ABNORMAL uterine bleeding is a common presentation in primary healthcare , and for perimenopausal women in particular there can be significant changes in menstruation that can be highly distressing for some . 1 These include heavy menstrual bleeding , irregular menses , intermenstrual bleeding and post-coital bleeding . 2 Although these symptoms may arise from expected hormonal fluctuations due to approaching menopause , it is important for healthcare providers to understand the range of potential pathologies behind perimenopausal bleeding in order to arrange appropriate workup and treatment . Causes
The perimenopausal phase is characterised by hormonal imbalances and unpredictable ovulation patterns . This often underpins the physiological menstrual irregularities experienced at this time . 3 , 4 Heavy menstrual bleeding and prolonged menses typically occur due to variable levels of oestradiol , combined with relatively lower levels of luteal phase progesterone . This causes increased endometrial proliferation , with subsequent heavy and prolonged bleeding when this sheds . Irregular menses can result from ovulatory interspersed with anovulatory cycles . 5 , 6 Additionally , oestrogen declines in later perimenopause , resulting in endometrial , cervical and / or vulvovaginal atrophy , which may lead to post-coital or intermenstrual bleeding . 7
The broad causes of non-gestational
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abnormal uterine bleeding were defined by the International Federation of Gynecology and Obstetrics working group on menstrual disorders and the acronym PALM-COEIN was devised , which presents aetiology based on structural and non-structural causes , as outlined in box 1 . 8
Polyps and leiomyomas ( fibroids ) are the most common structural causes of perimenopausal bleeding , and the impact of these , as well as adenomyosis , increases as women approach middle age . 9 Malignancy and dysplasia must always be considered in abnormal uterine bleeding , particularly given that perimenopause is associated with a significant increase in the number of days of unopposed oestrogen exposure , which carries a subsequent risk of endometrial hyperplasia or carcinoma . 10 Table 1 outlines the symptoms that tend to feature with different causes of perimenopausal bleeding .
Diagnosis
A systematic approach is warranted when investigating perimenopausal bleeding , beginning with a thorough history and examination , followed by pathology and imaging as indicated . 9 , 11 Focused historical features to assess are outlined in box 2 .
Examination involves assessment of BMI and thyroid , abdominal and pelvic examinations . A speculum examination is warranted to observe for obvious cervical or vaginal causes ; and a bimanual assessment to gauge the size , mobility and contour of the uterus . A cervical screening test and / or cervical and vaginal swabs can be taken opportunistically
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Box 1 . Causes of non-gestational abnormal uterine bleeding
• Structural causes — Polyp — Adenomyosis — Leiomyoma — Malignancy and hyperplasia
• Non-structural causes — Coagulopathy — Ovulatory dysfunction — Endometrial — Iatrogenic — Not otherwise classified
during the speculum examination . 9 , 11
In terms of investigations , a baseline blood panel for perimenopausal bleeding includes an FBC , iron studies , thyroid function tests and beta-hCG . 11 A hormonal profile is of no value as ‘ normal ’ values do not preclude the diagnosis of a perimenopausal state . One of the most important investigations in the workup of perimenopausal bleeding is a pelvic ultrasound , with a transvaginal approach being the gold standard . 9 , 11 This can be additionally performed with a sonohysterogram to assess the internal anatomy of the uterus , but this is not always necessary . Depending on the initial history , examination and investigation findings , further testing can be performed with endometrial sampling either via pipelle or ; if visualisation of the endometrium is warranted , via hysteroscopy with dilatation and curettage . 9
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Treatment options
The general aims of management for
abnormal uterine bleeding include treatment of the underlying causes , correcting associated issues ( such as anaemia ), and preventing recurrence . Management options should be tailored to the individual patient , taking into account the context of the clinical presentation and symptom impact on quality of life ( see table 2 ).
Non-structural medical causes , such as hypo- or hyperthyroidism , or bleeding diatheses warrant treatment to correct the underlying abnormality .
If malignancy has been excluded , and all investigations are normal , expectant treatment can be offered on the basis that women will likely transition to menopause after a few years and experience fewer symptoms . However monitoring should continue until this occurs , particularly to ensure that the patient does not become iron deficient .
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Box 2 . Focused history in perimenopausal bleeding |
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Perimenopause is characterised by hormonal imbalances and unpredictable ovulation patterns . |
• Obstetric history
• Gynaecological history — Including any surgery and treatment for disorders
• Menstrual history — Age of menarche — Nature of menstrual cycles
( duration , timing , regularity ) — In some cases a menstrual diary may be helpful
• Sexual health history
• Family history — Gynaecological disorders — Bleeding disorders
• Use of medications
• Checklist for malignancy risk factors including — Smoking — Nulliparity — Previous history of polycystic ovary syndrome
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