# Abnormal Uterine Bleeding in Perimenopause

> Anovulatory bleeding at 40 to 50 years, endometrial sampling thresholds and progestogen, IUS or ablation management, for NEET-PG Obstetrics and Gynaecology.

- Canonical URL: https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/abnormal-uterine-bleeding-in-perimenopause
- Exam / course: NEET-PG · Subject: Obstetrics and Gynaecology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-08
- Last updated: 2026-10-08
- Reference basis: Williams Gynecology; FIGO PALM-COEIN classification; Dutta's Textbook of Gynecology
- How to cite: "Abnormal Uterine Bleeding in Perimenopause", PrepElephant, https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/abnormal-uterine-bleeding-in-perimenopause

## Direct answer

Abnormal uterine bleeding in perimenopause is most often anovulatory bleeding from unopposed oestrogen, and it needs endometrial assessment when structural disease or hyperplasia is possible. Endometrial sampling is generally advised for women aged 45 and over with abnormal bleeding, and for younger women with risk factors. Treatment ranges from progestogens and the levonorgestrel intrauterine system to tranexamic acid, endometrial ablation and hysterectomy.

## What you must remember

- **Commonest cause:** Anovulation with unopposed oestrogen, producing irregular, prolonged or heavy bleeding.
- **FIGO PALM-COEIN:** Structural causes are polyp, adenomyosis, leiomyoma and malignancy or hyperplasia; non-structural causes are coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified.
- **Sampling threshold:** Age 45 and over with abnormal bleeding, and younger women with risk factors or persistent bleeding.
- **Endometrial thickness:** Thickness on transvaginal ultrasound guides sampling, though perimenopausal thresholds are less standardised than postmenopausal ones.
- **Hyperplasia risk:** Obesity, anovulation and PCOS increase unopposed oestrogen exposure, and cyclical progestogen reduces the risk.
- **Levonorgestrel IUS:** Effective for heavy bleeding and endometrial protection, and a strong option when the uterus is kept.
- **Tranexamic acid:** An antifibrinolytic for heavy bleeding, avoided in active or past thromboembolic disease.
- **Definitive treatment:** Hysterectomy after failed medical therapy, or for atypical hyperplasia or cancer.

## A stepwise pathway from bleeding to tissue diagnosis

A 46-year-old woman with six months of heavy, irregular bleeding cannot be labelled perimenopausal until structural and malignant causes are excluded. The steps below set out a standard evaluation.

1. **Exclude pregnancy and anaemia:** Check a pregnancy test and haemoglobin, since pregnancy and iron deficiency both change management.
2. **Check thyroid and prolactin:** Hypothyroidism and hyperprolactinaemia both cause anovulation and irregular bleeding.
3. **Image the uterus:** Transvaginal ultrasound assesses endometrial thickness, polyps, fibroids and adenomyosis. A normal scan does not exclude hyperplasia, so sampling still depends on age and risk.
4. **Sample the endometrium:** Sample when the woman is 45 or older, or younger with risk factors, persistent bleeding or a thickened endometrium on imaging.
5. **Choose treatment by histology:** Progestogens or the levonorgestrel IUS suit hyperplasia without atypia and anovulatory bleeding, while atypical hyperplasia or cancer needs hysterectomy.
6. **Reassess after treatment:** Persistent bleeding despite therapy calls for hysteroscopic evaluation, and bleeding-disorder screening if the history suggests it.

## Where the exam tries to catch you

Most traps here come from skipping sampling or pairing a treatment with the wrong pathology.

- **Trap:** Labelling heavy bleeding in a 46-year-old as dysfunctional without sampling. — **Correct:** Age 45 and over with abnormal bleeding warrants endometrial sampling first, to exclude hyperplasia and cancer.
- **Trap:** Offering endometrial ablation for endometrial hyperplasia. — **Correct:** Ablation suits non-hyperplastic bleeding with a normal cavity, while hyperplasia or cancer needs definitive management.
- **Trap:** Prescribing tranexamic acid to a woman with previous deep vein thrombosis. — **Correct:** It is contraindicated in active or past thromboembolic disease, so an alternative such as the levonorgestrel IUS is used.
- **Trap:** Treating anovulatory bleeding with oestrogen alone. — **Correct:** Unopposed oestrogen drives hyperplasia, so a progestogen is required to protect the endometrium.

## Frequently asked questions

### At what age should endometrial sampling be done for abnormal uterine bleeding?

Endometrial sampling is generally advised for women aged 45 years and above with abnormal uterine bleeding. Younger women with risk factors such as obesity, persistent bleeding or failed medical therapy also need it. Guidelines vary slightly, so local protocols should be followed.

### What do the letters in FIGO PALM-COEIN stand for?

PALM stands for polyp, adenomyosis, leiomyoma and malignancy or hyperplasia, which are structural causes. COEIN stands for coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified, which are non-structural causes. Anovulatory bleeding falls under ovulatory dysfunction in this classification.

### Why does anovulatory bleeding increase the risk of endometrial hyperplasia?

Without ovulation, no corpus luteum forms, so progesterone is absent while oestrogen continues. Unopposed oestrogen drives endometrial proliferation, which can progress to hyperplasia. Obesity and PCOS add to this oestrogen exposure, and cyclical progestogen therapy reduces the risk.

### Can the levonorgestrel intrauterine system treat heavy perimenopausal bleeding?

Yes, the levonorgestrel intrauterine system is effective for heavy perimenopausal bleeding and also protects the endometrium. It suits women who wish to keep the uterus. Its effect on bleeding usually builds over the first few months, so early counselling about spotting is useful.

### When is endometrial ablation a suitable option in abnormal uterine bleeding?

Endometrial ablation is suitable when the endometrium is non-hyperplastic, the uterine cavity is normal and medical therapy has failed. It is unsuitable when hyperplasia or endometrial cancer is present. Any wish for future pregnancy must be clarified before ablation, since it is not an option for that purpose.