Can Taking Estrogen progesterone Hormone Therapy After Menopause Cause You to Menstruate Again

Central points

• A modify in bleeding design is mutual during perimenopause.
• Heavy bleeding, prolonged haemorrhage, and whatsoever bleeding more than 12 months afterward the last menstrual catamenia need investigation.
• Endometrial ultrasound is the beginning investigation of choice, and the findings determine the demand for tissue sampling and or hysteroscopy.
• Medical management, later excluding a localised or neoplastic lesion, involves modification of the MHT dose or regimen.

Bleeding – perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT 398.55 KB

Perimenopausal bleeding

In the menopausal transition, hormonal fluxes may be chaotic with vaginal haemorrhage existence both ovulatory or non-ovulatory, lite or heavy, reasonably regular or entirely irregular (1). Especially in women considering menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT), abnormal bleeding should be investigated before prescribing. Heavy menstrual bleeding, rather than irregular bleeding itself is a hallmark of aberrant build- up of endometrium. Heavy bleeding after a prolonged interval without bleeding, or prolonged bleeding of any amount should exist investigated. A lower investigative threshold should use for loftier-gamble women e.one thousand. with polycystic ovary syndrome (PCOS), obesity or diabetes.

Postmenopausal haemorrhage in the woman not taking MHT

In the postmenopausal adult female, more than 12 months past the terminal natural menstrual period (LMP), who is not taking MHT, any vaginal bleeding needs investigation to elucidate the cause and exclude a sinister aetiology.

Bleeding in a adult female taking MHT

Bleeding on cyclical MHT

In the woman who is taking cyclical MHT, a withdrawal drain is expected and the patient should be counselled to wait it. Information technology should come toward the end of or after the progestogen containing phase of the cyclical regimen. Bleeding which is unpredictable, occurring not at the expected time, or excessively heavy should be investigated.

Bleeding on continuous combined MHT

Continuous combined MHT (CCMHT) contains oestrogen and progestogen throughout the month and is designed to eliminate vaginal bleeding. Continuous exposure to progestogen downgrades oestrogen receptors in the endometrium whilst treating menopausal symptoms with oestrogen. In the postmenopausal adult female taking CCMHT, the significance of breakthrough haemorrhage depends upon the recency of her LMP and on how long she has been taking CCMHT. A similar diagnostic and therapeutic arroyo applies to tibolone.

Within 12 months of the last menstrual menses

Women who are inside 12 months of the last natural menstrual period oftentimes do not achieve amenorrhoea with CCMHT, presumably because some residual endogenously oestrogen-stimulated endometrium is present. Unpredictable breakthrough bleeding is mutual in this state of affairs and does not demand investigation. To avert this, it is recommended that cyclical MHT be used for the first 12 months at to the lowest degree following the LMP.

After 12 months since the LMP and inside half dozen months of the institution of CCMHT

In women who are more than 12 months post the LMP, breakthrough haemorrhage is frequently mutual within the starting time six months of the institution of CCMHT and does non necessarily need investigation unless the bleeding is unusually heavy.

After 12 months since the LMP and later vi months of CCMHT

Bleeding should exist investigated if information technology occurs afterward six months use of CCMHT or tibolone, or starts after amenorrhoea has been established on this regimen. Why does quantum bleeding occur in a regimen designed to attain amenorrhoea? Amenorrhoea in this setting depends upon the balance between the oestrogenic effect and progestogenic effect of the MHT components on the endometrium. Inadequate progestogenic effect will event in endometrial proliferation and perhaps hyperplasia and bleeding. It may, similar unopposed oestrogen therapy, lead to endometrial cancer. However, more unremarkably in women taking pharmaceutical preparations of CCMHT, excessive progestogenic effect may produce bleeding from an atrophic endometrium.

Investigation of postmenopausal bleeding (PMB)

The chief goal in investigation is to exclude malignancy, and secondarily to elucidate a treatable non-malignant cause (ii). In particular, patients with diabetes, obesity, history of PCOS, or a family unit history of endometrial cancer are at greater gamble of malignancy (3). Patients taking non-conventional MHT, such equally troches and transdermal progestogen are at hazard of endometrial hyperplasia and cancer (4) (See AMS Information Sheet Bioidentical custom compounded hormone therapy).

