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Menopause - Management
How do I manage bleeding on monthly cyclical regimens?

  • Examine the woman, visualize the cervix and check smears are up to date, and refer for transvaginal ultrasound to exclude pelvic abnormalities before changing treatment.
  • Check for compliance with therapy, drug interactions (e.g. anticonvulsants), or gastrointestinal upset.
  • Altering the progestogen part of the regimen may improve bleeding:
    • Heavy or prolonged bleeding: increase the duration or dosage of the progestogen, or change the type of progestogen. Idiopathic menorrhagia may be helped by using the levonorgestrel-releasing intrauterine system combined with an oestrogen delivered orally or transdermally.
    • Bleeding early in the progestogen phase: increase dosage or change the type of progestogen.
    • Irregular bleeding: change regimen or increase the dosage of progestogen.
    • No bleeding whilst taking a cyclical regimen reflects an atrophic endometrium and occurs in 5% of women. Pregnancy needs to be excluded in perimenopausal women. Check compliance if the progestogen component is taken separately.
Clarification / Additional information
  • It is mandatory to investigate before changing treatment because pelvic pathology can be missed. Changing treatment before examination is unsafe practice and can lead to delayed diagnosis of endometrial cancer.
Basis for recommendation
  • These recommendations are based on published expert opinion [Rees and Purdie, 2006a; Menopause Matters, 2007a].
  • Monthly cyclical regimens should produce regular predictable bleeding starting towards or soon after the end of the progestogen phase. Unpredictable or unacceptable bleeding may be due to non-adherence to therapy, drug interactions, or gastrointestinal upset (or cancer, if not already excluded).

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