Fortnightly review: Management of abnormal bleeding in women receiving hormone replacement therapy

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Abstract
Introduction Hormone replacement therapy relieves climacteric symptoms and reduces the risk of cardiovascular disease and osteoporosis. Less than 10% of postmenopausal women, however, have ever taken hormone replacement therapy.1 Studies report a high degree of non-compliance, with about 70% of women stopping hormone replacement therapy after a year.2 One of the main reasons for non-compliance is vaginal bleeding, which occurs in 30-80% of women who stop treatment.3 4 Postmenopausal women who still have a uterus are given progestogens to protect the endometrium.5 6 Table 1 shows the types and doses of oral progestogens in current use. Progestogens can be administered sequentially for at least 10-12 days of each 28 day treatment cycle or calendar month. Sequential regimens are prescribed to perimenopausal and early postmenopausal women with intermittent and unpredictable ovarian function. About 85% of women receiving such sequential progestogen will experience withdrawal bleeding towards the end of, or immediately after, the progestogen phase (when the progestogen is added). Most women taking sequential therapy continue to bleed each month for as long as hormone replacement therapy is prescribed; a minority (often older women) develop amenorrhoea. View this table: In this window In a new window Table 1 Progestogens in current use with hormone replacement therapy To overcome the re-establishment of vaginal bleeding, progestogens are increasingly being administered continuously in combination with the oestrogen. The aim is to achieve amenorrhoea by rendering the endometrium atrophic.7 It is hoped that women who have been postmenopausal for many years and are used to not bleeding regularly will accept continuous combined therapies more readily than sequential ones. In some women additional factors may need to be considered: there are no data to show that continuous combined hormone replacement therapy reduces the risk of heart disease, so that sequential regimens are advised in women with cardiovascular risk factors such as a family history, hypertension, established coronary heart disease, and hypercholesterolaemia.

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