Heavy Bleeding During Perimenopause
Heavy menstrual bleeding (menorrhagia) is a common and normal phenomenon during perimenopause, occurring in approximately one-quarter to one-third of women, though it requires evaluation to exclude serious pathology. 1, 2
Why Heavy Bleeding Occurs in Perimenopause
Perimenopause is characterized by highly variable and unstable estradiol and progesterone levels—often described as a "hormonal roller coaster"—rather than the consistently low hormone levels seen in menopause. 3 This hormonal instability leads to:
- Anovulatory cycles becoming increasingly common, which is the most frequent cause of abnormal bleeding in otherwise healthy perimenopausal women. 4
- Irregular endometrial shedding due to unopposed estrogen exposure when ovulation fails to occur. 2
- Age-related increase in benign structural abnormalities like endometrial polyps (more common over age 40) and uterine fibroids (more common under age 40), both of which contribute to heavier bleeding. 5, 6
Menstrual blood loss naturally increases with age, and about one-third of women report heavy bleeding at some point in their lives. 7
When Heavy Bleeding Requires Evaluation
While perimenopausal heavy bleeding is often physiologic and tends to improve over time, approximately 25% of women will have persistent heavy flow beyond 3 months requiring medical intervention. 2 You must exclude serious pathology before attributing bleeding to normal perimenopause.
Mandatory Initial Assessment
Rule out pregnancy first in all reproductive-age women with a β-hCG test. 5, 6
Assess for hemodynamic instability: Urgent evaluation is needed if bleeding saturates a large pad or tampon hourly for at least 4 consecutive hours. 5
Perform speculum examination to exclude cervical or vaginal sources of bleeding and rule out sexually transmitted infections. 5, 1
Essential Laboratory Testing
- Complete blood count to assess for anemia requiring immediate treatment. 6, 1
- Thyroid-stimulating hormone (TSH) to detect thyroid dysfunction (both hypo- and hyperthyroidism cause heavy bleeding). 4, 5
- Prolactin level to identify hyperprolactinemia. 4, 5
First-Line Imaging
Transvaginal ultrasound with Doppler is the mandatory first-line imaging study to identify structural causes including polyps, fibroids, adenomyosis, and endometrial hyperplasia or malignancy. 4, 5, 6
When to Perform Endometrial Sampling
Endometrial biopsy is required in the following situations to exclude endometrial hyperplasia or cancer: 4
- Women over 45 years of age
- Obesity
- Unopposed estrogen exposure
- Failure of medical therapy
- Persistent irregular bleeding
Treatment Approach
Most Effective First-Line Medical Treatment
The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line medical treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 6 This is particularly important for women with cardiovascular disease where NSAIDs and tranexamic acid should be avoided due to MI and thrombosis risk. 5, 6
Alternative Medical Options
If the LNG-IUD is not suitable or desired:
- Tranexamic acid is highly effective for reducing heavy menstrual bleeding. 6, 7
- NSAIDs (such as mefenamic acid) reduce bleeding volume by 5-7 days of treatment. 8, 7
- Combined hormonal contraceptives are effective for ovulatory dysfunction bleeding and can be combined with NSAIDs for additional benefit. 6, 7
- Oral progestogens administered for 21 days per month reduce menstrual blood loss in women with cyclic heavy bleeding. 6, 7
Surgical Management
Endometrial ablation is a less invasive alternative to hysterectomy with efficacy comparable to the LNG-IUD for women who have completed childbearing. 6
Hysterectomy is the definitive treatment when medical management fails or is contraindicated, providing complete resolution and significantly better quality of life. 5, 6
Hysteroscopic procedures are appropriate for focal intrauterine lesions such as endometrial polyps or submucous fibroids. 1
Critical Pitfalls to Avoid
Do not assume all perimenopausal bleeding is benign. Endometrial cancer and hyperplasia must be excluded, especially in women with risk factors including postmenopausal status, obesity, diabetes, hypertension, unopposed estrogen exposure, tamoxifen use, or Lynch syndrome. 5
Do not rely on endometrial biopsy alone to rule out focal lesions—it has variable sensitivity. Saline infusion sonohysterography has 96-100% sensitivity and 94-100% negative predictive value for detecting polyps and fibroids. 4, 5
Avoid NSAIDs and tranexamic acid in women with cardiovascular disease due to increased risk of MI and thrombosis; use the LNG-IUD instead. 5, 6