Menstrual disturbances in perimenopausal women: What’s best?

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Clinical Inquiries

Menstrual disturbances in perimenopausal women: What’s best?

J Fam Pract. 2009 June;58(6):331c-331f

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References

1. Seltzer VL, Benjamin F, Deutsch S. Perimenopausal bleeding patterns and pathologic findings. J Am Med Womens Assoc. 1990;45:132-134.

2. Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007;(4):CD0004000.-

3. Casper R, Dodin S, Reid R, et al. The effect of 20 micrograms of ethinyl estradiol/1 mg norethindrone acetate (Minestrin), a low-dose contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause. 1997;4:139-147.

4. De Francis P, Cobellis L, Fornaro F, et al. Low-dose hormone therapy in the perimenopause. Int J Gynaecol Obstet. 2007;98:138-142.

5. Udoff L, Langenberg P, Adashi EY. Combined continuous hormone replacement therapy: a critical review. Obstet Gynecol. 1995;86:306-316.

6. Suckling LA, Barlow D, Farquhar CM, et al. Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev. 2004;(3):CD000402.-

7. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2008;(1):CD001016.-

8. Lethaby A, Cooke I, Reese M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005;(4):CD002126.-

9. Munro MG. Endometrial ablation for heavy menstrual bleeding. Curr Opin Obstet Gynecol. 2005;17:381-394.

10. Cooper KG, Jack SA, Parkin DE, et al. Five-year follow-up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes. BJOG. 2001;108:1222-1228.

11. Kuppermann M, Varner RE, Summitt RL, Jr, et al. Effect of hysterectomy vs. medical treatment on health-related quality of life and sexual functioning. The medicine or surgery (Ms) randomized trial. JAMA. 2004;291:1447-1455.

12. Lethaby A, Shepperd S, Cooke I, et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 1999;(2):CD000329.-

13. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Management of anovulatory bleeding. In J Gynaecol Obstet. 2001;72:263-271.

14. Practice Committee of the American society for reproductive Medicine. Committee opinion: the menopausal transition. Fertil Steril. 2006;86(suppl 5):S253-S256.

15. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Endometrial ablation. Obstet Gynecol. 2007;109:1233-1248.

Hormone therapy is also effective

An RCT of 132 perimenopausal women compared 24 weeks of combination hormonal therapy (20 mcg ethinyl estradiol/1 mg norethindrone acetate) with placebo for treating climacteric symptoms, including abnormal uterine bleeding.³ The combination therapy shortened the menstrual cycle (27.7 vs 30.4 days), decreased its variability (17.5-46.7 days vs 22.4-66 days), and lowered bleeding severity scores (6.9 vs 10.2).

FAST TRACK

Women using the LNG-IUD often canceled scheduled hysterectomy.

Hormonal therapy didn’t shorten bleeding episodes, however, and was associated with a higher incidence of intermenstrual bleeding during the first 3 months of treatment.

Continuous, combined estrogen/progestogen therapy

An RCT of 120 perimenopausal women with irregular menstrual cycles compared low-dose (1 mg) continuous estradiol and cyclical progestogens (10 mg dydrogesterone) with cyclical progestogens alone.⁴ In the combined treatment group, the incidence of cyclical menstrual bleeding was 86%, and 76% of all cycles were rated normal in amount and duration of bleeding. In the cyclical progestogen group, the incidence of cyclical menstrual bleeding during treatment was 76%, and 70% of all cycles were rated normal.

A systematic review, comprised primarily of RCTs, examined uterine bleeding patterns in 3000 postmenopausal women taking combined continuous hormones (various regimens of estrogen and progestin).⁵ In 22 of 23 studies that included data past 6 months, 75% or more of participants became amenorrheic while on therapy. Irregular uterine bleeding before 6 months of therapy was common, however, and was presumed to lower patient compliance.

Combined therapy avoids risk of endometrial hyperplasia

A more recent Cochrane review of 30 RCTs examined hormone replacement therapy for irregular bleeding and endometrial hyperplasia in postmenopausal women who had been amenorrheic for at least 6 months (a more liberal criterion for inclusion).⁶ The review concluded that many of the women treated with continuous estrogen and progestin became amenorrheic after 1 year of therapy. It also reiterated that unopposed estrogen increased the risk of endometrial hyperplasia, whereas continuous combined estrogen and progestogen treatment didn’t.

Evidence-based answers from the Family Physicians Inquiries Network