These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
Heavy, irregular menses are a hallmark of perimenopause and many treatment options are available. It’s also a time when conditions such as fibroids, adenomyosis and precancerous lesions which can cause these symptoms become more prevalent, and may need investigation and treatment.
A woman’s cycles “swing all over the place” during perimenopause, so altered bleeding patterns are to be expected, notes gynaecologist and reproductive endocrinologist Dr John Eden, VMO and Head of the Menopause Clinic at The Royal Hospital for Women and Conjoint Professor at the School of Women’s and Children’s Health, UNSW.
“If it’s a very low oestrogen month, you may not have a period, or if you have a period at all, it’s very light. And it’s not unusual for this to be followed by a huge surge of estrogen and sometimes bleeding can be so heavy a woman ends up in the emergency department,” he says.
According to RANZCOG and NICE Guidelines, heavy menstrual bleeding is best defined as an excessive loss of menstrual blood that disrupts a woman’s physical, emotional, social or material quality of life.
While heavy bleeding can be symptomatic of perimenopause itself, pathologies that cause it also become more common at this time of life, Dr Eden says. These include fibroids (which affect about 40% of women over 40), uterine polyps and adenomyosis.
Metabolic conditions, thyroid dysfunction and medications may also contribute to heavy bleeding, notes GP and medical educator Dr Sara Whitburn, Medical Director of Sexual Health Victoria and chair of the RACGP’s Sexual Health Specific Interest Group.
It’s crucial to exclude endometrial hyperplasia, she adds, especially in women with risk factors such as being over 40, overweight/obesity, and/or a history of unopposed oestrogen exposure.
Heavy bleeding can lead to other health issues, so it’s also important to consider its downstream impact.
“We know heavy bleeding can be a risk factor for iron deficiency and iron deficiency anaemia, which can make fatigue that people feel during the perimenopause worse,” Dr Whitburn points out.
The Australasian Menopause Society advises that any prolonged or heavy bleeding in perimenopause or menopause should be investigated.
Significant irregularities in the menstrual cycle also warrant investigation, says Dr Terri Foran, Sexual Health Physician and Conjoint Senior Lecturer, School of Women’s and Children’s Health, UNSW.
“If it’s three weeks between periods one month and the next it’s four and a half, then that woman probably doesn’t need investigation. But if she reports bleeding between periods or if she’s getting periods that last for 15, 16, 21 days, then obviously that needs to be investigated – firstly to eliminate the chance of a pathology underlying the problem, but also because the woman is going to end up with other issues associated with heavy bleeding, like anaemia.”
Investigation should start with history taking, Dr Whitburn says, and include a good quality gynaecological ultrasound.
The Australian Menopause Society’s guide to investigating and managing abnormal bleeding during the perimenopause and postmenopause notes endometrial ultrasound should be done by an experienced gynaecological ultrasonographer, and some women will need a hysteroscopy.
Refer to a specialist if ultrasound findings are suspicious for endometrial cancer (considering risk factors) or reveal significant pelvic pathology such as large fibroids or endometrial polyps.
Blood test-wise, Dr Eden recommends a full blood count, iron studies, cholesterol, fasting glucose, and thyroid, kidney and liver function tests.
When other pathologies have been ruled out and the bleeding is related to perimenopause itself, there are a number of medical management options that can usually be initiated in GP. Risk factors, symptoms, contraceptive needs and personal preferences will all factor into the choice.
Options include:
This antifibrinolytic agent works especially well on the uterus, Dr Eden says.
“A woman can take two tablets three times a day as soon as her periods start and it typically halves blood loss. And it has a very low side-effect profile,” he says.
It’s also used in emergency departments to control bleeding.
A low dose combined OCP is sometimes a good choice, Dr Whitburn says, stressing they can only be used up to the age of 50 after careful consideration of risk factors.
“Skipping the non-active pills can be a really useful way to manage heavy bleeding in this age group,” she says.
Dr Eden says Zoely® (2.5 mg nomegestrol acetate/1.5 mg estradiol) was designed for perimenopausal women.
“Taking something like Zoely for a year or two or three is a simple, elegant way of getting through the perimenopause and giving menstrual control as well.”
Zoely is not on the PBS.
Another drug used in the ED is Primolut (norethisterone), Dr Eden says.
“Typically two are given every four hours until the bleeding stops. And that’s been around for decades as an emergency measure.”
