Management of Abnormal Uterine Bleeding in Perimenopausal Women

Initial Diagnostic Workup

Pregnancy test must be performed despite perimenopausal status, as recommended by the American College of Obstetricians and Gynecologists 1
Hemodynamic stability assessment is urgently needed if saturating a large pad hourly for ≥4 hours, according to the American College of Obstetricians and Gynecologists 1
Speculum examination should be performed to exclude cervical or vaginal bleeding sources, as suggested by the American College of Obstetricians and Gynecologists 1
Bimanual examination is necessary to assess uterine size, contour, and adnexal masses, as recommended by the American College of Obstetricians and Gynecologists 1

Combined transabdominal and transvaginal ultrasound with Doppler is the most appropriate initial imaging study, according to the American College of Radiology 3, 1
Transvaginal approach provides superior endometrial and myometrial assessment, as suggested by the American College of Radiology 1
Saline infusion sonohysterography (SIS) should be performed if initial ultrasound shows focal endometrial abnormality or thickened endometrium, as recommended by the American College of Radiology 3, 1

Endometrial biopsy is required for perimenopausal women with abnormal uterine bleeding, as recommended by the American College of Obstetricians and Gynecologists 1
Additional risk factors requiring biopsy include obesity, diabetes, hypertension, or unopposed estrogen exposure, according to the American College of Obstetricians and Gynecologists 1

MRI of pituitary should be performed if prolactin remains elevated without medication cause, as suggested by the American College of Obstetricians and Gynecologists 1
Dopamine agonist therapy (cabergoline or bromocriptine) may be used if prolactinoma or idiopathic hyperprolactinemia is confirmed, according to the American College of Obstetricians and Gynecologists 1

Pulsatile courses of selective progesterone receptor modulators (ulipristal acetate where available) can bridge perimenopausal women to menopause while avoiding surgery, as recommended by the American Journal of Obstetrics and Gynecology 4

Refer to gynecology if endometrial thickness ≥4 mm with persistent bleeding after initial management, as suggested by the American College of Obstetricians and Gynecologists 1
Refer to gynecology if failed medical management after 3-6 months, according to the American College of Obstetricians and Gynecologists 1
Refer to gynecology if complex structural abnormalities requiring surgical expertise are present, as recommended by the American College of Obstetricians and Gynecologists 1