Unschedules bleeding with HRT 2019 Flashcards
Average age of menopause in UK?
50-51
What proportion of women experience hot flushes with menopause? How many women complain of hot flushes 5 years after last period?
70-80% menopause
25-30% at 5 years
Progressive loss of bone mass from which age?
25years
Which type of osteoporosis is more common in women?
Osteoporosis type 1 - travecular bone -15-20 years after menopause
(Osteoporosis type 2 trabecular and corticol occurs both in women and men)
How common is postmenopausal osteoporosis?
1/3 women after menopause, responsible for 50% fractures in PM women
Absolute contraindication to HRT
- Undaignosed vaginal bleeding
- Hepatic disorders
- Actue vascular thrombosis
Should bleeding occur on HRT?
If combined sequential, continuous oestrogen & cyclical progesterone (day 12-14) - bleeding expected at end of progesterone
Continuous not expected after 6 months, 80% have unscheduled bleeding for 1st 6 months
What proportion of women stop HRT due to unscheduled bleeding?
25-50%
What proportion of women on HRT >6 months will experience unsecduled bleeding
10%
Flow diagram to investigate unscheduled bleeding on HRT
Investigation for unscheduled bleeding
Full history - drug Hx
Clinical examination
Menstral diary
TVUS
Hystereoscopy
If sequential HRT when to measure ET
Within a week of the last progesterone pill
Chance of endometrial cancer with PMB (not on HRT), after TVUS <5mm
10%
1% after ET <5m
Pipelle endometrial biopsy can miss up to what pecentage of focal lesions like polyps?
20%
Endometrial detection rate of Pipelle?
99.6%
If recurrent PMB, when to reinvestigate
6 months
Referral criteria for USS to check ET
Any bleeding after 6 months of continuous combined hormone replacement therapy even in low-risk women
Bleeding after amenorrhoea has been established
Any bleeding in the first 6 months if any significant risk factors present
Criteria for hytereoscopy
Multiple bleeding episodes
Focal lesions on transvaginal ultrasound
Endometrial thickness (ET) >5 mm on continuous combined hormone replacement therapy (HRT) and ET >7 mm on sequential combined HRT
Incomplete visualisation of endometrial echo or fragmentation of endometrial echo on ultrasound scan
High-risk group with risk factors for endometrial disease or cancer (e.g. raised body mass index, family history of hereditary nonpolyposis colorectal cancer)
When are women normally switched from sequential to continuous
1 year past the menopause or 54 years (80% will be postmenopausal)
How to manage PMB on sequential HRT and normal endometrium
- Heavy prolonged bleeding
- Bleeding early in progesterone phase
- Spotting before withdrawal phase
- Irregular bleeding
- Painful bleeding
Address - poor compliance, drug interactions, malabsorption
Prolonged or heavy withdrawal bleed: increase dose/change type of progestogen or reduce estrogen
Bleeding occurs early in progestogen phase: increase the dose/change type of progestogen
Spotting before withdrawal period: increase estrogen dose
Irregular bleeding: change regimen or increase progestogen dose
Painful bleeding: change type of progestogen
How to manage PMB on continue HRT after excluding pathology
Consider lower oestrogen dose - better as women get older
Change the dose of type of progesterone - 52mg Mirena
If persistent consider stopping or gradually phasing out, or can try sequential HRT
Other options for managing PMB if above does not work
Stop HRT
Switch to non-oral HRT
Offer Mirena® (Bayer plc, Reading, UK)
Offer surgery (endometrial ablation, resection or hysterectomy) in refractory cases
