1
|
Manley K, Hillard T, Clark J, Kumar G, Morrison J, Hamoda H, Barber K, Holloway D, Middleton B, Oyston M, Pickering M, Sassarini J, Williams N. Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time. Post Reprod Health 2024; 30:95-116. [PMID: 38743767 DOI: 10.1177/20533691241254413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.
Collapse
Affiliation(s)
- Kristyn Manley
- Department of Gynaecology, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Timothy Hillard
- Department of Gynaecology, University Hospitals Dorset NHS Trust, Poole, UK
- British Menopause Society, Marlow, UK
| | - Justin Clark
- Department of Gynaecology, Birmingham Women's Hospital, Birmingham, UK
- British Gynaecological Endoscopy Society, London, UK
| | - Geeta Kumar
- Department of Gynaecology, Betsi Cadwaladr University Health Board, Wales, UK
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
- British Gynaecological Cancer Society, Bangor, UK
| | - Haitham Hamoda
- British Menopause Society, Marlow, UK
- Department of Gynaecology, King's College Hospital, London, UK
| | - Katie Barber
- British Menopause Society, Marlow, UK
- Primary Care Physician, Oxford, UK
| | - Debra Holloway
- Department of Gynaecology, Guys and St Thomas' Hospital, London, UK
| | - Bronwyn Middleton
- Department of Gynaecology, University Hospitals Sussex NHS Trust, Worthing, UK
| | - Maria Oyston
- NHS England Elective Recovery and Transformation Team, London, UK
| | - Mark Pickering
- Department of Gynaecology, University Hospitals Dorset NHS Trust, Poole, UK
| | - Jenifer Sassarini
- Department of Gynaecology, NHS Greater Glasgow and Clyde, Glasgow, UK
- Scottish Menopause Network, Glasgow, UK
| | | |
Collapse
|
2
|
Buchanan C, Robinson M, Macdonald MC. Endometrial cancer rate in Hormone replacement therapy users with postmenopausal bleeding: Retrospective cohort study. Post Reprod Health 2022; 28:143-148. [PMID: 35976770 DOI: 10.1177/20533691221116171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To establish the endometrial cancer detection rate in women using hormone replacement therapy presenting with postmenopausal bleeding. STUDY DESIGN Retrospective cohort study. Setting and populationRapid access gynaecology clinic at a tertiary hospital. Women aged under 60 years referred with postmenopausal bleeding. METHODS Retrospective study of referrals received between 1 January 2019 and 31 December 2020 including Hormone replacement therapy (HRT) use and histological diagnosis. MAIN OUTCOME MEASURES Histological diagnosis of endometrial cancer, borderline ovarian tumour or endometrial intraepithelial neoplasia. STATISTICAL ANALYSIS Chi squared test. RESULTS 1363 women were included. 214 women were using HRT when they experienced PMB and only one of these had endometrial cancer at histology (cancer detection rate 0.47%). 25 of the 1124 women who were not using HRT were diagnosed with endometrial cancer on histology (cancer detection rate 2.18%). Chi squared statistical analysis confirmed this was statistically significant (p value .0156). CONCLUSIONS The endometrial cancer detection rate in women aged under 60 years using HRT with PMB is very low. Referral on a two-week wait pathway for suspected cancer diagnosis induces stress and anxiety for the woman and may lead to more invasive initial investigation even though other diagnoses are far more likely. Women aged under 60 years with postmenopausal bleeding that have either commenced HRT or had a change to their preparation within the last 6 months should be seen on a less urgent referral pathway if necessary given the very low probability of endometrial cancer.
Collapse
Affiliation(s)
- Charlotte Buchanan
- Gynaecology Department, 7318Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Megan Robinson
- Gynaecology Department, 7318Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Madeleine C Macdonald
- Gynaecology Department, 7318Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
3
|
Hamoda H. British menopause society tools for clinicians: Progestogens and endometrial protection. Post Reprod Health 2021; 28:40-46. [PMID: 34841960 DOI: 10.1177/20533691211058030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Progestogen administration is required to oppose naturally produced or administered estrogens to provide endometrial protection. Within HRT regimens, this should be delivered for at least the same duration as that produced during the luteal phase of the monthly cycle and in the recommended doses to protect against the risk of endometrial hyperplasia and endometrial cancer. This includes progestogens administered for 12-14 days a month in sequential regimens and continuous daily intake in continuous combined HRT regimens. Shorter durations and lower doses of progestogen intake are likely to be associated with an increased risk of breakthrough bleeding, endometrial hyperplasia, and endometrial cancer.
Collapse
Affiliation(s)
| | -
- King's College Hospital, London, UK
| |
Collapse
|
4
|
Abdullahi Idle S, Panay N, Hamoda H. A cross-sectional national questionnaire survey assessing the views of members of the British Menopause Society on the management of patients with unscheduled bleeding on hormone replacement therapy. Post Reprod Health 2021; 27:159-165. [PMID: 34192961 DOI: 10.1177/20533691211024415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore the views of members of the British Menopause Society on the management of women with unscheduled bleeding on hormone replacement therapy. STUDY DESIGN An electronic cross-sectional questionnaire survey. MAIN OUTCOME MEASURES Investigations, treatment options and preferences for the management of women with unscheduled bleeding on hormone replacement therapy. RESULTS A total of 91/178 (51%) clinicians investigate patients with unscheduled bleeding within three to six months of starting sequential hormone replacement therapy (seq-HRT) versus 83/178 (47%) for continuous combined hormone replacement therapy (con-HRT). A total of 52/178 (29%) versus 54/178 (30%) would investigate unscheduled bleeding continuing beyond six months while 18/178 (10%) versus 26/178 (15%) would investigate within three months. Assessment is requested as urgent by 88/176 (50%) clinicians, routine by 47/176 (27%) and a two-week-wait-suspected cancer referral by 41/176 (23%). A total of 97/178 (55%) clinicians would continue seq-HRT and refer versus 117/178 (66%) for con-HRT. A total of 46/178 (26%) clinicians would change the progestogen preparation in women with unscheduled bleeding on seq-HRT. For women on con-HRT, 12/178 (7%) clinicians would change to seq-HRT and 8/178 (5%) to the Mirena IUS. The Mirena IUS is the preferred progestogen for 81/178 (45%) of clinicians when prescribing hormone replacement therapy. CONCLUSIONS There is a varied approach in the practise amongst British Menopause Society members to managing women with unscheduled bleeding on hormone replacement therapy. Further research is needed to determine the optimal assessment pathways for women with unscheduled bleeding on hormone replacement therapy.
Collapse
Affiliation(s)
- Salwa Abdullahi Idle
- King's College Hospital NHS Foundation Trust, Gynaecology Denmark Hill, London, UK
| | - Nick Panay
- Menopause and Menstrual Disorders Chelsea and Westminster Hospital, London, UK
| | - Haitham Hamoda
- British Menopause Society, Spracklen House, Dukes Pl, Marlow, UK
| |
Collapse
|
5
|
Hamoda H, Panay N, Pedder H, Arya R, Savvas M. The British Menopause Society & Women's Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reprod Health 2020; 26:181-209. [PMID: 33045914 DOI: 10.1177/2053369120957514] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Nick Panay
- Queen Charlotte's and Chelsea & Westminster Hospitals, London, UK
| | - Hugo Pedder
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Roopen Arya
- Haematological Medicine, King's College Hospital, London, UK
| | | |
Collapse
|