Perimenopausal bleeding in smokers

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I treat a number of smokers who are having difficulty with perimenopausal bleeding. What safe treatments can we provide for dysfunctional uterine bleeding, especially if the patient won't quit smoking? After endometrial biopsy is negative, many end up having a hysterectomy or ablation, which are invasive procedures. I am interested in alternative ways to treat their discomfort.
—Anne Morgan, FNP, Lansing, Mich.

Perimenopausal bleeding can range from mid-cycle spotting to heavy dysfunctional bleeding. Therapy should be tailored to the severity of the problem. Since smoking lowers endogenous estrogen levels, cycles will become irregular sooner, just as menopause occurs sooner in women who smoke.

Spotting and light bleeding are annoying but not clinically worrisome after pathology has been ruled out by endometrial biopsy and possibly ultrasound. However, heavy bleeding at this age is usually caused by uterine fibroids. Often, these are beyond pharmacologic management and require intervention. Occasionally, cycles will become anovulatory and bleeding heavy and irregular. These may be successfully managed either with a progesterone blockade, i.e., using IM medroxyprogesterone (Depo-Provera), or cyclic oral progesterone to regulate the cycle and endometrial buildup.
—Sherril Sego, MSN, FNP (101-6)

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