Postmenopausal Bleeding and HRT
Treatment of postmenopausal bleeding depends on the cause.
It is common for women just beginning HRT (hormone replacement therapy). to experience some bleeding. Also, most women who are on cyclic HRT, taking estrogen along with progesterone, may experience monthly withdrawal bleeding; this is a normal side effect that does not require treatment. Continuous HRT regimens usually do not cause monthly bleeds.
But you should remember that postmenopausal bleeding during HRT can be due to the HRT itself, or due to underlying medical problems that have nothing to do with the HRT. Therefore be sure to observe closely the symptom occurrence, and do not simply assume that this occasional bleeding is fine. The pattern of bleeding during HRT depends on the type of HRT being taken. For example, with continuous combined HRT, bleeding can occur unpredictably for up to 6 months or 1 year. Therefore, unless bleeding continues for more than one year or is unusually heavy, diagnostic testing is often not necessary. On the other hand, bleeding with cyclic HRT is usually regular and occurs after day 9 of the progesterone part of the HRT. Therefore, with cyclic HRT, if bleeding occurs before day 9, or is at unexpected times, or is unusually heavy or prolonged, evaluation is needed.
You can see that what is considered abnormal depends on exactly what type of HRT you are taking. Any bleeding during HRT needs to be reported to a doctor to see if the bleeding is expected or not, not only to guide testing and rule out uterine pre-cancers, but to see if an adjustment will help to decrease the annoying bleeding.
Minimizing Bleeding with HRT
Most women choose to take continuous HRT (estrogen and progesterone/progestin every day) if they have not had a hysterectomy because they do not desire to have menstrual periods. Since women who are closer to menopause often need higher doses of estrogen to control hot flashes and sleep disturbances, they will also need a proportionately higher progesterone/progestin level.
Regimens that can be evaluated for menopausal women who have not had a hysterectomy are:
- Women ages 45-55 and within 6 months of beginning menopausal symptoms or women having moderate to severe estrogen deficiency symptoms
· conjugated estrogens 1.25 mg, medroxyprogesterone acetate 5 mg
· micronized estradiol 2 mg, micronized progesterone 200 mg (natural HRT)
· transdermal (skin patch) estradiol 0.1 mg/day, norethindrone acetate 1 mg (orally)
- Women ages 55-65 or 45-55 and not having many estrogen deficiency symptoms
· conjugated estrogens .625 mg, medroxyprogesterone acetate 2.5 mg
· micronized estradiol 1 mg, micronized progesterone 100 mg (natural HRT)
· transdermal (skin patch) estradiol 0.05 mg/day, norethindrone acetate 140 mg
- Women ages 65-80
· conjugated estrogens .3 mg, medroxyprogesterone acetate 2.5 mg
· micronized estradiol 0.5 mg, micronized progesterone 100 mg (natural HRT)
Doses are then regulated up or down depending upon bleeding, other side effects and sometimes body size because heavy women may have more endogenous estrogens that need to be countered with higher progestin doses.
Vaginal bleeding after post menopause is usually caused by the condition atrophic vaginitis, which is a state that makes sexual intercourse painful for women because their vagina is not sufficiently lubricated. Postmenopausal bleeding due to bleeding from the vagina or vulva can be treated with local application of estrogen HRT.
Removal of tissue from the inside of uterus (curettage) may be all that is necessary to relieve postmenopausal bleeding.
Removal of polyps (polypectomy) will correct bleeding associated with their presence.
Cyclic progestin may be administered for treatment of overgrowth of the endometrium (simple endometrial hyperplasia), for up to 3 months. At completion of progestin therapy, a repeat D&C or endometrial biopsy will be performed to verify absence of hyperplasia. Then oral HRT with progestin may be given.
Hysterectomy may be necessary to treat endometrial hyperplasia with atypical cells, cancer of the uterus (endometrial), uterine fibroids, and bleeding that does not resolve with treatment (refractory) causing anemia due to chronic blood loss. Cancer of the uterus or cervix may require surgery and/or treatment with anti-cancer medications (chemotherapy) or radiation therapy.
Response to treatment for postmenopausal bleeding is highly individual and is not easy to predict. The out-come depends largely on the reason for the bleeding. Many women are successfully treated with hormones. As a last resort, hysterectomy removes the source of the problem by removing the uterus. However, this operation is not without risk and the possibility of complications. The prognosis for women who have various kinds of reproductive cancer varies with the type of cancer and the stage at which the cancer is diagnosed.
Profuse bleeding can cause anemia. Prolonged use of estrogen replacement therapy (ERT) that is not combined with progestin increases the risk of endometrial hyperplasia and endometrial cancer in women who have not had a hysterectomy. Cancer, both endometrial and cervical, can spread to other areas of the body.
Postmenopausal bleeding is not a preventable disorder. In some cases, this kind of bleeding is inevitable. But for most hormonally related bleeding events, maintaining an appropriate weight, and engaging in healthy lifestyle, dietary and stress reduction habits will help. Preventing or minimizing a predominance of estrogen in the years before and after menopause is likewise helpful. This can be facilitated through gentle endocrine support, improved nutrition and supplementation, and reducing stress and exposure to xenoestrogens.
You can look at your post-menopausal bleeding as warning call and certain inspiration to devote yourself to some serious self-care:
- The first step, always, is to call your practitioner and make an appointment for an evaluation.
- The second step is to clean up your diet, add some high quality nutrients and exercise daily for better nutrition and weight control. This can be done immediately and simultaneously with your evaluation.
- The third step is to try some progesterone support if your evaluation indicates it is suitable for you.
Note that more adipose tissue (fat) a woman has on board, the greater her statistical risk for the precancerous thickening of the uterus called hyperplasia and some types of uterine cancer. It’s likely that excess body fat both generates excess estrogen and stores estrogen and estrogen-mimicking compounds, all of which over stimulates the uterine lining over the years. So gradually losing that weight is an important step toward balancing your hormones and wellness.
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