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ChangesbeforethechangePerimenopausalbleedingAlthoughsomewomenmayabruptlystophavingperiodsleadinguptothemenopause,manywillnoticechangesinpatternsandirregularbleeding.Whilstthiscanbeanaturalphaseinyourlife,itmaybeimportanttoseeyourhealthcareprofessionaltoruleoutotherhealthconditionsifotherworryingsymptomsoccur.Whatismenopause?Strictly defined, menopause is the last menstrual period. It defines the end of a woman’sreproductiveyearsasherovariesrunoutofeggs.Nowthecellsintheovaryareproducinglessandlesshormonesandmenstruationeventuallystops.Whatisperimenopause?Onaverage,theperimenopausecanlastonetofouryears.Itistheperiodoftimeprecedingandjustafter the menopause itself. In industrialized countries, the median age of onset of theperimenopauseis47.5years.However,thisishighlyvariable.Itisimportanttonotethatmenopauseitselfoccursonaverageatage51andcanoccurbetweenages45to55.Actuallythetimetoone’slastmenstrualperiodisdefinedastheperimenopausaltransition.Oftenthetransitioncanevenlastlonger,fivetosevenyears.Whathormonalchangesoccurduringtheperimenopause?When a woman cycles, she produces two major hormones, Estrogen and Progesterone. Both ofthesehormonescomefromthecellssurroundingtheeggs.Estrogenisneededfortheuterineliningto grow and Progesterone is produced when the egg is released at ovulation. This ovulationhormone(Progesterone)isneededforpregnancy,butisalsoimportanttocontrolthegrowthoftheuterinelining.ToomuchEstrogenandmenstruationbecomesheavy;toolittleProgesteroneandtheuterineliningisnotcontrolledandbecomesthicker.Menstruationthenofcoursebecomesheavierstill. Think of Estrogen as being the fertilizer on the grass. It is the fertilizer to the uterine lining(endometrium) then and Progesterone on the other hand is the lawn mower and cuts theendometrial grass every month. This explains why menstrual periods become heavier andproblematic during the perimenopausal transition (too much Estrogen and not enoughProgesterone).As time goes on, during the transition, Estrogen levels also decrease and the uterine lining thenbecomes thinner. Ovulation becomes infrequent and especially in the last years before bleedingceases (the finalmenstrualperiod)periodsbecome lighter,more infrequentand then finally stop.ThisisatimeofEstrogendeficiency.Whatarethesymptomsofperimenopause?Thechangesinhormonelevelscanleadtoavariedsetofphysicalandemotionalsymptoms.Aswithmenstruationinyoungerlife,allwomenwillexperienceperimenopausedifferently.Whilesymptomsarecommoninperimenopause,womenwillexperiencedifferentcombinationsofsymptoms,andtovaryingdegrees.ProgesteroneDeficiencySymptoms© Bleeding

• Shortcycles• Heavierflow• Premenstrualspotting

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© PMS

(PremenstrualSyndrome–oftenseenduringpre-menopause)• Moodiness• Hotflushes• Depression• Poorconcentration• Irritability• Anxiety• Headaches(menstrualmigraine)

EstrogenExcessSymptoms© Bleeding

• Toomuch• Toolong• Toosoon• Erratic

© Breasttenderness© Bloating© Headaches© Weightgain© VaginaldischargeEstrogenDeficiencySymptoms© Hotflushes,nightsweatsandheatintolerance© Insomnia© Fatigue© Vaginaldryness© HeadachesAlthoughthesymptomslistedabovearecommonduringperimenopause,noteveryonewillhaveallof these.Womenmay have some symptoms, and theymay have few or no symptoms. It is stilladvisable to visit a healthcare professional to discuss the changes, as it is possible that yoursymptomscouldbepointingtowardsmoreserioushealthconditions.ShouldIvisitmyGP?ManywomenexperienceAbnormalUterineBleeding(AUB)duringperimenopause.AUB isdefinedas bleeding that differs in frequency, regularity, duration or amount compared to one’s regularmenstrualbleeding. [1.]Changes to themenstrualcycleoftencarrynosignificantconsequences [2.];however,theycanhavearangeofcauses.Althoughitmaysimplybeasymptomofperimenopause,itisstillsensibletoraisetheissuewithyourhealthcareprofessional.Athoroughhistoryandphysicalexamination will indicate the cause of uterine bleeding and help discern the need for furtherinvestigation and treatment. [3.] Other investigations for abnormal uterine bleeding include a PAPSmear, Endometrial orUterine Sampling (Endometrial Biopsy), aVaginalUltrasound (Echography),androutinelaboratorytesting.WhatelsemaycauseAUBbesideshormonalchanges?Thecausesareusuallybenignnotmalignant:

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• UterinePolyps• UterineFibroids• Adenomyosis• LowThyroidFunction(canbeseenin1in4womenage40to55)• OthermedicalconditionslikeHaematology(bloodproblems)

A uterine polyp is an outgrowth of the uterine lining. Fibroids are benign tumours of the uterinemuscle – rarely malignant. Adenomyosis is a down growth of the uterine lining into the uterinemuscle,oftenassociatedwithpainfulperiodsandpainfulintercourse.However the most important cause of AUB is cancer of the uterine lining (Endometrial Cancer).Althoughthis isuncommon(1 in1000women) itmustbediagnosedearly. It is infrequentlyfoundduringtheperimenopausebutmorecommonlyassociatedwithpostmenopausalbleeding.Diagnosiscanbedoneeasilyutilizingthemethodsnotedabove(UterineUltrasoundandEndometrialBiopsy).ThereisusuallyveryheavybleedingandcanceroftheuteruscanbeassociatedwithriskfactorssuchasObesity,Diabetes,PolycysticOvarianDisease,andlatemenopause(afterage55).ThesesituationsareallassociatedwithexcessEstrogenandinsufficientornoProgesterone.Other cancers can also be associated with AUB like Cervical Cancer and Ovarian Cancer. Thesecancersoftenpresentwithspottingandintermenstrualbleeding.IdentificationofCervicalCancerisdone by a PAP Smear, and may be associated with bleeding after intercourse. Obviously it isimportant to see a physicianwhowill investigate thoroughly. Abnormal bleeding in the 40’s andduringtheperimenopausaltransitionmustbetakenseriouslyandinvestigatedappropriatelytoruleoutcancer.HowdoIknowit'sAUB?Inperimenopausalwomen,AUBcanbedefinedasovulatoryoranovulatory,dependentonwhetheryouarestillovulating.Ovulatorybleedingoccurswhenyouarestillproducingeggsalbeit,theyaredecreasing. Ovulatory bleeding is associatedwith typical premenstrual symptoms and sometimespainful periods. Premenstrual spotting is common. Anovulatory bleeding, which is found morefrequently during perimenopause compared to the pre-menopause, is often linked to prolongedperiodsandaheavierflow.[4.]Itisthisanovulatorybleedingwhichhasastrongerlinktoendometrialcancer and precancer called endometrial hyperplasia (when the lining of the uterus becomes toothick).[5]AUBwithahistoryofanovulation(erratic,irregularandheavyperiods)shouldbeinvestigatedwithanultrasoundoftheuterus.Thisiscalledsonography.Oftenthereisathickenedendometrium,andanendometrialoruterinebiopsyisadvised.Apremenopausaluterineliningismeasuredanywherefrom3to12millimetres.Numbersgreaterthanthiscanbeveryserious.Whenconsideringyourowncycle,thereareafewredflagswhichmeanitistimetovisityourfamilydoctor:

• Bleedingthatrequiresanewpadeveryhourforover24hours• Bleedingthatlastsovertwoweeks• Anybleedingwhichhasbeenpresentafterthefinalmenstrualperiod.Thetimingisvariable.

TwelvemonthsafterthefinalmenstrualperiodisconsideredpostmenopausalbleedingIfyouareconcernedaboutAUB,itcanhelptokeeparecord(menstrualcalendar)ofyoursymptomsandtakethesewithyouwhenraisingtheissuewithyourhealthcareprofessional.Thismayhelpwiththeirexaminationanddiagnosis.[6.]

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Whatimportantconcernsaffecttheriskofendometrialcancer?Aswithanumberofmedicalconditions, theriskofendometrialcancer isstronglyassociatedwithobesity,[7.]particularlywomenwithaBodyMassIndex(BMI)over30kg/m.[8.]AddressingyourBMImaypotentially reduce the riskofdevelopingendometrial cancer,aswellashavingotherpositivehealth benefits. Being significantly overweight can also have an impact on treatment options forendometrial cancer. For very obese women, invasive surgery may not be a good option ascomplicationscanoccurduringtreatmentorduringtherecoveryperiod.[9]It'spossiblethatregularphysicalactivitycanhaveaprotectiveeffectagainstendometrialcancer[10.],butmorestudiesareneededtomoreaccuratelyestimatethemagnitudeoreffect[11.].Treating anovulatory bleeding with Progesterone and/or the low dose oral contraceptive willpreventendometrialcancerssignificantly.CanIrelievethesymptomsofAUB?LivingwithAUBcanbetroubling,anditisimportanttoaddresstherootcausebeforedismissingitasa symptom of perimenopause. Excessive uterine bleeding can have detrimental effects on awoman'squalityoflife.NotonlycanAUBcausestressanddiscomfort,withheavyandunpredictablebleeding,butitcanevenhaveaneconomicimpactbycausingmissedworkdays.[12.]WhatarestrategiestocopewithAUB?1. Ahealthylifestyleisimportant

Agooddiet,regularexercise,smokingcessation,andavoidanceofstreetdrugsandopioidsareallimportant.Trytomanagestressandalleviatetensioninyourlife.

