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Natural history of heavy menstrual bleeding in perimenopause

Clinical Question:
Is heavy menstrual bleeding likely to resolve spontaneously among naturally menstruating perimenopausal women?

Bottom Line:
Among naturally menstruating women, aged 40 years to 54 years, with periods they consider to be heavy, spontaneous resolution within 2 years occurs in less than 10%. However, for women aged 45 years to 54 years there is a significant association with spontaneous resolution without recurrence if they are skipping periods. This information may be helpful in clinical decision-making regarding treatment. (LOE = 1b)

Shapley M, Blagojevic M, Jordan KP, Croft PR. The spontaneous resolution of heavy menstrual bleeding in the perimenopausal years. BJOG 2012;119:545-553.  [PMID:22313942]

Study Design:
Cohort (prospective)



This is a population-based prospective cohort study of women in the United Kingdom to assess the prevalence of heavy menstrual bleeding among perimenopausal women and to determine the likelihood that it will resolve spontaneously within the next 6 months to 24 months. The population studied included 67,100 women with a mix of setting (urban and rural) and affluence. The authors included naturally menstruating women aged 40 years to 54 years who were willing to participate and return 5 questionnaires over 2 years. They excluded women receiving hormone therapy, using nonsteroidal anti-inflammatory drugs or tranexamic acid, with an intrauterine device, if they had been pregnant or had a gynecological surgery within the 6 months prior to the baseline survey, or had ever had an endometrial ablation. Periods were considered heavy when women responded to the question "Over the past 6 months how do you regard your periods?" with "very heavy," "fairly heavy," or "variable," and light if they responded with "neither heavy nor light," "fairly light," or "very light." Resolution was defined as transition from heavy to light, and recurrence was defined as transition back to heavy from resolved. Requirement for sample size was appropriately considered and met. There were 2051 women who met the inclusion criteria and consented to participate. The response rate remained above 80% for the duration of the study. The cumulative incidence of heavy menses by 2 years was 39%, and incidence of heavy menses that interferes with life was 7.1%. The overall rate of resolution without recurrence was less than 10%. However, there was an association for resolution without recurrence among women with skipped periods in the age range of 45 years to 49 years with rate ratio of 4.9 (95% CI, 2.1-12) at 2 years and for women in the age range of 50 years to 54 years with rate ratio of 3.2 (1.8-5.3) at 1 year. There was no association for resolution without recurrence among women with skipped periods in the age range of 40 years to 44 years.


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