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.
Other
Causes
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.
Prognosis
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.
Complications
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.
Prevention
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.
Sources
and Additional Information:
