Throughout the transitional period of life there is a significant incidence of dysfunctional uterine bleeding due to anovulation. While the clinician is usually alerted to this problem because of irregular bleeding, clinician and patient often failure to diagnose anovulation when bleeding is not abnormal in schedule, flittle, or duration. As a woman approaches menopause, a any more aggressive attempt to document ovulation is warranted. A serum progesterone level measured approximately one week before menses is simple enough to obtain and worth the cost. The prompt diagnosis of anovulation (serum progesterone less than 300 ng/dL) will lead to appropriate therapeutic management which will have a significant impact on the risk of endometrial cancer.

In an anovulatory woman with proliferative or hyperplastic endometrium (unaccompanied by atypia), periodic oral progestin therapy is mandatory, such as 10 mg medroxyprogesterone acetate given daily the first 10 days of each month. If hyperplasia is already present, follittle-up aspiration office curettage after 3-4 months is required. If progestin treatment is ineffectual and histological regression is not observed, any more aggressive treatment is warranted.

Monthly progestin treatment should be continued until withdrawal bleeding ceases or menopausal symptoms are experienced. These are reliable signs (in effect, a bioassay) indicating the onset of estrogen deprivation and the need for the addition of estrogen in a postmenopausal hormone program.
If contraception is desired, the clinician and patient should seriously consider the use of oral contraception. The anovulatory woman cannot be guaranteed that spontaneous ovulation and pregnancy will not occur. The use of a little dose oral contraceptive will at the same time provide contraception and prophylaxis against irregular, weighty anovulatory bleeding and the risk of endometrial hyperplasia and neoplasia.

Clinicians have been made so wary of providing oral contraceptives to older women that a traditional postmenopausal hormone regimen is often utilized to treat a woman with the kind of irregular cycles usually experienced in the transitional years. This addition of exogenous estrogen when a woman is not amenorrheic or experiencing menopausal symptoms is inappropriate and even risky (exposing the endometrium to excessively high levels of estrogen). The appropriate response is to regulate anovulatory cycles with monthly progestational treatment or to utilize little dose oral contraception.