- Perimenopausal bleeding can be due to structural causes (polyps, adenomyosis, leiomyomas, malignancy) or non-structural causes (coagulopathy, ovulatory dysfunction, endometrial factors, iatrogenic, or “not otherwise classified”.) Malignancy and ovulatory dysfunction in particular are more common in this population.
- Initial evaluation includes history & physical, ultrasound, and possible saline infusion sonohysterography or endometrial biopsy.
- Hormonal treatments can be used, just as with premenopausal women, but more frequent comorbidities and a possible need to transition to hormone replacement therapy may influence the choice of treatment. Newer oral GnRH analogues may be useful as well.
- Procedures such as hysteroscopic polypectomy, endometrial ablation, and uterine artery embolization can be considered when hormones are not helpful or contraindicated, though ablation in particular can make later evaluation of the endometrium challenging.
- Hysterectomy remains a reasonable choice for women who have failed more conservative management.