How to control vaginal bleeding post-menopause while on hormone replacement therapy (HRT)?

Question

Hello doctor,

I live in a remote area and I do not have access to a gynecologist. I had my last period one year ago. I underwent the standard tests (mammogram, pap test, blood work) which were all normal. I started HRT about one month ago on a transdermal continuous patch delivering 140 norethindrone acetate and 50 estradiol 17B (to be changed bi-weekly). The patch (Estalis) also exists as a 250/50 dosage (with more progestin). I started having very tender breasts and a few days ago I started bleeding. Five days ago I had bleeding that was not in huge amounts but steady like a period with no signs of stopping. I reduced my dosage three days ago by cutting one-fourth of my patch (it is a matrix patch so this seems to be acceptable to do so) and my breasts are less tender. Even though I have not experienced the resurgence of hot flashes or any of the menopause symptoms, the bleeding has not stopped. 15 years ago, I had an endometrial cyst removed. Later another cyst developed in the ovary but disappeared. Since then I have not experienced pain from endometriosis other than very short (a few minutes) rare bouts of that typical pain I experienced while I had the cyst. I have never been able to conceive, but have never investigated even though in my mind I feel it is probably due to some form of endometriosis. So my questions are as follows:

What should I do regarding the bleeding?
I am unwilling to stop HRT because I feel so much better after using it, but I don't think that continuous bleeding is very good either. Should I just wait to see if it stops?
Should I change my dosage by increasing the progestin or changing it to another type of progestin?

I am going to see a doctor tomorrow and I could forward your advice. And can I use vitamin K preparation to reduce the bleeding?

Answer 1

Hello,

Welcome to icliniq.com.

Thank you for your query.

First of all, you need to know that vaginal bleeding is not good for you at all. As a result of aging, you can have endometrial hyperplasia due to hormonal effects and that can lead to endometrial cancer. HRT (hormone replacement therapy) affects directly on endometrium and breast and gives symptoms that can differ from person to person in different means. The effects can be both short-term and long-term. I suggest you to follow a few instructions mentioned below:

You should take a transvaginal scan to check for any kind of pelvic pathologies or any accumulated fluid.
It is better to have an endometrial biopsy as it will guide you about how early you need to have a total abdominal hysterectomy and bilateral salpingo-oophorectomy as it is common to have ovarian cancer at this age, especially in ladies who do not have children at all.
For now, I suggest you to have tablet Ponstan 500 mg and tablet Tranexamic acid 500 mg eight hours once to reduce bleeding. Kindly consult a specialist, talk to them and take medications with their consent.
Just reducing the dose cannot show any effect magically. You can request to have the least dose of estrogen and progesterone so that you will have fewer side effects.
Have an endometrial biopsy, outpatient hysteroscopic examination, and cervical smear, and check all the results here or with your gynecologist to discuss the complete removal of the uterus and ovaries to get rid of your ovarian or uterine cancer risk.

I hope this has helped you. Thank you.