ABNORMAL UTERINE BLEEDING ON HORMONE REPLACEMENT - THE IMPORTANCE OF INTRAUTERINE STRUCTURAL ABNORMALITIES

Objective: To examine the importance of submucous myomas and endometri al polyps before and after menopause and in abnormal withdrawal bleedi ng on hormone replacement therapy (HRT). Methods: between May 1991 and May 1993, women presenting with abnormal withdrawal bleeding on HRT ( n = 106) menstrual problems in pre-menopause (n = 92), or postmenopaus al bleeding (n = 33) underwent diagnostic outpatient hysteroscopy fdr the presence of intrauterine structural abnormalities. The findings we re compared with a control group of post- and perimenopausal women wit hout bleeding problems (n = 183). Results: When compared with women wh o had normal uterine cavities, the presence of submucous myomas was as sociated with a threefold increase in the risk of abnormal menstrual b leeding in premenopausal women (odds ratio [OR] 3.34, 95% confidence i nterval [CI] 1.77-6.43; P < .001) and a twofold increase in the risk o f abnormal withdrawal bleeding in post- and perimenopausal women (OR 2 .4, 95% CI 1.25-4.53; P = .004). This did not seem to be related to th e number of myomas detected. The frequency of endometrial polyps was n ot found to be significantly higher in women who had menstrual disorde rs or abnormal withdrawal bleeding on HRT. Postmenopausal bleeding wit hout hormonal stimulation was not significantly associated with submuc ous myomas or polyps. Conclusion: As increasingly more women request H RT, bleeding problems presenting pre-menopause can no longer be expect ed to resolve ''naturally'' after menopause. In the presence of submuc ous myomas, these women will continue to have a higher risk of abnorma l withdrawal bleeding when treated with hormone replacement, whereas e ndometrial polyps are not associated with an increased bleeding risk. Hysteroscopic assessment of the uterine cavity and subsequent counseli ng as to the risk of heavy or prolonged bleeding will be helpful in th eir future management and may improve compliance.