This document discusses the diagnosis and management of peri-menopausal bleeding. It defines peri-menopause as occurring between ages 45-55 years, when hormonal changes can cause abnormal bleeding. Evaluation involves medical history, physical exam, and non-invasive tests like ultrasound and endometrial biopsy. Potential causes include fibroids, polyps, and cancer. Treatment options include observation, medical therapies like oral contraceptives or Mirena IUD, and surgical procedures such as endometrial ablation or hysterectomy. A thorough evaluation is needed to identify the cause and guide appropriate management of abnormal bleeding during peri-menopause.

1. Peri-Menopausal Bleeding
Diagnosis & Management
A Gari MD.
Obstetrician & Gynecologist
Gynecologic Oncologist
gari505@yahoo.ca

2. Objectives
• Definitions
• Pathophysiology
• Assessment modalities (invasive vs non invasive)
• Management
Medical options
Surgical options

3. What is :
• Reproductive age group?
• What is menopausal age ?
11 45 51 55 70
• Peri-menopausal age ?
45-55 y

4. • What is the main hormaonal changes during
perimenopause ??
• The impact on OVULATION (extremes of
RAG)
Abnormal bleeding :
• Menorrhagia & Inter-menestrual bleeding

5. Anatomy & Histopathology

6. US

8. Histopathology report (Benign)
Atrophy:
Absence of a hormonal effect
Proliferative endometrium:
Estrogen effect
Secretory endometrium:
Progestin effect
Disordered endometrium:
Irregular shedding secondary to unopposed estrogen & endometritis.

9. • Incidence : 10 % (5% of Gyne clinic visits)
• Examine your patient !!!
• Take Hx (risk assessment)
• cervix, vagina, vulva
• Non-gynecologic sites (urethra, bladder, rectum/bowel).
• DUB
• Fibroid
• Endometrial/Cx polyps
• Adenomyosis
• Endometrial Hyperplasia cancer
• Cervical cancer

10. Assessment modalities
Basic investigations
• CBC
• Coagulation profile
• Pap smear
• TSH
Invasive
• Endometrial Bx
• D&C
• Hysteroscopy
Non invasive
• US
• HSG
• ?CT & MRI

11. Endometrial Bx (Pipelle)
 Endometrial sampling vs D&C vs Hysteroscopy:
• The sensitivity (by Pipelle) in postmenopausal women was
91- 99.6 percent.
• The specificity 98 to 100 percent.
• Insufficient or no sample Less 5%.
• Remember 90 - 90 - 90%

12. Insufficient tissue for diagnosis
• Remember the 90/90/90 rules
• Re-assess the case
• Symptoms (bleeding or not)
• US (endometrial stripe) < 5 > mm
• No bleeding + thin endometrial stripe
• Still bleeding + thick endometrial stripe
• Discuss the results/plan with the pt. & document it

13. Dilation and curettage
D&C is a diagnostic procedure NOT therapeutic
Indications:
• Intolerance of the office Bx (pain or anxiety)
• After a non-diagnostic office Bx in women
who are at high risk of endometrial ca.
• Benign histology on office Bx but persistent
bleeding.
• Insufficient office biopsy ***
• Cervical stenosis.

14. • Hysteroscopy
• Diagnostic vs Operative
• Office vs OR
• It should be with a biopsy (35% false –ve)
• It improves the sensitivity of D&C
* Deckardt R et.al. J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):277-82.

15. Management options
Observation:
Medical options :
• NSAID
• Tranexamic acid
• OCPs
• Levonorgestrel-releasing IUS (Mirena)
• Progestogens (cyclical)
• Danazol and (GnRH) analogues

16. Surgical treatment
• Endometrial ablation
• Uterine artery embolization (UAE)
• Hysterectomy

17. Thank you