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.

Continuous progestogen regimen has blood loss benefit

No randomized trials have compared oral progestogens with placebo. A Cochrane review examined the use of cyclical progestogens (given from 10 to 20 days per cycle) for heavy menstrual bleeding.⁷ Cyclical progestogens appeared comparable in efficacy to NSAIDs for their effect on duration of menstruation; no statistically significant difference in menstrual blood loss was noted. Progestogens given in more continuous regimens offered greater benefit in terms of blood loss.

FAST TRACK

Among patients followed for more than 5 years after endometrial ablation, 20% to 40% required repeat treatment or hysterectomy.

IUDs help avoid surgery, but can have side effects

A Cochrane review found that progestogen-releasing IUDs significantly reduce heavy menstrual bleeding and are more effective than cyclical norethisterone (21 days). Patients did, however, report greater progestogenic side effects (breast tenderness and intermenstrual bleeding) than cyclical therapy.⁸

One unblinded RCT that randomized women scheduled for hysterectomy for heavy bleeding to the levonorgestrel intrauterine device (LNG-IUD) or their existing medical therapy (not further described) found that women in the LNG-IUD group were more likely to cancel surgery.

Another RCT comparing hysterectomy with the LNG-IUD found that women with the LNG-IUD reported greater pain. The LNG-IUD was more cost effective at 1 and 5 years, primarily because of reduced surgical expenses. Some patients or physicians may have ethical issues with the device’s mechanism of action.

Uterine ablation when preserving fertility doesn’t matter

A review article of currently available evidence on endometrial ablation for heavy menstrual bleeding concluded that both resectoscopic endometrial ablation (via hysteroscopy) and nonresectoscopic endometrial ablative technologies (radio-frequency electrosurgical ablation, balloon thermal ablation, free fluid ablation, cryotherapy, microwaves) significantly reduce menstrual blood flow.⁹ These minimally invasive techniques were an option for women who weren’t concerned about preserving fertility. However, 20% to 40% of patients who were followed for more than 5 years required repeat treatment or hysterectomy.

Heavy bleeding and transcervical endometrial resection

An RCT of 187 women, average age 42 years, compared immediate transcervical resection of the endometrium to medical management for heavy menstrual bleeding.¹⁰ A 5-year follow-up was completed on 144 patients. The study showed transcervical resection of the endometrium to be superior with regard to menstrual status (less bleeding or no bleeding), patient satisfaction with outcomes, and health-related quality of life as indicated on patient questionnaires.

FAST TRACK

ACOG recommends initial medical management for anovulatory bleeding in women ≥ 40.

When other options fail…

Patients who fail medical treatment and minimally invasive uterine ablation may require hysterectomy. An RCT of 63 premenopausal women (30-50 years of age) with abnormal uterine bleeding compared hysterectomy with medical treatment.¹¹ Hysterectomy was superior with regard to symptom resolution and health-related quality of life after 6 months.

A Cochrane review of 5 RCTs that compared endometrial resection and ablation with hysterectomy for heavy menstrual bleeding reported a significant advantage for hysterectomy in symptom resolution and patient satisfaction.¹² Although the initial cost was higher for the hysterectomy group, the difference narrowed over time because of the need for retreatment in the endometrial destruction group.

Recommendations

The American College of Obstetricians and Gynecologists (ACOG) recommends initial medical management (cyclic progestins, low-dose oral contraceptives, or cyclic hormone replacement therapy) for anovulatory bleeding in women 40 years and older.¹³

The Practice Committee of the American Society for Reproductive Medicine lists low-dose combination hormonal pills, progestin, progestin-containing IUDs, and hormone replacement therapy as medical treatment options.¹⁴

ACOG notes that minimally invasive surgical options such as hysteroscopic endometrial ablation result in less short-term morbidity and cost less than hysterectomy.¹⁵ Results with resectoscopic and nonresectoscopic techniques are similar. Hysterectomy rates following these approaches are at least 24% at 4 years.¹⁵

Evidence-based answers from the Family Physicians Inquiries Network