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The perimenopause is the time between when a woman starts to experience the first signs of the menopause and when she has had 12 months without a period. Although some women will have an early menopause, finishing their periods before their mid-40s, half the women in the UK go through the menopause by the age of 51/52. Eighty percent of women will have stopped having periods by 55.

This article was included in issue 80 (spring 2019) of The Menopause Exchange newsletter.

The length of time between the first signs of the menopause (bleeding between periods or missing a period) and finally being menopausal is very variable, and some women in the early stages have spells of having all the symptoms of the menopause and then everything reverting to normal for weeks or months. The occasional bleed between periods or missing a period is common at any age but if an irregularity persists for longer than two or three months, or if bleeding occurs after sex, it’s recommended that women seek advice from a doctor or nurse.

Period changes
Usually, the perimenopause lasts for two to three years. Periods occur less often and usually become lighter and eventually stop. Hot flushes and night sweats are commonly a late feature of the perimenopause, accompanied by fatigue, insomnia, irritability and headaches.

Sometimes, periods become heavier during the perimenopause instead, due to hormonal fluctuations or fibroids, and this can trigger iron-deficiency anaemia. Having ruled out any specific causes, such as polyps or endometrial cancer, heavy periods can usually be treated with tablets containing tranexamic acid or nonsteroidal anti-inflammatory drugs, such as mefenamic acid (Ponstan). Current NICE guidelines suggest that a progestogen coil, such as a Mirena, can be fitted if there are no reasons why a woman can’t have one. The combined contraceptive pill or progestogen-only pill can also be used, especially if contraception is still needed.

If a woman has fibroids larger than 3cm or more in diameter, ulipristal (Esmya) is a possible treatment, but this is normally only prescribed by a hospital consultant and within certain guidelines, as there’s risk of rare but serious liver injury. Uterine artery embolisation is yet another option and is increasingly becoming more available on the NHS. Endometrial ablation of the latest type can also be used. Surgery to remove fibroids (called a myomectomy) or hysterectomy (removal of the uterus with or without both ovaries and/or the cervix) is considered to be a final resort for fibroids these days, in comparison to 20 to 30 years ago, when total hysterectomy was the most common treatment for heavy periods.

Looking at all these various options and choosing the right one can be difficult. I would advise that women with heavy or unusual bleeding patterns ask for a referral to a specialist menopause clinic, if possible, or a gynaecologist with a special interest in the menopause, so that all of the latest advice and guidelines can be considered, depending on what’s available locally.

HRT and bleeding patterns
With regard to bleeding patterns when taking HRT, it depends on whether a woman has been prescribed cyclical or continuous combined HRT. With cyclical HRT, the HRT consists of oestrogen in the first two weeks of the pack, which thickens the uterine lining (endometrium), and then progestogen for two weeks, which makes the lining stay in place. The change between the two hormones mimics the body’s natural cycle, so most women on cyclical HRT will have a ‘withdrawal bleed’ at the end of each pack, like a light period.

Around the age of 54, a woman can try changing to a continuous combined type of HRT, where the two hormones (oestrogen and progestogen) are mixed together and the lining of the uterus is held in a thin layer that shouldn’t come away, so the woman is then bleed-free.

If the bleeding is very irregular or heavy on cyclical HRT, then increasing the amount of progestogen, to keep the endometrium in place, will usually help. If this doesn’t settle the problem, or bleeding becomes heavier, then investigations should take place to look at any underlying cause, such as fibroids or adenomyosis, using vaginal ultrasound/ hysteroscopy. Bleeding persisting after stopping HRT, when the woman previously had no periods, should also be checked out.

Occasionally, doctors prescribe a type of cyclical HRT that has nearly three months of oestrogen followed by a short course of progestogen to cause a withdrawal bleed. This is a short-term measure to help with irregular heavy periods in the perimenopause. It’s not recommended for long-term use due to an increased risk of endometrial cancer because the oestrogen isn’t being counteracted by progestogen for a much longer time than normal cyclical HRT.

Breakthrough bleeding is common in the first three months of taking continuous combined or long-cycle cyclical HRT, but should be reported to a doctor or nurse if it continues for longer than this.

Any vaginal bleeding after the menopause is treated as an urgent problem by doctors, as this can be due to endometrial cancer. The NHS treats all cases of post-menopausal bleeding as ‘fast track’, meaning an appointment and assessment should be offered within two weeks of the GP sending a referral to the local hospital.

Fortunately, most women with postmenopausal bleeding have a far less serious reason for their bleeding, such as atrophic vaginitis (thinning of the vaginal tissues) or endometrial polyps, but it’s a symptom that should never be ignored. If post-menopausal bleeding occurs more than six months after an earlier episode, it will be treated as a new symptom and the woman re-referred to a clinic or specialist doctor for further tests.

Bleeding patterns in women during the perimenopause can commonly be irregular, but any persistent or unusual symptoms should always be discussed with a healthcare professional, especially if she is on HRT for longer than three months or after her periods have stopped.

About the author
Dr Jeni Worden is a GP in Christchurch, Dorset, with a special interest in women’s health, especially the menopause.

Created Spring 2019

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