2. IncreaseyourironintakeIncreasedbloodlosscanleadtoanaemiaasyourbodystrugglestoreplenishiron.[13.]Increasingyourironintakecanhelptoreducetheriskofbecominganaemic.Ironrichfoodsincludespinachand other leafy greens, redmeat and eggs. Youmay also find certain breads or cereals haveaddediron.[14.]Itmaybenecessarytotakeanironpilladayorevenmore.TrytotakeirononanemptystomachwithVitaminC,eitheratabletoraglassoforangejuice.Remember,certainirontabletscanbeconstipatingandyoumayneeddirectionfromyourfamilydoctor.

3. Hormonetherapy

Using oral contraceptives or daily oral progestogens (Progesterone) can help decrease heavybleeding and regulate the menstrual cycle. Remember Progesterone will control the uterinelining,thuswillsupressthegrowthofendometrialtissues.[15.]Yourdoctorwillbeabletoadvisewhetherhormonetherapyissuitableforyou.Individualisationiskeyinthedecisiontousethiskindoftreatment.Rememberthatsmokingiscontraindicatedifyouareutilizingalowdosebirthcontrol pill. Personal risk factors, such as age, time since menopause, risk of heart disease,strokeorbreastcancer,shouldallbetakenintoconsideration.[16.]

4. Anti-inflammatoryagents

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for the first three days ofmenstruationtoreducebloodflow.[17.,18.]NSAIDsmayalsodecreasemenstrualcramping.InAUBwhichisaresultofendometrialdysfunctionorovulatorydysfunction,NSAIDshasbeenshowntoreducemenstrualbleeding.[19.]Careful,NSAIDscanirritateasensitivestomach.

5. IntrauterineDevice(IUD)

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IUDsareaneffectiveformofcontraception.OnlyonetypecanrelievethesymptomsofAUBandcontroluterinebleeding.ThisisanIUDcontainingaprogestogen(progesterone)withmorethanonenowavailable.Thissmalldevicecaneasilybeinsertedintotheuterus.Asitisactivatedwithprogesterone,thehormone locallycontrolsthegrowthoftheuterine lining,where95%ofthehormone acts. Very little is absorbed into the general circulation, thus having few sideeffects.ThefirstIntrauterineSystem(IUS),theLevonorgestrelReleasingIUS,hasbeenavailablesincethe1980’s,andhasbeenlinkedwithasignificant95%reductioninmenstrualbloodloss.This occurs within 6 to 12 months and canlast up to 5 years. Of course, this is also a veryeffectiveformofperimenopausalcontraception.

Whatnext?If youhave any concerns aboutperimenopause, or anyof the conditionsdiscussed in this leaflet,pleasevisityourhealthcareprofessional.Theywillbeabletohelpyouexploreoptionsfordiagnosis,preventionandsymptommanagement,aswellastreatmentoptionswhereneeded.Yourdoctormayofferothermedicaltreatments,evensurgicaloptionsafterathoroughevaluation.These can include D and C’s (dilation and curettage), Polypectomy, Myomectomy (removal offibroids), and Endometrial Ablation (surgery to permanently thin the uterine lining). Conservativemanagement (preserving the uterus) ismore common today than ten years ago. AHysterectomy(surgicalremovaloftheuterus)maybenecessaryasalastresortifallelsefails.ContactdetailsInternationalMenopauseSocietyMsLeeTomkinsIMSExecutiveDirectorPOBox751CornwallTR24WDUKTel:+441726884221Email:leetomkinsims@btinternet.comWebsite:www.imsociety.org

CopyrightInternationalMenopauseSociety2017

DisclaimerInformationprovidedinthisbookletmightnotberelevanttoaparticularindividual’scircumstancesandshouldalwaysbediscussedwiththeindividual’shealthcareprofessional.Thispublicationprovidesinformationonly.TheInternationalMenopauseSocietycanacceptnoresponsibilityforanyloss,howsoevercaused,toanypersonactingorrefrainingfromactionasaresultofanymaterialinthispublication

orinformationgiven.

