The use of estrogen or hormone replacement therapy remains very controversial because of the weak association between estrogen use and breast cancer.  However, there are women who need to continue with estrogen or hormone replacement therapy after menopause.   One of their major concerns is the return of menstruation. Many women were delighted when their periods stopped and they did not have to deal with cycles each month. Many women feel that post-menopausal bleeding is bad because it is a sign of uterine cancer. In truth, for most women, menstruation after menopause, if they are taking hormone replacement therapy, is perfectly normal. Furthermore, it is a good sign and it simplifies menopause management for the clinician. Let's review the problem of post menopausal bleeding in contemporary terms:

Estrogen circulating in the blood is beneficial because of the effects on the  skeleton, skin, and genital organs. To accomplish these effects, one needs to get a therapeutic level of the hormones which simulate the natural levels women experienced before menopause. Most authors agree that the minimum level of serum estrogen to achieve any tissue effects is approximately 60 pg/ml (picograms/ milliliter). At approximately 100 pg/ml, there is enough tissue effect on the lining of the uterus to simulate menstruation. Serum estrogen levels in normally menstruating women range from 100 to 300 pg/ml. From a positive perspective, bleeding during menstruation means that you are getting enough estrogen into your body to achieve a tissue effect. In other words, monthly menstruation tells you that the medication is actually working.

As we pointed out above, there are several ways to take estrogen if your uterus has not been removed. If you are taking it with cyclic progesterone such as Provera (medroxyprogesterone acetate), than a short period 2-3 days after completing the progestin is totally normal. If you are taking estrogen and progesterone daily (not cyclically) and you occasionally have a little spotting, there is no cause for alarm. However, if you have irregular bleeding throughout the month, that is abnormal and you need to consult with your care provider to make sure that there is no serious problem. The most typical problem is either a polyp or small fibroid within the uterine cavity.  This can be diagnosed easily by trans vaginal ultrasound.  Only rarely is either malignant.

There is no doubt that the use of estrogen and progesterone combination therapy in any form reduces the risk of uterine cancer in women. This is nicely illustrated in a study which was performed about 25 years ago. It is important to note that uterine cancer is a relatively uncommon cancer. In this study, the incidence was cut by approximately 60% by taking combined hormone replacement therapy compared to non-users.

The traditional view has been that post-menopausal bleeding was bad and equaled uterine cancer until proven otherwise. Considering that the risk of having uterine cancer for post menopausal women taking combined hormone replacement therapy is less than 1/1000 and that many of these women will be having post menopausal bleeding-- particularly if they have an adequate dose of hormone replacement therapy means that newer models for the management of post menopausal bleeding have to be developed.

One of the revolutions in modern gynecology is vaginal ultrasound. This enables the gynecologist to actually see what is happening within the uterus. This is a simple an totally painless diagnostic procedure where sound (similar to sonar) is used to examine the contents of the uterus. A number of studies have been done which show that a thin uterine lining (less than 5 mm) is never associated with uterine cancer. Another variation of vaginal ultrasound is hysterosonography where a small amount of fluid is placed in the uterine cavity at the same time the ultrasound is done. This outlines the contents of the uterine cavity. When there is a thickening of the cavity (more than 5 mm), hysterosonography is done. If the thickening is generalized, an endometrial biopsy is done in the office. If the thickening is localized, than a simple outpatient surgical procedure called a hysteroscopy ( where the physician looks inside of the uterus) and a D and C (a scraping out of the thickened area) is done.

There are some post menopausal women who are simply tired of menstruating and who want to continue to have the benefits of estrogen replacement therapy.  New surgeries which have been developed for the management of excessive menstruation or post-menopausal bleeding caused by benign disease which are simple, relatively inexpensive, and entail virtually no convalescence or pain.  These are called hysteroscopic endometrial ablation.

Drs. Caroline Dott and Andrew Dott are professional lecturers and teachers with a special interest in the interactions between the biological and psychological basis of human behavior at midlife.   Among their lecture topics are female and male menopause, the hormonal basis of human behavior, and issues related to depression and anxiety.  They are available to travel and give seminars on the topics covered in this website both nationally and internationally.