Perimenopause II: Now What???

In the first segment on this subject the basics of this issue were reviewed. Perimenopause is not a disease and requires no management except as related to troublesome symptoms that occur in a minority of women. That symptom is usually abnormal uterine bleeding.

For many women episodes of problem bleeding are limited and take care of themselves. They often prompt a doctor visit, but not specific therapy. A conference with the gynecologist most often suffices. For others, bleeding episodes are frequent (more than monthly) long (more than seven days) or heavy. These problems are often accompanied by significant discomfort and worry. These require evaluation as previously outlined.

They also require therapy, done in a variety of ways. Hormones can be used, destruction of the uterine lining might be worthwhile, and in some cases hysterectomy is done (though much less so than in the past). Sometimes the diagnostic procedure of dilation and curettage (D&C) can actually be therapeutic as well.

When hormones are used they can be applied in a variety of ways, accomplished with different hormones. A single course of a form of progesterone over a period of days or weeks can produce loss of the uterine lining and cessation of the problem. Another alternative would be to “cycle” the progesterone over a period of months. As long as the patient does not smoke, standard oral contraceptive pills can regulate cycles in a way acceptable to the patient.

Intrauterine devices containing progesterone can be uses to either stop bleeding altogether or to significantly reduce it. This is an attractive, simple and well tolerated method, and carries little of the baggage associated with the IUD’s of the 1970’s and 1980’s.

Another means of bleeding control involves destruction (ablation) of the uterine lining. Following procedures of this nature, often performed in the office of the gynecologist, almost half of women have no further bleeding and the majority show at least an improvement. Ablation is reserved for women with no further interest in child bearing and those with relatively normal configuration of the cavity of the uterus.

In a minority of women, usually with complicating factors, hysterectomy is still done. Usually this means removal of the uterus (total hysterectomy) but also might involve removal of the tubes and ovaries (total hysterectomy with salpingoophorectomy).

Perimenopause... What is it?

“Perimenopause” is a commonly used word these days, and seems to carry a dreaded connotation, at least among many women. Most of the time it doesn’t mean anything much except that menopause itself can be anticipated in a few years.  “Menopause” means ceasing of menses but it is the decline and ceasing of ovarian function that is the prime mover of symptoms.

Ovarian function begins to decline before menopause itself comes at the average age of 51. This fact is of little significance for most women, but can cause conception to become difficult.  The decline comes to women in their 30’s, but, at least initially causes few symptoms.  By the time women are in their 40’s, symptoms of ovarian dysfunction become common and are usually in the form of abnormal bleeding.  This era from about age 45 until menopause is the time most appropriately referred to as “Perimenopause.”  Women in this age group are not ill and experience little or none of the problems that can arise during menopause itself.  They do however have problems with cycles that become abnormally frequent or too seldom or too heavy.  This can be a minor, self-limited problem or can make women clinically ill with pain or even anemia from blood loss.

When women have abnormal bleeding in the 40’s, it is most often from the phenomenon usually referred to by doctors as “Dysfunctional Uterine Bleeding”. Other possibilities exist however, because the problem could come from disease and not just “dysfunction”.  These include polyps inside the uterus, overgrowth in the uterine lining, or even cancer of the uterine lining. Because of these possibilities, the doctor needs to demonstrate that these problems are not present  before proceeding to treat the dysfunction, rather than assume that there is no disease present.  Ultrasound of the uterus and biopsy of the uterine lining are the procedures most commonly used for that purpose.  And these are most often done in the doctor’s office. More extensive evaluations such as dilation and curettage (D&C) are sometimes done in operating rooms because they might require anesthesia.