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Problems: Abnormal Uterine Bleeding". www.acog.org/-/media/For-Patients/faq095.pdf?dmc=1&ts=20170530T2118409798(CitedMay2017).

2. (2016)."AbnormalUterineBleeding".JournalofMidwifery&Women'sHealth,61(4).522-527.3. Singh S, Best C, Dunn S, LeylandN,WolfmanWL, et al (May 2013). Clinical Practice –Gynaecology Committee. "Abnormal

uterinebleedinginpremenopausalwomen".JournalofObstetricsandGynaecologyCanada,35(5):473–479.4. BlaserFarrukh,Jill;McKee,Nora;Towriss,Kellie(August2015)."Abnormaluterinebleeding:Takingthestressoutofcontrolling

theflow".CanadianFamilyPhysician,61(8):693–697.5. Singh S, Best C, Dunn S, LeylandN,WolfmanWL, et al (May 2013). Clinical Practice –Gynaecology Committee. "Abnormal

uterinebleedinginpremenopausalwomen".JournalofObstetricsandGynaecologyCanada,35(5):473–479.6. TraceeCornforth,(2017)."IsIrregularBleedingNormalDuringPerimenopause?".VeryWell:www.verywell.com/bleeding-after-

sex-during-perimenopause-3522479(CitedJune2017).7. DrPLMartin-Hirsch,DrSGhaem-Maghami(2012)."EndometrialCancerinObeseWomen".ScientificImpactPaperNo32:2.8. FoleyK,LeeRB.Surgicalcomplicationsofobesepatientswithendometrialcarcinoma.GynecolOncol1990;39:171–4.9. PaolaAGehrigetal(2008)."Whatistheoptimalminimally invasivesurgicalprocedureforendometrialcancerstaginginthe

obeseandmorbidlyobesewoman?"GynecologicOncology,111(1):41-45.10. Weightcontrolandphysicalactivity.In:H.VainoandF.Bianchini(eds),IARCHandbookforCancerPreventionVol.6,pp.1–315.

Lyon,France:IARCPress,2002.11. RudolfKaaks,Annekatrin Lukanova,MindySKurzer (2002). "Obesity,EndogenousHormones,andEndometrialCancerRisk".

CancerEpidemiology,Biomarkers&Prevention.Volume11,Issue12,pp.1531-1543.12. IanSFraser,SueLangham,KerstinUhl-Hochgraeber,(2014)."Health-relatedqualityoflifeandeconomicburdenofabnormal

uterinebleeding".ExpertReviewofObstetricsandGynecology,4(2):179-189.13. VercelliniP,VendolaN,RagniG,TrespediL,OldaniS,CrosignaniPG,(1993).Abnormaluterinebleedingassociatedwithiron-

deficiencyanemia.Etiologyandroleofhysteroscopy".TheJournalofReproductiveMedicine,38(7):502-504.14. EMDeMaeyeretal.(1989)."Preventingandcontrollingirondeficiencyanaemiathroughprimaryhealthcare:Aguideforhealth

administratorsandprogrammemanagers".WorldHealthOrganization,www.who.int/iris/handle/10665/39849.15. JoAnn V Pinkerton (2015). "Dysfunctional Uterine Bleeding (DUB) (Functional Uterine Bleeding)" . MSD Manual,

www.msdmanuals.com/en-gb/professional/gynecology-and-obstetrics/menstrual-abnormalities/dysfunctional-uterine-bleeding-dub

16. TheNorthAmericanMenopauseSociety,theAmericanSocietyforReproductiveMedicine,andTheEndocrineSociety(2017)."The experts do agree about hormone therapy." The North American Menopause Society: www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/the-experts-do-agree-about-hormone-therapy (Cited June2017).

17. Association of Reproductive Health Professionals, (2008). "Abnormal Uterine Bleeding". www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/Abnormal-Uterine-Bleeding(CitedJune2017)

18. S. R. Goldsteina,M. A. Lumsdenb and D. F. Archerc, 2017, Abnormal uterine bleeding in perimenopause, Climacteric 2017(pendingpublication).

19. KristenAMattesonet al (2013). "Non-surgicalmanagementof heavymenstrual bleeding:A systematic reviewandpracticeguidelines".ObstetGynecol,121(3):632-643.

20. SuhairWreikatetal (2015). "Acceptabilityandefficiacyof levonorgestrel intrauterinedevice for treatmentofmenorrhagia".JournalofBasicandAppliedResearchInternational,2(2):48-56.

21. MarkLivingstone,IanSFraser,(2002)."Mechanismsofabnormaluterinebleeding".HumanReproductionUpdate,8(1):60-67.