workup for Prolonged Vaginal Bleeding in Perimenopause

• The workup for prolonged vaginal bleeding in perimenopause should include a thorough evaluation of the patient's medical history, physical examination, and laboratory tests 2.
• Transvaginal ultrasound is a useful initial test to measure endometrial thickness and detect other pelvic pathology such as leiomyomas and ovarian tumors 3.
• The threshold for endometrial thickness to exclude carcinoma is still a topic of debate, but a thickness of 3-4 mm may be used to maximize sensitivity 4.
• However, it is essential to note that postmenopausal bleeding remains the most reliable indicator of endometrial pathology, and further evaluation is necessary even if the endometrial thickness is within normal limits 4.

Diagnostic Evaluation

• The diagnostic evaluation should include:
  • Speculum examination and cervical cytology
  • Transvaginal ultrasound to measure endometrial thickness and detect other pelvic pathology
  • Endometrial biopsy to diagnose or exclude endometrial cancer or pre-malignancies 3
• Hysteroscopy may be used when focal lesions affecting the uterine cavity are suspected, such as endometrial polyps or sub-mucous fibroids 3.

Therapeutic Options

• Hormonal contraceptives may be used to treat abnormal uterine bleeding, relieve vasomotor symptoms, and provide endometrial protection in women using estrogen therapy 5.
• Other therapeutic options, such as medical and surgical treatments, should be considered based on the patient's individual needs and risk factors 2.