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).