What can be done to stop the bleeding on hormone replacement?

A bleeding side effect from HRT is the most common cause for discontinuance (4). It was the primary reason for stopping in 52% of women over 65 and 29% of younger women age 50-55.

To minimize the bleeding if it persists beyond 3 months of starting therapy and an endometrial biopsy or some type of sampling of the endometrium has been performed to rule out cancer or premalignant hyperplasia, the doses of estrogen and progesterone/progestin must be altered.

Sometimes the solution is to lower the estrogen level and other times the solution is to raise the progesterone/progestin level. Again, it does not matter if the hormone therapy is "natural" or other types of estrogens and progestins.

A general rule of thumb is to raise the progesterone dose if it is low (e.g., 2.5 mg medroxyprogesterone acetate, 100 mg micronized progesterone (natural)) and the estrogen dose is medium or above (0.625 - 1.25mg conjugated estrogen, 1 - 2 mg estradiol).

If a woman has mood symptoms from too much progesterone (irritability, feeling poorly) then is is better to lower the estrogen dose. Admittedly, the real difficulty comes when the doses are changed to control the bleeding.

And because of the change, a woman has other hormonal side effects:

estrogens get too low

• hot flashes
• night sweats, difficulty sleeping
• depression, teariness
• vaginal dryness

progesterone/progestins get too high

• moodiness
• feel poorly
• dizziness
• drowsiness
• depression

What is the best regimen for menopausal hormonal replacement to minimize bleeding?

Most women choose to take continuous HRT (estrogen and progesterone/progestin every day) if they have not had a hysterectomy because they do not desire to have menstrual periods.

Since women who are closer to menopause often need higher doses of estrogen to control hot flashes and sleep disturbances, they will also need a proportionately higher progesterone/progestin level.

Regimens that I have found useful for menopausal women who have not had a hysterectomy are:

Women ages 45-55 and within 6 months of beginning menopausal symptoms or women having moderate to severe estrogen deficiency symptoms

• conjugated estrogens 1.25 mg, medroxyprogesterone acetate 5 mg
• micronized estradiol 2 mg, micronized progesterone 200 mg (natural HRT)
• transdermal (skin patch) estradiol 0.1 mg/day, norethindrone acetate 1 mg (orally)

Women ages 55-65 or 45-55 and not having many estrogen deficiency symptoms

• conjugated estrogens .625 mg, medroxyprogesterone acetate 2.5 mg
• micronized estradiol 1 mg, micronized progesterone 100 mg (natural HRT)
• transdermal (skin patch) estradiol 0.05 mg/day, norethindrone acetate 140 mg

Women ages 65-80

• conjugated estrogens .3 mg, medroxyprogesterone acetate 2.5 mg
• micronized estradiol 0.5 mg, micronized progesterone 100 mg (natural HRT)

Doses are then regulated up or down depending upon bleeding, other side effects and sometimes body size because heavy women may have more endogenous estrogens that need to be countered with higher progestin doses.

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