Over their reproductive years, women come to expect a certain degree
of predictability with regard to their menstrual cycle. Whether it is
timing, length or amount of flow, there is generally not much variation
from month to month. As women approach menopause, all of this changes.
Some of these changes are manageable, some are not. Dr. James Kolter
takes us through what can be expected and how to approach these new
facts of life. — Beverly
Vaughn, MD, Medical Coordinator, Menopause and You Program
As a woman approaches menopause, the function of her ovaries gradually
declines. Once she completes a year without menstruation, she has
arrived at menopause. The average age for this to occur is 51. However,
it can occur anytime after the age of 40.
To appreciate the changes that are occurring, it is helpful to
understand the normal menstrual cycle. A woman releases estrogen in
response to pituitary hormones in the first half of the cycle. After
ovulation, progesterone is also produced. Estrogen and progesterone help
prepare the lining of the uterus (endometrium) with a thick, lush layer
to receive a fertilized egg. These hormones peak approximately 7-10 days
after ovulation. If pregnancy does not occur, the lining sheds. Thus, a
period takes place; and the cycle will then repeat.
What is Perimenopause?
Perimenopause is a transitional time 3-5 years prior to menopause that
is usually characterized by a change in the normal menstrual cycle. The
cycles may be shorter or longer, and the flow may vary from light to
heavy. As ovarian function is declining, ovulation may not occur. The
estrogen that has been released will cause the uterine lining to
thicken. Without progesterone to oppose the estrogen, the lining will
continue to build-up; and breakthrough bleeding can result. This
abnormal, thickening of the endometrium is called hyperplasia, and in
some instances, it may ultimately lead to endometrial cancer. Polyps and
fibroids, which are benign, may also cause changes in bleeding pattern.
Abnormal bleeding, especially bleeding that saturates a pad per hour for
24 hours or bleeding that lasts longer than two weeks, should be
evaluated by a physician or healthcare provider.
Evaluating Perimenopausal Bleeding
The evaluation will often include a history and physical exam. Various
tests may be ordered to diagnose the cause of the abnormal bleeding.
These might include tests for certain hormone levels and, possibly,
blood tests, including coagulation studies to identify clotting
abnormalities. Most women may need to have the endometrial lining
assessed. This is commonly done in an office setting with a biopsy
instrument with minimal discomfort. If the diagnosis is still uncertain,
vaginal pelvic ultrasound is useful. Finally, a hysteroscopy may be done
to evaluate abnormal bleeding. A hysteroscope is a lighted instrument
that is passed through the vagina into the uterus. This is commonly done
in a hospital outpatient facility. A D&C (dilation
and curettage) may be performed at this time.
Fibroids and Polyps
A fibroid is a fibromuscular type of tumor that often grows within the
muscular layer of the uterus. Most commonly, fibroids are incidental
findings on an examination, but if they’re located so as to jut into the
endometrial cavity, abnormal bleeding can result. Polyps are benign
growths composed of the endometrial lining and contain no muscle tissue.
Both fibroids and polyps can be a source of extra bleeding due to their
location within the interior of the uterus.
Treatment will be determined by the diagnosis. Growths, like fibroid
tumors and endometrial polyps, are often removed in various ways in an
operating room. These options should be discussed with
a healthcare provider.
If there is no pathologic cause for the bleeding, and an ovulation is
merely a phase of the perimenopause, continued observation and
re-evaluation may be the best plan. For persistent abnormal bleeding,
however, hormone therapy is often instituted. Usually, this will not
only help the bleeding problem, but also alleviate the associated
symptoms of the perimenopause, such as hot flashes and night sweats.
Depending on the results of your evaluation, this could be an
oral-contraceptive-type pill or a hormone-replacement alternative. Some
women respond to a progesterone-containing IUD call Mirena. This
provides the endometrial lining with a boost in progesterone while not
necessitating a systemic dose of hormones. Placement of this type of IUD
is done in a doctor’s office with no need for anesthetics.
There are a variety of surgical therapies available to women for whom
the hormonal approach is not effective or who cannot tolerate certain
side effects of the hormonal approach, such as bloating or breast
tenderness. The simplest of these procedures is endometrial ablation.
With this technique, the endometrial lining is cauterized or resected in
the operating room with light sedation, similar to the hysteroscopy
procedure. Over 90% of women obtain a satisfactory result.
Finally, for persistent difficult bleeding, a hysterectomy may be
suggested. This will certainly correct the bleeding completely but will
involve a more aggressive surgery and a recovery period of 3-6 weeks.
This decision is best made after thoughtful discussion with your
In summary, persistent or excessive bleeding should be evaluated
thoroughly. Treatment options are based on the results of the evaluation
and are designed to help a woman cope with the changes of the transition
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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