Perimenopausal Bleeding - What's Normal?

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What is menopause?
Menopause is the time in a woman's life when the ovaries stop producing estrogen. Menopause is usually recognized by the cessation of menstrual periods. Other symptoms of menopause include flashes, mood changes, difficulty sleeping, and vaginal dryness. If a woman is not menstruating because she has had a hysterectomy or endometrial ablation, other symptoms of menopause often alert her that menopause is starting.

When does menopause start?
The average age of the onset of menopause is 51 years, and it is most commonly occurs from age 47 to 53. Perimenopause is the period immediately before and after the onset of menopause, and averages 4 years.

How is menopause diagnosed?
A simple blood test measuring follicle stimulating hormone (FSH) is usually all that is needed to diagnose menopause.

What happens to periods during menopause?
Although some women may abruptly stop having menstrual periods, many women will notice that their periods space out for months to years before bleeding stops permanently. Although pregnancy is unlikely in this age group, it is essential to do a pregnancy test to be absolutely sure.

Why is bleeding irregular in perimenopause?
Regular periods are the result of a precise hormone balance causing regular ovulation. In perimenopause changes in hormone levels interfere with ovulation.

If ovulation does not occur, the ovary will continue making estrogen, causing the endometrium to keep thickening. This often leads to a late menstrual period followed by irregular bleeding and spotting. This can also result in endometrial polyps, a greater thickening called "hyperplasia," or in extreme long-standing cases, cancer of the lining of the uterus.

How do I know if my bleeding is abnormal?
It is not unusual to have irregular bleeding for up to 6 months before menstrual periods stop completely. Unless the bleeding is excessive, or a woman it at high risk for uterine cancer, this is generally not of concern.
 

I tell my patients to notify me if they have:

• Bleeding that requires the use of a pad every hour for over 24 hours
• Bleeding that lasts more than 2 weeks
• Any bleeding after bleeding has been absent for over 6 months. (An exception is women who starts estrogen replacement therapy.)
   

In addition, women who are obese, have diabetes, and/or high blood pressure are at increased risk for cancer of the uterus. I feel it is best to evaluate the cause of any irregular bleeding in high risk women.

How is abnormal uterine bleeding in menopause or perimenopause evaluated?
Traditionally, an endometrial biopsy, or sampling of the lining of the uterus is done. This is a simple office procedure to rule out cancer or pre-cancer. It is not accurate for diagnosing polyps or fibroids. Vaginal probe ultrasound is a quick and painless screening exam and has frequently made endometrial biopsy unnecessary. It is also possible to look directly into the uterus using a thin telescope called a hysteroscope. Hysteroscopy is usually a simple office procedure that gives far more information than endometrial biopsy alone. While D&C (dilation and curettage) may be used in an emergency to stop extremely heavy bleeding, I feel that as a diagnostic tool it is obsolete and should be replaced by hysteroscopy with endometrial sampling.

How is abnormal uterine bleeding in menopause or perimenopause treated?
As in all women, the cause of the abnormal bleeding first needs to be determined. If the bleeding is caused by lack of ovulation, cycling with progesterone will usually control the problem.

For some women, surgery is the another alternative. Many women think that hysterectomy is the only choice left, but many alternatives to hysterectomy are available. Before deciding on any surgical treatment, it is important to understand what alternatives to hysterectomy are available.
 

The large number of surgical possibilities may at first seem confusing. Many have fancy names and may be promoted as being the latest and the greatest. It is easier to understand these surgical procedures when you realize that all of them fall into one or more of the following categories:
 

• Removing the uterus (hysterectomy)
• Removing fibroids through an incision in the abdomen or through a laparoscope (myomectomy)
• Removing fibroids or polyps through the cervix using a resectoscope
• Removing or destroying the lining of the uterus (endometrial ablation)
   

Most polyps can be removed with the resectoscope. If I do this, I will usually suggest doing an endometrial ablation at the same time to decrease the risk that polyps will regrow. Endometrial ablation in a menopausal woman takes quite a bit of skill, as the walls of the uterus are thin, but in skilled hands the procedure is often an excellent alternative for bleeding that would otherwise require hysterectomy.