Perimenopausal transition

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A. Perimenopause is defined as the two to eight years preceding menopause and the one year after the last menstrual period. It is characterized by a normal ovulatory cycle interspersed with anovulatory cycles. Menses become irregular, and heavy breakthrough bleeding can occur. Some women complain of hot flashes and vaginal dryness.

B. Chronic anovulation and progesterone deficiency in this transition period may lead to long periods of unopposed estrogen exposure and endometrial hyperplasia. Oligomenorrhea (irregular cycles) for six or more months or an episode of heavy dysfunctional bleeding is an indication for endometrial surveillance. Endometrial biopsy is the standard to rule out endometrial hyperplasia, but screening with vaginal ultrasonography is acceptable. Biopsy can be deferred if endometrial thickness is 4 mm or less.

C. Irregular bleeding and menopausal symptoms during this perimenopausal transition may be treated by estrogen-progestin replacement therapy. However, some women still require contraception. In this case, menopausal symptoms may be effectively treated with a low-dose oral contraceptive if the woman does not smoke and has no other contraindications to oral contraceptive therapy.

D. The oral contraceptive can be continued until the onset of menopause, determined by a high serum FSH concentration after six days off the pill. Estrogen replacement therapy can be started at this point.

E. In women with no symptoms of estrogen deficiency but with dysfunctional uterine bleeding who smoke or have other reasons to avoid an oral contraceptive, monthly withdrawal bleeding can be induced with medroxyprogesterone acetate (5 to 10 mg daily for 10 to 14 days per month).

II. Menopause occurs at a mean age of 51 years in normal women. Menopause occurring after age 55 is defined as late menopause. The age of menopause is reduced by about two years in women who smoke.

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