Primolut can also be taken three weeks on and one week off, as can other older progestogens such as Provera (medroxyprogesterone acetate), he says, and both are PBS listed.
“Although often women are sick of having terrible periods like this, they just want their periods turned off, and we often give them back-to-back to produce no periods at all.”
Newer progesterone drugs, such as Slinda, can have fewer side effects, he notes.
“The progestogen that’s in Slinda, drospirenone, is a nice progestin compared with the older ones. The older ones were good, but had a bit of weight gain, a bit of fluid retention, could have an adverse effect on mood. And Slinda, no weight gain, less likely to affect mood.”
Slinda, not PBS listed, is currently marketed as a pill to take if you get migraines, he says.
“But it’s also a useful pill for women who are perimenopausal because they take it in a calendar pack like the other pills, 24 days on, four days off. And you get tight menstrual control, and minimal risk of DVT or stroke, because there’s no synthetic oestrogen in it.”
Importantly, about one in eight women experience mood changes on progestins, including those in combined OCPs, he notes. Women with a history of depression or anxiety are especially vulnerable.
“If a woman who suffers from depression wants to try the pill or progestin, I always say watch your mood very closely in the first two weeks. Because this happens quickly. It doesn’t happen three months later.”
“If they’re going to get the side effect, usually by the end of the first week they’re feeling like something’s not quite right. As they get further into the treatment, they get worse and worse. By the second week they’re going ‘Oh stop this, let’s do something different.’”
The 52 milligram levonorgestrel IUD “is a really great way to manage bleeding when you’ve checked that it’s due to perimenopause,” Dr Whitburn says.
In women under 45, it can be used for up to eight years if the bleeding pattern is acceptable, she says. “If the bleeding pattern comes back, it can be changed when convenient.”
Dr Foran agrees a hormonal IUD “is a great choice if a woman is keen to consider it during her perimenopausal years because it greatly reduces the amount of bleeding, as well as providing really effective and very convenient contraception. And as a bonus, it’s PBS subsidised.”
Dr Eden says the Mirena revolutionised heavy bleeding management.
“When Mirena came along, the hysterectomy rate in Australia fell some 30-40% to 3% in three or four years,” he says, adding that about 90% of women like it.
“It seems to work quite well for heavy menstrual bleeding for four to five years,” he says.
“And the put-in and-forget aspect of it is amazing.”
Importantly, as a progestin-containing device with systemic effects, consider the impact it may have on mood, especially in women with a history of depression or anxiety.
MHT can be used to manage heavy bleeding in women aged 45 to 55 in whom pathologies have been excluded and who don’t want a Mirena or the low-dose OCP, Dr Whitburn says.
“Sometimes people feel that you can’t use menopausal hormone therapy until people are post-menopausal or not having periods, but actually you can use it at this time. It can be a good way to manage bleeding and other menopausal symptoms,” she says.
Dr Foran cautions, however, that MHT sometimes has the opposite effect in perimenopause.
“The trouble is it doesn’t always suspend that natural cycle,” she explains. “So during the months when hormone levels are high, you can actually make symptoms worse.”
This achieves similar results to a Mirena, and some women prefer it to having a device within their uterus, Dr Eden says.
Women usually have some bloody discharge for about four weeks after the procedure, he says, “but after that, periods are reduced by about 90%. And that typically lasts about four or five years.”
The Australian Commission on Safety and Quality in Health Care’s 2024 Heavy Menstrual Bleeding Clinical Care Standard recommends early referral to an appropriate specialist under the following circumstances.
1. If assessment or ultrasound findings are suspicious, with consideration of endometrial cancer risk factors such as:
2. If ultrasound reveals significant pelvic pathology such as large fibroids or endometrial polyps.
3. If symptoms on initial presentation are severe.
4. If medical management is not suitable or the patient does not respond to it, or if they ask for procedural treatment.
Cancer Australia has a diagnostic flowchart that may be helpful.
Based on this educational activity, complete these learning modules to gain additional CPD.
Listen to expert interviews.
Click to open in a new tab
Browse the latest articles from Healthed.
Once you confirm you’ve read this article you can complete a Patient Case Review to earn 0.5 hours CPD in the Reviewing Performance (RP) category.
Select ‘Confirm & learn‘ when you have read this article in its entirety and you will be taken to begin your Patient Case Review.
