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    Peri-Menopause and Fibroids
    4midlife7 posted:
    Dr. Minkin:
    I hope you can help. I am a 47 yr old in the throes of peri-menopause. Diagnosed with Fibro-Cystic disease in 1996 -- occasional ovarian cysts, but no problems. Irregular bleeding (in time and flow) started early 2012. My physical med history is good with HCTZ 25 mg controlling BP since 2009 and all labs well within their prospective ranges. Since 2009 my regular physician has done my paps with no problems. Since the peri-craziness started last year, I decided that this year I would go to a female OB-GYN to see, if possibly, their were some things that could be done to control the symptoms (mood swings, sleeplessness, no libido, etc.). Let me note that my regular doctor says no to hormones and I agree. I was actually very disappointed with OB-GYN. She had a litany of things for me to do, but I didn't like much of it. It included Effexor, Estratest (low dose bc), an ultra sound and pelvic exam (vaginal probe w/camera) and histological biopsy. No Effexor-I do not want to mess with my body chemistry like that. No hormones and I'm a moderate smoker. The imaging (including mammo) I did gladly and fibroids were discovered. The histo/biop, I have not completed. My normal annual physical was in June and this occurred in July. My lab work was excellent in June. Is it really necessary to have another camera look-see and biopsy? I feel fine and exercise often, but I am just not comfortable doing the histo/biop. If I had one symptom that I would like to control, would be the bleeding. It can be excessive at times, but it will also disappear for 8 or 9 weeks at a time. Thank you so much for your time.
    Mary Jane Minkin, MD responded:
    Dear 4midlife7,
    I hope I can help. The bleeding pattern does sound classic perimenopausal. Of course, strange bleeding can also be a sign of abnormalities in the lining of the uterus. One way to try to avoid a biopsy: did she comment on the width of the lining of your uterus? Was it 5 mm or less? And was the ultrasound done right after a bleed? In general, if the lining of the uterus (so call endometrial echo) is 5 mm thick or less, it would be very unusual to have significant pathology in the lining (such as hyperplasia or cancer). If it was thicker but not right after a good clean out bleed, I would suggest you take some progestin to help clean things out (totally safe), and then remeasure the lining. If it thick, then it is reasonable to do a sampling of the lining. One way to manage bleeding in the perimenopausal time frame is to periodically take some progestin, to induce a clean out bleed (what is happening is that you are still making some estrogen, but not ovulating super well-and we make our progesterone when we ovulate)-and the easy way to think of progesterone is the policeman (or lawn mower ) of the lining of the uterus (thinking of estrogen as the fertilizer for the lining of the uterus-as eloquently described by Professor Nanette Santoro). Another option to control bleeding in the perimenopause is to insert a Mirena IUD-which is coated with progestin, and it keeps the lining of the uterus thin. There are two bioidentical progesterone products available: one is a pill called Prometrium and the other is a vaginal gel known as Crinone, which are both bioidentical plant derived progesterone.
    One suggestion: you didn't mention hot flash symptoms; but there is good data available showing that smokers have worse hot flashes than non smokers; so working on stopping smoking can also benefit menopausal symptoms.
    Good luck,
    Mary Jane

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