TYPES OF HRT AVAILABLE: WHAT IS THE RELATIONSHIP BETWEEN THE OESTROGEN DOSE AND THE LIKELIHOOD OF WITHDRAWAL BLEEDING BEING ESTABLISHED?

Little information is available to address this question. It is stressed that withdrawal bleeding will only occur if the oestrogenic stimulus is sufficient to cause endometrial stimulation, and if the progestogen is administered at adequate daily dose and for sufficient duration . Assuming that the latter criteria are fulfilled, it is to be expected that the percentage of women experiencing withdrawal bleeding will rise as the oestrogen dose is increased. In our experience, almost all patients receiving oestradiol implants experience withdrawal bleeding, and this most probably reflects the more than adequate plasma oestradiol levels achieved with this form of therapy. With conjugated equine oestrogens 0.625 mg/day (or an equivalent such as transdermal oestradiol, 50 mg/day), approximately 85% of women experience withdrawal bleeding: the remainder do not. The absence of bleeding is not a cause for concern and endometrial biopsy is not indicated because of amenorrhoea. The lack of bleeding in this minority most probably reflects the wide inter-patient variation in plasma oestradiol values achieved with all therapies .
Few data are available with lower doses administered systemically, such as transdermal oestradiol 25 mg/day. In our experience, approximately 50% of patients experience withdrawal bleeding with this dose when a progestogen is added.
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