A detailed history should be taken. When does the bleeding occur? Is it post-coital? What medications is the patient taking? Is the patient taking tamoxifen? Is the patient taking and then-chosen "bioidentical" hormones? Has the patient missed MHT doses? When was the terminal Pap smear?

Physical examination should include inspection of the vulva, vagina and the cervix for visual prove of lesions or bleeding, taking note of any signs of atrophy. Bleeding from the perineum, urethra and anus is also a possibility. A Pap smear should exist done.

Endometrial ultrasound

Endometrial ultrasound is the commencement investigation of choice. This should be done by an experienced specialist gynaecological ultrasonographer and with transvaginal ultrasound (TVUS). In women taking cyclical MHT, it should be washed immediately after the withdrawal drain (5). The ultrasound should exist able to identify any localised uterine lesion which may contribute to bleeding – endometrial polyp, submucosal fibroid, hyperplasia or cancer. The significance of PMB for the hazard of malignancy differs with use of MHT and endometrial thickness on TVUS. What investigations are done adjacent will depend very much upon the ultrasound findings, then the experience of the ultrasonographer is disquisitional. After excluding localised lesions, the post-obit algorithm is useful (adapted from Foy et al.) (6). Note that this algorithm does not apply to women taking tamoxifen.

	All women with PMB (non on tamoxifen)
MHT use	Current or recent cyclical MHT		Never OR not in last 12m OR on CCMHT
Hazard of cancer	ane-ane.five%		10%
Endometrium	< 5mm	>5mm	< 4mm	>4mm
Probability of cancer	0.1-0.2%	two-5%	0.6-0.viii%	>20-22%
Action	None	Tissue sampling	None	Tissue sampling

Tamoxifen therapy

Tamoxifen therapy is associated with stimulation of the endometrium and an increased take chances of endometrial cancer (vii). Tamoxifen therapy invariably produces a thickened endometrium which is not always indicative of neoplasia. Therefore TVUS is not useful for the investigation of PMB in a adult female on tamoxifen therapy and test of the uterine cavity by hysteroscopy is recommended (2).

Histological assessment

A patient with PMB with endometrial thickness exterior the parameters listed higher up or with a localised lesion seen on ultrasound should be referred for tissue sampling. Blind tissue sampling such equally Pipelle or D&C may exist sufficient for pathology that affects the entire endometrial surface, but information technology is inadequate for detecting localized lesions such every bit endometrial polyps, which may be cancerous (ii). Hysteroscopy is superior to endometrial biopsy and ultrasonography for the identification of these structural lesions and is recommended.

Management

Medical management

When a localised or neoplastic lesion is institute, the management is surgical. However, when the findings are benign and the patient is taking MHT some modification of the MHT dose or regimen is required. Although there is an abundance of literature most the incidence of haemorrhage on MHT and the histological findings, unfortunately, the literature is lacking in data from randomised clinical trials of therapeutic interventions. Therefore, the following recommendations are based on clinical practise advice from the literature and based on the patterns of histology seen in women with breakthrough bleeding (8-11). They are made hither with the proviso that continued haemorrhage should prompt re-investigation, as above.

a) Cyclical MHT with unpredictable bleeding and negative histological screen for pathology

This may reply to a change in the progestin component of the MHT either past changing dose or progestin type or mode of commitment eastward.thousand. intrauterine progestin.

b) CCMHT with quantum haemorrhage, endometrium >4mm and negative histology

If less than 12 months mail service LMP, change to cyclical MHT or intrauterine progestin. If more than 12 months mail service LMP, modify oestrogen/progestin balance by reducing oestrogen or changing progestin dose, type or commitment.

c) CCMHT with breakthrough bleeding, endometrium <4mm

This is the nearly difficult scenario to manage, especially in a patient who wants to have no withdrawal bleeding. The TVUS suggests acceptable, if not excessive, progestogenic effect, particularly if tissue sampling demonstrates an atrophic sample. Increasing the dose or changing the progestogen formulation does not ever accost the underlying problem. Continuous progestogen consequence on the endometrium exposes superficial dilated blood vessels which predispose to haemorrhage (12). The same may occur with prolonged tibolone therapy. A alter back to cyclical MHT, at to the lowest degree for a while, is recommended or an increment in the oestrogen dose may be effective.

