1. Vaginal Bleeding in the Perimenopause (Age 35-50)
Ralph Anderson, M.D., F.A.C.O.G., F.R.C.S. (C)
Chairman and Professor
Department of Obstetrics and Gynecology
University of North Texas Health Sciences Center
Fort Worth, Texas

2. Classification of Abnormal Uterine Bleeding
Menorrhagia: heavy bleeding; loss of more than 80 mL of blood and/or increased duration of flow (> 7 days) at regular intervals.
Menometrorrhagia: increased loss or duration of bleeding occurring at irregular intervals.

3. Pelvic – no abnormalities Hb – 9.5 Hct 28
A 40-year-old female presents with irregular bleeding over the past year.
Menstrual history
1st period age 15
Bleeding q x 3-5 days until 1 year ago
Now bleeding is heavy and very irregular (menometorrhagia)
Gen Px normal
Pelvic – no abnormalities
Hb – Hct 28
What is the first step in the management?
Pregnancy test
Pregnancy Related Complications
Threatened abortion
Incomplete abortion
Complete abortion
Missed abortion
Trophoblastic disease

4. Pelvic – no abnormalities Hb – 9.5 Hct 28
A 40-year-old female presents with irregular bleeding over the past year.
Menstrual history
1st period age 15
Bleeding q x 3-5 days until 1 year ago
Now bleeding is heavy and very irregular (menometorrhagia)
Gen Px normal
Pelvic – no abnormalities
Hb – Hct 28
What is the first step in the management?
Pregnancy test negative
What is the next step in the management?
Endometrial biopsy
Proliferative endometrium
Ultrasound
Normal uterus, tubes and ovaries
What is the likely diagnosis?
Anovulatory cycles

5. Menometorrhagia (Heavy bleeding at Irregular Intervals)
Excessive estrogen production and domination
Anovulatory cycles
Polycystic ovaries
Obesity
Hypothalamic Dysfunction
Anorexia
Exercise

7. Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles
1. Observation
2. Oral contraceptives
3. Oral progesterone
Provera 5mg daily
Provera 5mg for 14 days of each month
4. Depoprovera
5. Progesterone IUD
6. D&C
7. Hysterectomy

8. Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles
1. Observation
2. Oral contraceptives
3. Oral progesterone
Provera 5mg daily
Provera 5mg for 14 days of each month
4. Depoprovera
5. Progesterone IUD
6. D&C
7. Hysterectomy

9. General Physical Examination normal Pelvic examination Hb 9.2 Hct 26
A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.
General Physical Examination normal
Pelvic examination
Uterus enlarged to 8 week size
Hb 9.2 Hct 26
Pregnancy test negative
Endometrial biopsy shows secretory endometrium with no evidence of hyperplasia or malignancy.
What is the next step in the management?
Transvaginal ultrasound
Saline Infusion Transvaginal ultrasound

10. Heavy Bleeding with Regular Menstrual Cycles (Menorrhagia)
Benign gynecologic disease
Endometrial polyp
Fibroids
Adenomyosis
Neoplasm of uterus
Hyperplasia
Cancer

11. Benign Conditions of the Uterus

12. A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.
General Physical Examination normal
Pelvic examination
Uterus enlarged to 8 week size
Hb 9.2 Hct 26
Pregnancy test negative
Endometrial biopsy shows adenomatous hyperplasia with atypia.
What is the management
A. D&C
B. Progesterone IUD
C. Provera or Megace
D. Hysterectomy

13. Hyperplasia of Endometrium
Oral progesterone
Progesterone IUD
(Mirena)
D&C
Hysterectomy and
Bilateral salpingo
oophorectomy
1-3% risk of cancer
1% risk of cancer
15-20% risk of cancer

14. Cancer of the Endometrium

15. A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.
General Physical Examination normal
Pelvic reveals a normal size uterus and no pelvic pathology.
Hb 9.2 Hct 26
Pregnancy test negative
Endometrial biopsy reveals secretory endometrium
Transvaginal ultrasound reveals normal uterus and ovaries.
What are your thoughts?

16. Think of Systemic Disorders Hyperthyroidism
In a reproductive age woman with menorrhagia or menometorrhagia not related to
Pregnancy
Benign uterine pathology
Hyperplasia or cancer
Think of Systemic Disorders
Endocrine
Hyperthyroidism
Liver Disease
Renal Disease
Obesity
Hypothalamic Disorders
Anorexia
Exercise 16

17. Abnormal Uterine Bleeding
Medications Associated with Menorrhagia
Antidepressants
Antipsychotics
Interferes with stimulatory and inhibitory nervous impulses that control hypothalamic function resulting in anovulation and abnormal uterine bleeding
Anabolic steroids
Amenorrhea or irregular vaginal bleeding due to the androgenic effects of the steroids.
Aspirin and other prostaglandin synthase inhibitors inhibit platelet function
Heparin and warfarin interferes with clotting mechanisms.
Digoxin
Propranolol
Corticosteroids

18. Iatrogenic Causes of Menorrhagia and Menometorrhagia in the Perimenopausal Female
Oral contraceptives
Depot medroxyprogesterone acetate
Post menopausal therapy
Anticoagulants
Herbal supplements

19. Vaginal Bleeding in the Perimenopause (35-50)
Pregnancy Related Problems
Heavy bleeding at Irregular Intervals
Anovulatory cycles
Heavy bleeding with Regular Menstrual Cycles
Benign gynecologic disease
Polyp ∙Fibroids ∙ Adenomyosis
Neoplasm of the uterus
Hyperplasia ∙Cancer
Metabolic Disorders
Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity
Medications associated with Menorrhagia
Antidepressants ∙Antipsychotics ∙ Aspirin

20. Vaginal Bleeding in the Perimenopause (35-50)
Pregnancy Related Problems
Heavy bleeding at Irregular Intervals
Anovulatory cycles
Heavy bleeding with Regular Menstrual Cycles
Benign gynecologic disease
Polyp ∙Fibroids ∙ Adenomyosis
Neoplasm of the uterus
Hyperplasia ∙Cancer
Metabolic Disorders
Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity
Medications associated with Menorrhagia
Antidepressants ∙Antipsychotics ∙ Aspirin