World Menopause Day: Changes before the Change

World Menopause Day is celebrated on 18^th October to raise awareness of midlife women’s health that concentrates on perimenopausal bleeding; a common problem faced by women of age 47 in Pakistan.

Perimenopausal Bleeding

Abnormal Uterine Bleeding (AUB)

Bleeding that is unlike normal menstrual flow in terms of frequency, duration and quantity. It includes infrequent or frequent bleeding, heavy menstrual bleeding or intermenstrual bleeding.

AUB is a leading cause for gynecological consultations in the peri- and post-menopausal age groups.

AUB subsets in the Perimenopause

Ovulatory AUB:

Ovulatory bleeding may be heavy and can be associated with typical premenstrual symptoms and painful periods.

Anovulatory AUB:

Anovulatory bleeding, which is found more frequently during the perimenopause compared to the premenopause, is often linked to prolonged periods, heavier flow and an irregular cycle. If prolonged (e.g. in PCOS or associated with obesity), anovulatory bleeding has a stronger link to endometrial cancer and endometrial hyperplasia.

Abnormal Uterine Bleeding – Diagnosis

The goal of diagnosis is to distinguish women with anatomic causes from women with normal anatomy.

Identifying endometrial malignancy, although uncommon among the AUB etiologies, is often the main purpose of the investigations.

Assessment of Abnormal Uterine Bleeding:

• General assessment
• History and bleeding pattern
• Physical, pelvic and speculum examination

Laboratory Tests Include:

• Full blood count, iron studies, (thyroid, hCG – if indicated)
• Disorders of hemostasis (if indicated)

Evaluate Pelvic Organs and Endometrium

• Ultrasound scan
• Hysteroscopy
• MRI (if indicated)

Treatment of Abnormal Uterine Bleeding

Treatment goals for patients with AUB include regulation of menstrual cycles, minimization of blood loss and improvement in quality of life.

Treatment options include pharmacological approaches (either hormonal or non-hormonal), and surgical or radiological procedures.

Awareness, reassurance and keeping a healthy lifestyle will contribute to the treatment options for AUB.

Management of Abnormal Uterine Bleeding

Non-Hormonal Medical Treatments:

• Non-steroidal anti-inflammatory drugs
• Anti-fibrinolytic agents (ie, tranexamic acid)
• Iron supplements, in case of anemia

Hormonal Medical Treatments:

• Cyclical or long-acting progestogens
• Combined oral contraceptives
• GnRH analogs (fibroid-associated)
• Selective progesterone receptor modulators (fibroid-associated)
• Levonorgestrel intrauterine system (LNG-IUS)

Other Treatment Options:

• Endometrial ablation
• Uterine artery embolization (fibroid-associated)
• Hysterectomy