Hormone replacement therapy: aspects of bleeding problems and compliance

Mitigation of vasomotor symptoms and urogenital problems, along with reductions in osteoporosis and cardiovascular disease, provides the rationale for using hormone replacement therapy (HRT), and the duration of use. However, user surveys have indicated poor compliance with HRT, and that means user time may be less than 12 months, a period unlikely to influence metabolic disorders. The main reasons for discontinuing HRT are unacceptable bleeding pattern and fear of cancer. There is solid evidence that HRT does not increase gynecological, gastrointestinal, or other adenocarcinomas. In fact, the only remaining controversy relates to breast cancer. Since the media often underscore and strengthen "old wives' tales" about the menopause and HRT, access to correct, unbiased information is the key to combating the misconceptions about HRT. Information also helps women understand the nature of menstrual-like bleeding, and thus contributes to compliance. Unfortunately, existing formulations do not control the bleeding pattern in every women. Our understanding of spotting and breakthrough bleeding is still poor. Older data, which suggested routine endometrial histology to find the cause and select treatment of vaginal bleeds, have been contradicted, rendering endometrial biopsy less useful in decision making; endometrial ultrasonography seems to be of more value for endometrial surveillance in HRT. Recent advances in understanding the nature and function of growth factors in uterine tissues help to unravel an array of events of importance for explaining the bleeding sometimes encountered during continuous combined therapy. The pharmaceutical industry should be challenged to work closely with scientists and regulating agencies. Doing so will help to advance our knowledge and therapeutic modalities, which will help us to combat the chief cause of poor compliance to, and discontinuation of, a very important potential contributor to maintaining quality of life of elderly women.