Perimenopausal vaginal bleeding: diagnostic evaluation and therapeutic options

While significant awareness has been raised about menopause, less attention has been focused on the perimenopausal or "menopausal transition" period. Many women and their physicians remain unaware of the impact of this transitional phase into menopause. Specifically, heavy and unpredictable perimenopausal bleeding is extremely common. It is a normal phenomenon of aging and tends to improve over time. However, about one quarter of perimenopausal women will have heavy flow that persists beyond 3 months and will require medical assistance. The purpose of this review is to focus on the hormonal and physiologic changes that are associated with perimenopausal heavy vaginal bleeding, to present the essential evaluation of causes for this heavy flow, and to outline the evidence for effective medical and surgical treatments. Advances in the understanding of the normal physiology of perimenopause have led to medical therapies that may lead to fewer surgical procedures and hysterectomies and should be of interest to health care practitioners focusing on women's health. Although these issues are addressed in the gynecologic literature, there is relatively less published in other disciplines.