Surgical management

Surgical management is appropriate for neoplastic and local lesions causing bleeding. However, women who take heavy or unmanageable quantum bleeding in the absence of pathology, may prefer to have a hysterectomy, after which they demand take merely oestrogen as MHT. The alternative is endometrial ablation. This may resolve the PMB but it should be noted that progestogen is still necessary since there volition be residuum endometrium left. Moreover, the to a higher place investigations – TVUS, hysteroscopy, endometrial sampling - volition exist difficult if there is subsequent PMB (13).

References

1. Hale GE, Hughes CL, Burger HG, Robertson DM, Fraser IS. Singular estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition. Menopause. 2009;16(1):50-9.
2. Munro MG, The Southern California Permanente Medical Group'south Abnormal Uterine Bleeding Working Group. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. Permanente Journal. 2014;eighteen(1):55-seventy.
3. Lash MM, Armstrong A. Impact of obesity on women'south health. Fertil Steril. 2009;91(5):1712-half-dozen.
4. Eden JA, Hacker NF, Fortune Grand. 3 cases of endometrial cancer associated with "bioidentical" hormone replacement therapy. Med J Aust. 2007;187(four):244-5.
5. Affinito P, Palomba S, Sammartino A, Bonifacio M, Nappi C. Ultrasonographic endometrial monitoring during continuous-sequential hormonal replacement therapy regimen in postmenopausal women. Maturitas. 2001 Sep 28;39(iii):239-44.
6. Foy R, Warner P. About time: diagnostic guidelines that help clinicians. Quality & Safety in Wellness Care. 2003 Jun;12(3):205-ix.
7. Mourits MJ, De Vries EG, Willemse PH, X Hoor KA, Hollema H, Van der Zee AG. Tamoxifen treatment and gynecologic side furnishings: a review. Obstet Gynecol. 2001;97(5 Pt 2):855-66.
8. Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practise Guideline. J Clin Endocrinol Metab. 2015;100(xi):3975-4011.
9. de Medeiros SF, Yamamoto MMW, Barbosa JS. Abnormal bleeding during menopause hormone therapy: insights for clinical direction. Clinical Medicine Insights Women's health. 2013;6:xiii-24.
10. Spencer CP, Cooper AJ, Whitehead MI. Management of abnormal bleeding in women receiving hormone replacement therapy. BMJ. 1997;315(7099):37-42.
11. Hillard TC, Siddle NC, Whitehead MI, Fraser DI, Pryse-Davies J. Continuous combined conjugated equine estrogen-progestogen therapy: effects of medroxyprogesterone acetate and norethindrone acetate on bleeding patterns and endometrial histologic diagnosis. Am J Obstet Gynecol. 1992;167(1):1-7.
12. Thomas AM, Hickey Thou, Fraser IS. Disturbances of endometrial bleeding with hormone replacement therapy. Hum Reprod. 2000;15 Suppl 3:vii-17.
13. Ang WC, Hickey M. Postmenopausal bleeding afterwards endometrial ablation: where are we at present? Maturitas. 2011;69(3):195-half dozen.

Note: This fact canvass is designed to be informative and educational. Information technology is non intended to provide specific medical advice or replace advice from your health practitioner.

This Information Sheet may contain copyright or otherwise protected textile. Reproduction of this Information Sheet past Australasian Menopause Society Members and other health professionals for clinical practice is permissible. Any other utilize of this data (hardcopy and electronic versions) must exist agreed to and canonical by the Australasian Menopause Club.

Content updated March 2017

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Source: https://www.menopause.org.au/hp/information-sheets/postmenopausal-bleeding-including-breakthrough-on-mht-hrt

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