Frederick R. Jelovsek MD
When your doctor recommends hormone replacement therapy (HRT) after
menopause, do visions of menses forever appear? How much
bleeding should you expect? There are two basic dose frequencies
-- sequential estrogen followed by progesterone and continuous
estrogen and progestin (synthetic progesterone). With the
sequential regimen there is almost always some menstrual bleeding
or spotting just like with birth control pills. The continuous
regimen is much better however, with many women having no bleeding
at all.
In a recent article, Nand et al: Bleeding pattern and
endometrial changes during continuous combined hormone
replacement therapy. Obstet Gynecol 1998;91:678-84,
investigated estrone 1.25 mg (OgenŽ) with 3 different doses
of medroxyprogesterone acetate (ProveraŽ) 2.5 mg, 5.0 mg and
10mg. They recorded how much bleeding 568 women had over 2 years
on the different regimens.
Interestingly, the investigators didn't find a significant
difference between the three different progestin doses as to a
lower incidence of bleeding on the higher doses. At the end of 3
months of therapy 58% of women were amenorrheic while 42% still
had some bleeding. At 6 months, 75-80% of women had no vaginal
bleeding at all. By 24 months, 90-94% of women were amenorrheic.
Almost 10% of women had bleeding no matter what dose of progestin
they were taking.
The study also tells us that the average number of days of any
bleeding on these hormonal regimens started out from 6-9 days per month at
the beginning of therapy and declined to about 3 days of bleeding per month
after 2 years. There were no cases of endometrial cancer or
hyperplasia that occurred during the study period.
The lessons to learn from this are:
-
even though many women don't have bleeding on this continuous
regimen, some do no matter how long they take the medication.
-
raising the progestin dose is unlikley to lessen the bleeding for
most women who are having it
-
women should expect bleeding problems for the 1st 6-9 months on
this regimen
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