Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy

Abstract

This study correlates the transvaginal ultrasound findings with histopathology results in women who present with unscheduled bleeding on hormone replacement therapy. Study design: Retrospective analysis of 469 consecutive cases with unscheduled bleeding on hormone replacement therapy (203 patients on sequential hormone replacement therapy (seq-HRT) and 266 patients on continuous combined hormone replacement therapy (con-HRT)). Main outcome measures: Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy. Results: Normal appearance of the endometrium on pelvic ultrasound was seen in 62% patients on seq-HRT and 43% of women on con-HRT. These women required no further assessment and were discharged. Histological assessment showed normal endometrial tissue in 22% of women on seq-HRT and 22% of con-HRT group. Benign endometrial polyps were noted in 8% of women on seq-HRT versus 18% of women on con-HRT. Hyperplasia without atypia was noted in 0.5% of woman on seq-HRT versus 0.4% of women on con-HRT while atypical hyperplasia/endometrial cancer was noted in 2% of women on seq-HRT versus 1% of women on con-HRT. Conclusion: Women who present with unscheduled bleeding on hormone replacement therapy both on sequential and continuous combined regimens can be reassured that the risk of pathology is low.

A cross-sectional national questionnaire survey assessing the views of members of the British Menopause Society on the management of patients with unscheduled bleeding on hormone replacement therapy

“…6 In women on HRT, the risk has been estimated to be 1–2% as reported in previous studies. 2 , 5 The Million Women Study 13 reported a reduced risk of endometrial cancer in those on con-HRT, and no difference in those on seq-HRT as compared to women on no HRT.…”

“…In patients with abnormal TVUS results (EMT ≥5 mm or polyps), results in our recent retrospective study revealed that the risk of atypical hyperplasia/endometrial cancer was low (2% and 1% for seq-HRT versus con-HRT). 5…”

“…Further investigation when warranted includes a transvaginal ultrasound scan (TVUS) to assess endometrial thickness (EMT) and morphology, the uterus for pathology and the adnexa for ovarian/tubal tumours. 5…”

“…Unscheduled bleeding is a common complaint which can lead to up to 50% of women ceasing their HRT within 6–12 months following an episode. 3 With complaints of unscheduled bleeding reported in 38% of women on seq-HRT and 41% of women on con-HRT, 4 it is important for clinicians to reassure women at low risk of pathology 5 whilst appropriately managing those who need further investigations.…”

“…Commonly a transvaginal ultrasound scan (TVUS) is carried out to assess endometrial thickness (EMT) and morphology and to assess both the uterus and the adnexa for endometrial/ovarian/tubal tumours. 5…”