Unschedules bleeding with HRT 2019

Question 1

Average age of menopause in UK?

Answer 1

50-51

Question 2

What proportion of women experience hot flushes with menopause? How many women complain of hot flushes 5 years after last period?

Answer 2

70-80% menopause
25-30% at 5 years

Question 3

Progressive loss of bone mass from which age?

Answer 3

25years

Question 4

Which type of osteoporosis is more common in women?

Answer 4

Osteoporosis type 1 - travecular bone -15-20 years after menopause

(Osteoporosis type 2 trabecular and corticol occurs both in women and men)

Question 5

How common is postmenopausal osteoporosis?

Answer 5

1/3 women after menopause, responsible for 50% fractures in PM women

Question 6

Absolute contraindication to HRT

Answer 6

• Undaignosed vaginal bleeding
• Hepatic disorders
• Actue vascular thrombosis

Question 7

Should bleeding occur on HRT?

Answer 7

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

Question 8

What proportion of women stop HRT due to unscheduled bleeding?

Answer 8

25-50%

Question 9

What proportion of women on HRT >6 months will experience unsecduled bleeding

Answer 9

10%

Question 10

Flow diagram to investigate unscheduled bleeding on HRT

Answer 10

Question 11

Investigation for unscheduled bleeding

Answer 11

Full history - drug Hx
Clinical examination
Menstral diary
TVUS
Hystereoscopy

Question 12

If sequential HRT when to measure ET

Answer 12

Within a week of the last progesterone pill

Question 13

Chance of endometrial cancer with PMB (not on HRT), after TVUS <5mm

Answer 13

10%
1% after ET <5m

Question 14

Pipelle endometrial biopsy can miss up to what pecentage of focal lesions like polyps?

Answer 14

20%

Question 15

Endometrial detection rate of Pipelle?

Answer 15

99.6%

Question 16

If recurrent PMB, when to reinvestigate

Answer 16

6 months

Question 17

Referral criteria for USS to check ET

Answer 17

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

Question 18

Criteria for hytereoscopy

Answer 18

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)

Question 19

When are women normally switched from sequential to continuous

Answer 19

1 year past the menopause or 54 years (80% will be postmenopausal)

Question 20

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

Answer 20

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

Question 21

How to manage PMB on continue HRT after excluding pathology

Answer 21

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

Question 22

Other options for managing PMB if above does not work

Answer 22

Stop HRT
Switch to non-oral HRT
Offer Mirena® (Bayer plc, Reading, UK)
Offer surgery (endometrial ablation, resection or hysterectomy) in refractory cases