Clinical inquiries. Menstrual disturbances in perimenopausal women: what's best?

It's best to start with nonsteroidal anti-inflammatory drugs (NSAIDs), which effectively reduce heavy menstrual bleeding. Perimenopausal women with heavy bleeding not controlled by NSAIDs, or other forms of dysfunctional uterine bleeding, can benefit from continuous, combined hormonal therapy with estrogen and progestin; hormonal therapy with estrogen and a cyclical progestin; or a cyclical progestin alone. Intrauterine devices (IUDs) containing levonorgestrel also effectively reduce bleeding and may avoid surgical intervention. If medical management fails, endometrial ablation offers an effective, minimally invasive alternative to hysterectomy. Hysterectomy should be considered when medical management or endometrial ablation fails.