Unscheduled bleeding with hormone replacement therapy

Dave, Fulva Gajjar; Adedipe, Tolu; Disu, Stewart; Laiyemo, R

doi:10.1111/tog.12553

Cited by 12 publications

(9 citation statements)

References 31 publications

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“…Consideration is also required in the presence of high-risk factors including raised BMI or Lynch syndrome or a family history suggestive of Lynch syndrome. 24 The findings of our study with a very low rate of endometrial cancer concur with this review. The limitation of this review is that it is only available in The Obstetrician and Gynaecologist journal and is unlikely to be readily accessible by primary care providers.…”

Section: Discussionsupporting

confidence: 90%

Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study

2022

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Objective To establish the endometrial cancer detection rate in women using hormone replacement therapy presenting with postmenopausal bleeding. Study Design Retrospective cohort study. Setting and population Rapid access gynaecology clinic at a tertiary hospital. Women aged under 60 years referred with postmenopausal bleeding. Methods Retrospective study of referrals received between 1 January 2019 and 31 December 2020 including Hormone replacement therapy (HRT) use and histological diagnosis. Main outcome measures Histological diagnosis of endometrial cancer, borderline ovarian tumour or endometrial intraepithelial neoplasia. Statistical analysis Chi squared test Results 1363 women were included. 214 women were using HRT when they experienced PMB and only one of these had endometrial cancer at histology (cancer detection rate 0.47%). 25 of the 1124 women who were not using HRT were diagnosed with endometrial cancer on histology (cancer detection rate 2.18%). Chi squared statistical analysis confirmed this was statistically significant ( p value .0156). Conclusions The endometrial cancer detection rate in women aged under 60 years using HRT with PMB is very low. Referral on a two-week wait pathway for suspected cancer diagnosis induces stress and anxiety for the woman and may lead to more invasive initial investigation even though other diagnoses are far more likely. Women aged under 60 years with postmenopausal bleeding that have either commenced HRT or had a change to their preparation within the last 6 months should be seen on a less urgent referral pathway if necessary given the very low probability of endometrial cancer.

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Section: Discussionsupporting

confidence: 90%

Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study

2022

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“…25 GABA neurotransmission is the most widespread neuroinhibitory system in the brain, with progestogens also exerting complex and incompletely understood interactions with serotonergic, cholinergic and dopaminergic receptors. 26 In case of a severe effect on mood, halving the dose or reducing the duration to 7-10 days a month can be considered, 27 but the woman should be advised this will increase the risk of endometrial hyperplasia. 18 There should therefore be a lower threshold for ultrasound investigation of abnormal bleeding in these women.…”

Section: Progestogenic Side Effectsmentioning

confidence: 99%

“…If altering the dose or route of progestogen does not resolve the unscheduled bleeding, an ultrasound assessment of the endometrium should be performed 30 and if endometrial thickness is found to be ≥4 mm for those on continuous combined HRT or ≥ 7 mm for sequential HRT, an endometrial biopsy or hysteroscopy should be performed. 26 If the entire cavity cannot be appropriately visualised or a polyp is suspected, then hysteroscopic assessment is indicated. 31 Women who report breakthrough bleeding using the LNG-IUS can be given supplementary progestogens (such as MPA or NET) for a few weeks to control the bleeding.…”

Section: Progestogenic Side Effectsmentioning

confidence: 99%

“…Oral progestogens can exert a sedative effect, through GABAA receptors, which have also been implicated in premenstrual dysphoric disorder 25 . GABA neurotransmission is the most widespread neuroinhibitory system in the brain, with progestogens also exerting complex and incompletely understood interactions with serotonergic, cholinergic and dopaminergic receptors 26 …”

Section: Progestogenic Side Effectsmentioning

confidence: 99%

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A focus on progestogens in hormone replacement therapy

Ghosh,

Imrie,

Goadsby

et al. 2023

The Obstetric & Gynaecologis

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Key content Women receiving estrogen replacement require concomitant progestogen to prevent endometrial hyperplasia and carcinoma. A variety of progestogens are used in hormone replacement therapy (HRT), with different advantages and disadvantages and routes of administration. Progestogenic side effects may be mild but can be debilitating and lead to the discontinuation of HRT, so progestogens should be tailored to the individual woman. Combined HRT containing estrogen and progestogens may be associated with a small increase in the absolute risk of breast cancer, which is not seen in women taking estrogen alone. However, this risk is small, particularly when compared with other modifiable lifestyle risk factors. The addition of certain progestogens to estrogen in the long term may be associated with an increased risk of heart disease, breast cancer and dementia. Learning objectives To understand relative advantages and disadvantages of the different progestogens, regimens and routes of administration. To be aware of current evidence for types, dose and routes of administration of different progestogens. To be able to prescribe progestogens safely in terms of side effect and risk profiles that are individualised to the patient. Ethical issues Well‐informed counselling including absolute, individualised risks for women considering HRT with a progestogenic component is essential to allow patients to make well‐informed choices.

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“…An EMT cut-off of 5–8 mm has been quoted in the literature as the indication for endometrial biopsy. 6–8 Several guidelines exist to guide clinicians in their investigation and management of this clinical issue. 6,9,10 This had led to a varied approach to the management of unscheduled bleeding on HRT amongst practitioners.…”

Section: Introductionmentioning

confidence: 99%

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

Idle

Panay

Hamoda³

2021

Post Reprod Health

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Objective To explore the views of members of the British Menopause Society on the management of women with unscheduled bleeding on hormone replacement therapy. Study design An electronic cross-sectional questionnaire survey. Main outcome measures Investigations, treatment options and preferences for the management of women with unscheduled bleeding on hormone replacement therapy. Results A total of 91/178 (51%) clinicians investigate patients with unscheduled bleeding within three to six months of starting sequential hormone replacement therapy (seq-HRT) versus 83/178 (47%) for continuous combined hormone replacement therapy (con-HRT). A total of 52/178 (29%) versus 54/178 (30%) would investigate unscheduled bleeding continuing beyond six months while 18/178 (10%) versus 26/178 (15%) would investigate within three months. Assessment is requested as urgent by 88/176 (50%) clinicians, routine by 47/176 (27%) and a two-week-wait-suspected cancer referral by 41/176 (23%). A total of 97/178 (55%) clinicians would continue seq-HRT and refer versus 117/178 (66%) for con-HRT. A total of 46/178 (26%) clinicians would change the progestogen preparation in women with unscheduled bleeding on seq-HRT. For women on con-HRT, 12/178 (7%) clinicians would change to seq-HRT and 8/178 (5%) to the Mirena IUS. The Mirena IUS is the preferred progestogen for 81/178 (45%) of clinicians when prescribing hormone replacement therapy. Conclusions There is a varied approach in the practise amongst British Menopause Society members to managing women with unscheduled bleeding on hormone replacement therapy. Further research is needed to determine the optimal assessment pathways for women with unscheduled bleeding on hormone replacement therapy.

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Unscheduled bleeding with hormone replacement therapy

Cited by 12 publications

References 31 publications

Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study

Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study

A focus on progestogens in hormone replacement therapy

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

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