Perimenopausal abnormal uterine bleeding

Abstract

Abnormal uterine bleeding is a very frequent symptom in the perimenopause. The causes are numerous ranging from physiological reactions due to decreasing/instable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas are increasing with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should also be excluded by speculum examination. Sexually transmitted diseases should be ruled out in the perimenopausal women in new relationships. Measurement of hemoglobine, human chorion gonadotropine and thyreoid hormones are relevant in selected cases. Transvaginal ultrasound is the primary diagnostic tool in perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the findings by ultrasound, more invasive procedures such as blind endometrial biopsy or hysteroscopy can be planned. Once premalignant and malignant causes are excluded, the necessity for treatment can be evaluated in collaboration with the individual woman. Severe heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding expectant management can be considered. Hormonal medical treatment e.g., progestins or insertion of levonorgestrel-releasing intrauterine system (LNG-IUS) is a possibility in case of anovulatory bleeding interfering with the quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs and LNG-IUS. In case of focal intrauterine lesions, such as endometrial polyps or submucous myomas, operative hysteroscopic procedures are warranted in the treatment of abnormal uterine bleeding. Other minimally invasive procedures, such as endometrial ablation or endometrial resection, is a good choice in selected cases, but some women will need a hysterectomy as a definite treatment of abnormal uterine bleeding in perimenopause.