Menstrual disturbances in perimenopausal women: What’s best?

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Clinical Inquiries

Menstrual disturbances in perimenopausal women: What’s best?

J Fam Pract. 2009 June;58(6):331c-331f

By

Edward C. Chen, MD

Peter G. Danis, MD

Elizabeth Tweed, MLIS, AHIP

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References

1. Seltzer VL, Benjamin F, Deutsch S. Perimenopausal bleeding patterns and pathologic findings. J Am Med Womens Assoc. 1990;45:132-134.

2. Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007;(4):CD0004000.-

3. Casper R, Dodin S, Reid R, et al. The effect of 20 micrograms of ethinyl estradiol/1 mg norethindrone acetate (Minestrin), a low-dose contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause. 1997;4:139-147.

4. De Francis P, Cobellis L, Fornaro F, et al. Low-dose hormone therapy in the perimenopause. Int J Gynaecol Obstet. 2007;98:138-142.

5. Udoff L, Langenberg P, Adashi EY. Combined continuous hormone replacement therapy: a critical review. Obstet Gynecol. 1995;86:306-316.

6. Suckling LA, Barlow D, Farquhar CM, et al. Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev. 2004;(3):CD000402.-

7. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008;(1):CD001016.-

8. Lethaby A, Cooke I, Reese M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005;(4):CD002126.-

9. Munro MG. Endometrial ablation for heavy menstrual bleeding. Curr Opin Obstet Gynecol. 2005;17:381-394.

10. Cooper KG, Jack SA, Parkin DE, et al. Five-year follow-up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes. BJOG. 2001;108:1222-1228.

11. Kuppermann M, Varner RE, Summitt RL, Jr, et al. Effect of hysterectomy vs. medical treatment on health-related quality of life and sexual functioning. The medicine or surgery (Ms) randomized trial. JAMA. 2004;291:1447-1455.

12. Lethaby A, Shepperd S, Cooke I, et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 1999;(2):CD000329.-

13. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Management of anovulatory bleeding. In J Gynaecol Obstet. 2001;72:263-271.

14. Practice Committee of the American society for reproductive Medicine. Committee opinion: the menopausal transition. Fertil Steril. 2006;86(suppl 5):S253-S256.

15. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Endometrial ablation. Obstet Gynecol. 2007;109:1233-1248.

EVIDENCE-BASED ANSWER

It’s best to start with nonsteroidal anti-inflammatory drugs (NSAIDs), which effectively reduce heavy menstrual bleeding (strength of recommendation [SOR]: B, systematic review of randomized clinical trials [RCTs]).

Perimenopausal women with heavy bleeding not controlled by NSAIDs, or other forms of dysfunctional uterine bleeding, can benefit from continuous, combined hormonal therapy with estrogen and progestin; hormonal therapy with estrogen and a cyclical progestin; or a cyclical progestin alone (SOR: B, RCTs and a systematic review of RCTs). Intrauterine devices (IUDs) containing levonorgestrel also effectively reduce bleeding and may avoid surgical intervention (SOR: B, systematic review of RCTs).

If medical management fails, endometrial ablation offers an effective, minimally invasive alternative to hysterectomy (SOR: B, systematic review of RCTs and 1 RCT). Hysterectomy should be considered when medical management or endometrial ablation fails (SOR: B, systematic review of RCTs and 1 RCT).

Evidence summary

Perimenopause encompasses the period of irregular menstrual cycles and flow that precedes menopause (absence of menstrual bleeding for 1 year). Menopause generally occurs between 45 and 55 years of age; the average is 51 years. A review of 500 perimenopausal women seen sequentially by a gynecology service found that 18% had menorrhagia (heavy bleeding), metrorrhagia (intermenstrual bleeding), or hypermenorrhea (frequent periods).¹

FAST TRACK

Medical management with NSAIDs is the first choice for initial treatment of abnormal uterine bleeding.

Because few studies have examined the treatment of abnormal menstrual bleeding specifically during perimenopause, therapeutic approaches are based primarily on studies of women before and shortly after this stage. Once malignancy and other causes of abnormal uterine bleeding (pregnancy, bleeding disorders, infection, thyroid disorders, uterine fibroids, or polyps) have been excluded, treatment of perimenopausal dysfunctional uterine bleeding should address the goals of:

stopping acute bleeding
avoiding future irregular or heavy bleeding
considering future family planning needs
preventing complications (anemia, unnecessary therapeutic procedures).

NSAIDs reduce heavy bleeding

A Cochrane review of 16 small RCTs that examined the use of NSAIDs for menorrhagia found NSAIDs to be superior to placebo and comparable to other medical treatments such as luteal progestin, oral contraceptive pills, and progestin-releasing intrauterine systems.²

Evidence-based answers from the Family Physicians Inquiries Network