Menstrual disorders in perimenopause

In this session, the medical and surgical approaches to management of abnormal uterine bleeding were discussed by three leading experts: Steven Goldstein, Risa Kagan and John Sciarra.

Abnormal Uterine Bleeding (AUB)

AUB is the cause of 33% of all gynaecology outpatient visits and more than 70% of the cases are among peri- and post-menopausal women.

PALM-COEIN Classification System for AUB

Previously, there was a general inconsistency in the nomenclature used to describe AUB. To standardise this approach in 2011, the PALM-COEIN Classification System was introduced. The system classifies AUB into either structural (PALM) or non-structural (COEIN) causes of AUB:

Polyp
Ademomyosis
Leiomyoma
Malignancy & Hyperplasia

Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified

Clinical studies show that 20% of AUB is structural and that 80% is non-structural (COEIN category). Before treating AUB it is critical to firstly perform a proper diagnosis (ruling out any anatomic abnormality), as well as ensuring that there is no pregnancy or malignancy.

Medical treatment

For non-structural causes of AUB, the most appropriate first-line treatment considered should be medical. Combined hormonal contraceptives, such as combined oral contraceptives (COCs), patches, and vaginal rings are ideal for non-smoking women, with no medical contraindications. As well as this, they function as an effective contraception and treat common peri-menopausal conditions.

Progestogens are the first-line therapy for women with contraindications to oestrogens (COCs) and can induce a regular withdrawal bleed. Continuous oral P, LNG-IUS, and DMPA can induce amenorrhea if required. Progestogens can also prevent hyperplasia.

Parenteral oestrogen can be considered in severe haemorrhagic AUB but it is recommended that this is short-term, with patients moving onto COCs for longer-term management. GnRH agonists induce reversible atrophy. Additional treatment options include NSAIDS, the synthetic steroid danazol and tranexamic acid. It should be noted, that the former is contraindicated in women at risk for VTE.

Medical treatments may also represent the most appropriate option for certain structural abnormalities. One of the more recent options available for non-surgical treatment for fibroids are Selective Progesterone Receptor Modulators (SPRMs). The UPA Pearl Trials have demonstrated decreases in bleeding and fibroid volume with SPRM use.

Surgical treatment

John highlighted that before considering surgery, the most like etiology should be evaluated and if possible, medical treatment should be first-line.

Traditional diagnostic tools for AUB include:

  • History and careful pelvic examination
  • Transvaginal ultrasound
  • Office endometrial biopsy
  • Hysteroscopy

John underlined the value of hysteroscopy - the use of modern small diameter endoscopes allows the clinician the ability to differentiate between bleeding secondary to an atrophic endometrium, to benign intracavity uterine lesions such as polyps or submucous fibroids and endometrial adenocarcinoma.

Steven previously outlined the limitations of pipelle catheter - as the sample area is limited - cancers, fibroids or other intrauterine pathologies can be missed.

Diagnostic hysteroscopy and transvaginal ultrasound have the benefits of efficacy and ease - they can be office procedures with no anaesthesia and no cervical dilation.

If medical management has failed, surgical alternatives may offer a therapeutic relief of AU:

  • Hysteroscopic resection
  • Uterine arterial embolization (UAE)
  • Endometrial ablation
  • Ulipristal Acetate (UPA)
  • Hysterectomy

UAE is successfully completed 98-100% of the time and results in an 80-90% relief of menorrhagia. Complications are few but these are occasionally serious. Endometrial ablation is used for heavy menstrual bleeding in a normal size uterus - previously, resectoscope was used commonly but now second generation global endometrial ablation is universal. This method is extremely effective for the control of UAB, especially in those who have failed medical management.

All speakers stressed that medical therapy (COCs, progestogens, NSAIDs) should always be the first options. Although efficacious, endometrial ablation and UAE are not 100% effective. If hysterectomy is to be performed, vaginal and laparoscopic approaches should be preferred.