Endometrial ablation for refractory postmenopausal bleeding with continuous hormone replacement therapy

OBJECTIVE: To determine the role of endometrial ablation and benign uterine pathology in menopausal women with refractory bleeding who were treated with continuous hormone replacement therapy (HRT). DESIGN: Prospective. SETTING: Health maintenance organization. PATIENTS: One hundred seventy-one menopausal women with an average age of 55 were enrolled in an algorithm of continuous HRT, endometrial biopsy for bleeding with initial therapy, doubling of the progestin dose, hysteroscopy, and endometrial resection-ablation for continued refractory bleeding. INTERVENTION: Endometrial biopsy, hormone manipulation, office hysteroscopy, and hysteroscopic resection-ablation. MAIN OUTCOME MEASURES: Refractory menopausal bleeding and benign uterine pathology. RESULTS: One hundred sixty-two women completed the study. One hundred six (65.4%) remained free of bleeding at the end of the initial 3 months of hormone therapy. Fifty-six (34.6%) had one or more bleeding episodes and required office biopsy and an increase in dosage of progestin. Bleeding ceased in an additional 35 (87%) while 21 (13%) continued to bleed. Those patients underwent endometrial resection-ablation. Surgical specimen demonstrated endometrial polyps, submucous leiomyomas, and adenomyosis in 85.7% of the cases. All patients are now free of bleeding. CONCLUSION: Many women became amenorrheic on the initial dose of continuous HRT; however, if bleeding continues, most stop when the dosage of progestin is doubled. Benign uterine pathology may cause refractory bleeding in a small group of patients but may be eliminated with endometrial resection-ablation.