Clinical Inquiries

Menstrual disturbances in perimenopausal women: What’s best?

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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

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

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