Approximately 50% of women with an intact uterus, who elect to have estradiol implants or pellets placed, will experience bleeding . If a menopausal patient has bleeding, she must notify her gynecologist or family physician. A workup, including a vaginal ultrasound and endometrial biopsy, may be required. The primary cause of uterine bleeding is inadequate use of progesterone. Estrogen stimulates the uterine lining to grow and progesterone protects it from growing too thick. This may result in bleeding.
Options for estrogen therapy include:
• A patient may choose not to use an estrogen pellet. Estrogen may be given as a transdermal patch, topical gel or oral capsule. One of the most effective and safest ways to deliver estrogen is by a vaginal cream . This treats vaginal symptoms like dryness and discomfort, along with urinary symptoms like urgency, frequency, hesitancy, nocturia (waking at night to urinate) and incontinence. A combination of estrogens, including estriol , which is less stimulatory to the breast tissue and uterus and estradiol , the estrogen found in pellets, may be used along with progesterone. All 3 hormones may be combined in a single cream which makes it convenient. The vaginal cream is also effective in relieving symptoms of menopause.
• A patient may choose to have an estradiol pellet placed. If so, she must be consistent on the daily use of her progesterone. This is usually given as an oral capsule or a vaginal cream. Even with consistent use of progesterone, bleeding or spotting may occur and a workup would be indicated. If bleeding occurs while on progesterone, it should be discontinued for 10-14 days to allow the uterine lining to shed. It may then be resumed. Oral progesterone, taken daily, may be combined with vaginal progesterone, used 2-3 times weekly, to control bleeding. An IUD, delivering progestin locally to the uterus, may also be used to prevent proliferation of the lining.
• A patient may choose to have regular menstrual cycles to ‘shed’ the buildup of the uterine lining. This may be accomplished by giving progesterone or a synthetic progestin for 12-14 days every 2-3 months. Stopping the progestin would be followed by a period or ‘withdrawal’ bleeding.
• A patient may choose not to use estradiol (stronger estrogen) at all. Many women continue to make estrogen (estrone and estradiol) into their 70’s and 80’s. They may not need supplemental estrogen. Excess estrogen can cause weight gain, tender breasts, emotional lability and mood swings.
Remember, hormones may need to be adjusted during therapy. Patient input is important to achieving optimal hormone balance and patient satisfaction.