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Menstrual Bleeding and Bio-identical Hormones

To Bleed or Not To Bleed Women and Bio-identical Hormone Therapy

Ashok Kadambi MD, FACE, Fort Wayne Endocrinology, PC

Celebrity Suzanne Somers has taken menopause by storm in her new book. Mobs of over-50, menopausal woman find hope in the message of sexy aging. Ms. Somers spotlights the term “bio identical hormones” and makes it hot on the lips of every woman (and man) coming to grips with the aging process. Now we can expand the term “natural” with “bio identical”, giving everyone a new appreciation for hormone replacement.

A major issue in the book has made woman apprehensive. Some are even scared enough to avoid HRT. Ms. Somers claims that cycling (creating a period every month) is recommended and natural. Because we menstruate while we are “young” it is advantageous to continue to menstruate forever.

What is cycling? It is the fall of woman’s hormones that results in menstruation. Therefore if a woman stops the progesterone for a few days every month she will cycle and bleed.

Menopausal Woman Do Not Need To Menstruate – Taking Hormones Does Not Necessitate Cycling.

First of all: hormone replacement therapy does not put one in a state of pregnancy as Suzanne Somers claims. During pregnancy, the levels of estrogen might be in the thousands. On estrogen replacement, ideal estradiol levels are typically 50-100 mg/dl.

Secondly: the reason a woman menstruates is to clean the uterus in preparation for the eventual implantation of a fertilized egg. If one is not interested in becoming pregnant, there is no physiologic reason to menstruate.

A recent article in the Obstetric/Gynecological literature claimed that unexpected vaginal bleeding was the most common reason women stopped taking HRT. The cessation of periods was one thing women welcomed with menopause. The medical literature often addresses how to stop and prevent post-menopausal vaginal bleeding so that woman will be comfortable in continuing HRT. Dr. Kadambi has always advocated increasing progesterone to prevent post-menopausal bleeding. With the appropriate balancing of estrogen and progesterone, women should not bleed and will be more satisfied with continuous use of HRT.

For years, women have been treated with birth control pills taken continuously and not cycle to control pre-menstrual syndrome (PMS). It is the fall of a woman’s hormone levels that takes place right before their menses that causes the symptoms of PMS. By taking birth control pills continuously, a woman can avoid this drop in hormone levels and counteract the symptoms associated with PMS.

The pharmaceutical industry has now caught onto this and promotes a new birth control pill that is cycled for bleeding every four months. The researchers claim that while no menstruation is necessary, the cycling allows women to menstruate every four months to make them feel more “normal”. Research has also shown there is no need for pre-menopausal or post-menopausal women to menstruate.

Another reason not to cycle the progesterone is the loss of protection against uterine cancer that takes place when the progesterone is not present. Bio-identical progesterone protects against uterine cancer. The bleeding that takes place with menstruation does not provide a protection against uterine cancer, it is the direct effect of progesterone on the uterus that protects the uterus. Stopping progesterone for a week means that the body is without the protective benefits of progesterone for those days.

Studies have shown that Provera (Medroxy Progesterone) increases the risk of breast cancer and increases the thickening of the breast tissue. It does this by direct stimulation (up regulation) of receptor sites in the breast. One study showed that Provera increased breast stimulation by 400% over baseline. The same study showed that bio-identical progesterone (different from Provera), does not stimulate breast tissue, it down regulates receptor sites in the breast. Leading to the question, why lose this protective effect of progesterone by stopping it for a few days every month?

There is a condition known as “endometrial hyperplasia”. This condition causes increased thickening of the endometrial stripe (uterine lining) which is a precursor to cancer. This condition must be treated to avoid the development of cancer. The treatment is high dose progesterone to shrink this tissue. If repeat ultrasound does not show a decrease in endometrial lining, then the dose of progesterone is doubled.

In summary, women on hormone replacement therapy do not need to cycle (stop the progesterone) and bleed at various times to feel “normal”. There is no substantiated benefit for the body to regularly bleed.

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