Doctors want to rule out cancer or other serious illness so high-risk persons–such as those with obesity, diabetes or high blood pressure–are advised to take action sooner rather than later.
Simple office procedures can be used to make a diagnosis. An older procedure, dilation and curretage (D&C), uses a long metal instrument with a loop on the end to scrape the walls of the uterus and remove a specimen for biopsy. A more common method today, however, is hysteroscopy. Using a thin, lighted scope, a doctor can examine the inside of the uterus and remove any abnormalities that are found. Other useful diagnostic tools include transvaginal ultrasound and hysterosonography–both using sound waves to create images of the uterus.
Causes of perimenopausal bleeding include:
1. LACK OF OVULATION: Most women have fairly regular periods for most of their lives, maintained by an exact balance of hormones. When ovulation does not occur regularly, the hormonal balance is upset, leading to a number of problems.
2. POLYPS are growths attached to the inner wall of the uterus. There can be one polyp or many, and their growth is sped up by estrogen. When they become large enough, polyps can irritate surrounding tissue, revealing tiny blood vessels and leading to spotting or excessive bleeding.
In the past, D&C–a gentle scraping of the uterine lining–was used to remove polyps, but it was an imperfect method; some polyps usually escaped. Hysteroscopy allows a doctor to see a polyp, grasp it with a cutting instrument and remove it from the uterine lining.
3. ENDOMETRIAL HYPERPLASIA is a growth or thickening of the lining of the uterus that can occur during perimenopause, as a result of too much estrogen compared to progesterone. The most common symptom is abnormal vaginal bleeding.
When a woman takes estrogen after menopause, some form of progesterone is usually included in the prescription to lessen the risk of endometrial hyperplasia and uterine cancer. Likewise, when a woman stops having monthly periods, she may need to take a form of progesterone to prevent this excessive growth of the endometrium. If a woman is overweight, weight loss may also help.
4. ENDOMETRIAL CANCER is the fourth most common cancer in women. Abnormal vaginal bleeding–typically heavy and draw out–is one of the most common signs, occurring in 90 percent of cases.
Although it is a distinct condition from endometrial hyperplasia, the two share some of the same risk factors: exposure to unopposed estrogen, obesity, diabetes and high blood pressure. Women who do not ovulate and those who have used tamoxifen are also at risk because of the effect on estrogen levels.
5. FIBROIDS develop in as many as 75 percent of women, usually during childbearing years and often cause no symptoms. When they are large and located so that they project into the uterus, they can be the cause of prolonged, heavy menstrual bleeding.
Options for the removal of fibroids include having a hysterectomy, surgical removal through myomectomy, which leaves the uterus in place, and uterine artery embolization, which shrinks the fibroids by cutting off their blood supply.
In the past women who were overwhelmed by irregular and excessive vaginal bleeding, have often chosen hysterectomy. With the advantage of the diagnostic tools available, they can now choose from a range of less invasive treatment options.
In conclusion, perimenopausal women who experience extreme spotting to heavy bleeding should make an appointment with their doctor for further evaluation to make sure that no other issues are present.
Kerri Musselman, PharmD—Rev. 5/12/10 TNK
