Postmenopausal Bleeding in Women Utilizing Hormone Replacement Therapy: Not all the patients need to be referred or investigated

Abstract

Background: Unscheduled bleeding while on Hormone replacement therapy (HRT) is a common concern, and it is one of the most typical reasons for dissatisfaction for women on HRT and a recognized reason for its discontinuation. The primary strategy for managing unscheduled bleeding in women using HRT is, first, to identify the pathology and, secondly, to correct the cause.Objective: To investigate the occurrence, pattern of referral, and the aetiological factors of postmenopausal bleeding in women using HRT. Methods:This was a retrospective study involving women referred from primary care with postmenopausal bleeding while using HRT from January 1, 2022, to June 30, 2022. Medical records were reviewed, and relevant data, including demographics, type and duration of HRT, and investigation results, were extracted. Data was entered on an Excel spreadsheet and anonymized. Descriptive statistics were used to calculate the proportion, mean, and standard deviation. The data is presented in charts and text.Results: A total of 147 patients met the inclusion criteria. The incidence of postmenopausal bleeding (PMB) while on HRT was 12.4%, the mean age was 56 years, and the average duration of use of HRT was 16 months. Most patients were on combined HRT (84%), and the patch was the most typical form of HRT. Among women using continuous HRT, more than half (57.2%) had been using the preparation for less than six months. All the patients had pelvic ultrasound scans for endometrial assessment, and those meeting criteria had Hysteroscopy and endometrial sampling. Most patients had no sinister pathology identified, but one patient who had used HRT for over three years was diagnosed with endometrial cancer. Depending on the clinical situation, most patients were managed conservatively by expectant management, altering the HRT regimen, or surgical treatment. Conclusion:Diagnostic evaluations, including Hysteroscopy, endometrial sampling, and transvaginal ultrasound, play a pivotal role in determining the underlying pathology associated with PMB in women on HRT. These investigations aid in distinguishing benign causes from potentially more serious conditions, such as endometrial hyperplasia or cancer, as was found in this study. It also highlights the need to ensure referred patients meet the referral criteria.