"Is it normal for a woman on Natural Hormone
Replacement (from a compounding pharmacy) to experience
a period after 2 and one-half months on the NHR? I
have not had a "real" period for 2 years.
Can hormones initiate ovulation AGAIN??
I am 50, post menopausal, history of normal periods.
The only other medication I take is Lipitor 10mg.
Excellent health. Normal weight. "
Kris
A woman who starts on hormonal replacement therapy
(HRT) after the menopause can have bleeding on any
hormonal regimen, natural or not. As far as studies
go, there do not seem to be differences in the incidence
or amount of bleeding depending on what type of HRT
is used. It only varies by the relative doses of the
estrogens and progesterone/progestin and by whether
those ingredients are both taken every day continuously
or in a cyclical fashion with the estrogen every day
and the progesterone/progestin for two weeks out of
four.
Why do women have bleeding while on hormonal replacement
therapy?
Most women have some bleeding in the first three months
on HRT. It is the rule rather than the exception.
The main reasons for bleeding are: too much endometrial
tissue stimulated by estrogen or too thin a lining
(atrophic) due to too high a progesterone effect.
There is a third possibility and that is that there
is abnormal tissue inside the uterus like a polyp,
premalignant hyperplasia or even a cancer.Bleeding
during the first three months of HRT is usually attributed
to a hormonal cause. Bleeding after that needs to
be investigated to make sure there is not a malignancy.
On a continuous hormonal regimen, only about 2/3's
of women stop bleeding at all by 6 months. By one
year almost 80% of women will have no bleeding on
oral medications and over 85% on transdermal combined
therapy (1). If women take HRT cyclically, they usually
have some withdrawal bleeding each month. Thus a cyclical
regimen makes bleeding more predictable but you still
have regular menses.
Can hormone replacement cause a woman to ovulate again?
Rarely, estrogen can induce ovulation in women who
have ovarian failure and are menopausal. We do not
know how often it occurs and most studies about this
have been performed on women who had a premature menopause
(below age 40) and not on women undergoing natural
menopause in the late 40's and early 50's (2). When
women with premature menopause underwent a randomized
clinical trial in which some were prescribed estrogens
and the others placebo, ovulation was induced in 46%
of those women although only 25% of women who had
been amenorrheic more than 3 months ovulated (3).
Certainly the incidence of ovulation must go down
as a woman is further removed in time from stopping
menses but we do not know what the time period is
to absolutely no ovulations induced by HRT. I would
guess that at age 50 and being 2 years post menopause
would make ovulation very rare indeed.
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. |
