Perimenopausal Bleeding: The Roller Coaster of Mid-life Steven R. Goldstein, M.D..FACOG,CCD,NCMP, RCOG(H) Professor of Obstetrics & Gynecology New York University School of Medicine Director of Gynecologic Ultrasound Co-Director of Bone Densitometry New York University Medical Center

PERIMENOPAUSE (DEFINED) Harlow, Siobán D. , et al PERIMENOPAUSE (DEFINED) Harlow, Siobán D., et al. Executive summary of the Stages of Reproductive Aging Workshop+ 10: addressing the unfinished agenda of staging reproductive aging. Climacteric 2012: 15.2 : 105-114. The STRAW+10 system for reproductive aging in women defined “perimenopause” as the “early” and “late” menopausal transition.

“Early” menopausal transition: Variable duration Cycle length variable “persistent ≥ 7day difference in length of consecutive cycles”. Lab tests FSH: variable AMH (Anti- Mullerian Hormone): low Inhibin B: low Antral follicle count: low

“Late” Menopausal Transition Duration 1-2 years. Interval of amenorrhea of ≥ 60 days. Lab tests FSH: elevated AMH: low Inhibin B: low Vasomotor symptoms “likely”.

PERIMENOPAUSE: CLINICAL SEQUELAE Some have likened perimenopause as the mirror image of adolescence. Corollary to this: one is the coming onto the reproductive years, the other the coming off.

PERIMENOPAUSE: CLINICAL SEQUELAE Characterized by oligoovulation Hallmark of ovulation: regular cyclic, predictable menses. Hallmark of anovulation/oligoovulation: irregular timing and length of uterine bleeding.