Management of Increased Perimenopausal Bleeding
Begin with transvaginal ultrasound to exclude structural pathology, followed by endometrial biopsy if the patient is ≥45 years old, has risk factors for endometrial cancer, or shows concerning ultrasound findings—then treat with combined hormonal contraceptives or progestin-only therapy as first-line medical management. 1, 2, 3
Initial Diagnostic Evaluation
Mandatory First Steps
Order transvaginal ultrasound (TVUS) combined with transabdominal imaging as the initial diagnostic test to assess endometrial thickness, identify structural lesions (polyps, fibroids, adenomyosis), and evaluate for malignancy or hyperplasia. 1, 2, 3
Perform a pregnancy test (β-hCG) in all perimenopausal women presenting with abnormal bleeding, regardless of contraceptive use or perceived fertility status. 2, 4
Conduct speculum examination with Pap smear to exclude cervical pathology as the bleeding source and rule out cervical malignancy. 1, 3, 5
Measure hemoglobin and iron levels if the bleeding history suggests significant volume loss or if the patient reports fatigue, pallor, or other anemia symptoms. 3, 6
Check thyroid-stimulating hormone (TSH) and prolactin levels to identify reversible endocrine causes of ovulatory dysfunction. 1, 4
When to Proceed Directly to Endometrial Biopsy
Endometrial sampling is mandatory before initiating hormonal therapy in the following scenarios:
All women ≥45 years old with abnormal uterine bleeding, regardless of ultrasound findings, because anovulatory cycles and unopposed estrogen exposure markedly increase the risk of endometrial hyperplasia and carcinoma in this age group. 2, 7
Endometrial thickness ≥10 mm on TVUS or any focal endometrial lesion identified on imaging. 2, 3
Risk factors for endometrial cancer present, including obesity (BMI >30), diabetes mellitus, hypertension, nulliparity, polycystic ovary syndrome, or tamoxifen use. 1, 2, 7
Persistent or recurrent bleeding after initial negative evaluation, because office endometrial biopsy has a 10% false-negative rate. 2
Office endometrial biopsy using Pipelle or Vabra devices achieves 99.6% and 97.1% sensitivity, respectively, for detecting endometrial carcinoma. 2
Advanced Imaging When Initial TVUS Is Inadequate
Perform saline infusion sonohysterography (SIS) when focal lesions are suspected or when standard TVUS cannot adequately visualize the endometrium due to body habitus, uterine position, or interfering pathology (large fibroids, adenomyosis). SIS demonstrates 96–100% sensitivity for detecting endometrial pathology. 2, 3, 5
Escalate to hysteroscopy with directed biopsy if the initial endometrial biopsy is non-diagnostic, inadequate, or negative but symptoms persist, as blind sampling may miss focal lesions such as polyps or submucous fibroids. 2, 3
Medical Management After Malignancy Is Excluded
First-Line Hormonal Therapy
Combined hormonal contraceptives (CHCs) or progestin-only contraception are the recommended first-line medical treatments for perimenopausal abnormal uterine bleeding caused by ovulatory dysfunction. 1, 4
CHCs are particularly appropriate when contraception is desired and the patient has no contraindications to estrogen (e.g., history of thromboembolism, stroke, migraine with aura, uncontrolled hypertension, or breast cancer). 1, 4
Cyclic progestin therapy (e.g., medroxyprogesterone acetate 10 mg daily for 10–14 days per month) is the alternative for women who cannot use estrogen-containing products or have contraindications to CHCs. 1, 4
Levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective medical treatment for heavy menstrual bleeding, reducing menstrual blood loss by >90% and offering long-term contraception. 8, 6
Non-Hormonal Medical Options
Tranexamic acid (1–1.5 g orally three times daily during menses) reduces menstrual blood loss by 40–50% and is indicated when hormonal treatment is contraindicated or immediate pregnancy is desired. 8, 6
NSAIDs (e.g., ibuprofen 400–600 mg three times daily during menses) reduce menstrual blood loss by 20–30% and are less effective than tranexamic acid or hormonal therapies but can be combined with other treatments. 8, 6
Iron supplementation is mandatory for patients with iron-deficiency anemia secondary to heavy bleeding. 6
Monitoring Response to Medical Therapy
Reassess patients at 3–6 months to evaluate treatment response, menstrual pattern normalization, and patient satisfaction. 4
If bleeding persists despite medical therapy or the patient finds it unacceptable, counsel on alternative methods and offer surgical options. 1, 4
Surgical Management When Medical Therapy Fails
If medical treatment fails, is contraindicated, or is not tolerated, surgical options—including endometrial ablation or hysterectomy—should be considered. 1
Conservative Surgical Options
Second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency) are preferred over first-generation techniques (endometrectomy, roller-ball) due to lower operative morbidity and the ability to perform them as outpatient procedures. 8, 6
Hysteroscopic resection of endometrial polyps or submucous fibroids is indicated when focal intrauterine lesions are identified as the cause of bleeding. 3, 6
Definitive Surgical Treatment
- Hysterectomy remains the definitive treatment when medical therapies have failed and endometrial ablation is not suitable, but should be performed by vaginal or laparoscopic routes rather than as a first-line intervention. 8, 6
Common Pitfalls and Caveats
Never initiate hormonal therapy without first excluding endometrial malignancy in women ≥45 years old or those with risk factors, as unopposed estrogen from anovulatory cycles significantly increases cancer risk in this population. 2, 7
Do not accept a negative or inadequate endometrial biopsy as reassuring if symptoms persist, because the false-negative rate is approximately 10%; escalate to hysteroscopy with directed biopsy. 2
Ultrasound alone cannot differentiate hyperplasia, polyps, or malignancy; histologic tissue sampling remains necessary for definitive diagnosis when endometrial thickness is ≥10 mm or focal lesions are present. 2
Women aged 51–55 years with endometrial risk factors and ovarian cysts on ultrasound require heightened vigilance for atypical endometrial hyperplasia and endometrial cancer, as the prevalence is significantly higher in this subgroup. 7
Consider inherited bleeding disorders (present in up to 20% of women with heavy menstrual bleeding) by obtaining a bleeding score; additional hematological investigations are warranted if the score suggests coagulopathy. 8