MedicalJOBS CLINICAL FOCUS 39
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MedicalJOBS CLINICAL FOCUS 39
Table 1 . Features of different causes of perimenopausal bleeding
Causes of perimenopausal bleeding
Structural
Nonstructural
Heavy menstrual bleeding
Irregular menses
Symptoms
Intermenstrual bleeding
Polyps ( including endocervical ) ✓ ✓ ✓ Adenomyosis ✓ ✓
Leiomyoma ✓ ✓ Malignancy and hyperplasia ✓ ✓ ✓ ✓
Coagulopathy ✓ ✓ ✓
Ovulatory / hormonal ✓ ✓ ✓ ✓
Endometrial ✓ ✓ ✓ ✓
Iatrogenic ✓ ✓ ✓ ✓
Atrophy ✓ ✓
Post-coital bleeding
Table 2 . Treatment options for perimenopausal bleeding
Category Lifestyle
Medical
Treatments
• Weight loss
• Smoking cessation
• Regular exercise
• Nutritional supplementation
• Non-hormonal — NSAIDs — Antifibrinolytic ( eg , tranexamic acid )
• Hormonal — Combined oral contraceptive pill — Progesterone-only medications ( eg , mini-pill , depot medroxyprogesterone )
— Levonorgestrel IUD
Polyps and leiomyomas ( fibroids ) are the most common structural causes of perimenopausal bleeding .
Medical management can involve the use of non-hormonal medications — such as NSAIDs or antifibrinolytic agents ( such as tranexamic acid ) to reduce menstrual flow ; or hormonal therapies to regulate menstruation . Hormonal options include the combined oral contraceptive pill and progesterone-only hormonal medications ( such as oral progesterone or IM depot medroxyprogesterone or a levonorgestrel IUD ). 6 , 11 When prescribing the combined oral contraceptive pill it is essential to consider the individual ’ s risk of VTE and the presence of other comorbidities that may be potential contraindications ( see online resource ), and to provide counselling about risks associated with use .
Cyclical menopausal hormone therapy may be an option in some women , particularly those with menopausal symptoms . Cyclical therapy will cause less breakthrough bleeding than continuous combined therapy . It is important to discuss the need for contraception as pregnancy is still a possibility , albeit unlikely .
Surgical management includes a range of different procedures , most of which
address structural causes . Hysteroscopic resection of fibroids or polyps may be considered where these have been suspected or identified on ultrasound . Fibroids can also be removed laparoscopically or managed radiologically with uterine artery embolisation or via magnetic resonance-guided focused ultrasound destruction of fibroids .
In cases of malignancy or endometrial hyperplasia , a total hysterectomy and bilateral salpingo-oophorectomy may be offered under specialist management . Endometrial ablation may also be offered as a minimally invasive procedure
to patients experiencing heavy menstrual bleeding who have been unsuccessfully managed with medical approaches and in whom malignancy has been excluded . 11
Additionally , lifestyle modifications such as weight loss , smoking cessation , and a nutritionally replete or supplemented diet , may help to reduced symptomatology for patients , in conjunction with medical or surgical management . 6
For women who wish to preserve childbearing potential , medical therapies , fertility preserving surgical approaches ( hysteroscopy , myomectomy ) or expectant management are the only suitable options .
Conclusion
Perimenopausal bleeding affects more than 75 % of women during their menopausal transition and many of these will present to their primary healthcare
Surgical management includes a range of different procedures , most of which address structural causes .
providers . 12 Given the risk of pathology , understanding the underlying causes of abnormal uterine bleeding in this specific population is crucial for accurate diagnosis and effective management . Providing timely and tailored management to
Surgical
Other
Online resource
patients can significantly improve disease burden , quality of life and reduce re-presentation .
References on request from kate . kelso @ adg . com . au
• Endometrial ablation
• Hysteroscopy — Dilatation and curettage — Resection of polyp or fibroid
• Myomectomy
• Hysterectomy ± bilateral salpingo-oophorectomy
• Uterine artery embolisation or magnetic resonanceguided focused ultrasound
• Expectant management
• UK Faculty of Sexual and Reproductive Healthcare : Medical eligibility criteria for contraceptive use bit . ly / 3N439NP