Uterine Blutungen bei internistischen Grunderkrankungen

Clinical management of unscheduled uterine bleeds in women using hormone replacement therapy (HRT) involves reconsideration of the selected individual therapy. Special attention should be given to the dose of the estrogen and progestin, the adequacy of both the progestin phase and the regimen – sequential or continuous combined therapy. A progestin should be administered for at least 10 days. It is unknown whether tibolone is an alternative for women with irregular bleeding on continuous combined therapy. These considerations also apply to women with uterine myoma. Transvaginal sonography may help identify women with thickened endometrium demanding histopathological assessment. Various controlled clinical trials suggest different cut-off values for a “normal” endometrial thickness (double-layer). A threshold of 7 mm appears to offer a reasonable compromise between sensitivity and specificity. A single episode of bleeding in the presence of an endometrial thickness ≤ 4 mm may allow for follow-up without endometrial sampling. Adherence to HRT may be enhanced by selecting the lowest doses of estrogens and progestins, including progesterone, achieving alleviation of climacteric symptoms without compromising endometrial safety. Parenteral use of estrogens and progestins is preferable in women with impaired liver function, as this mode of administration avoids the first-pass effect. This relatively small group of women may be eligible for replacement therapy if hepatic function reaches an equilibrium prior to initiation of therapy. Scarce clinical data indicate that systemic lupus erythematosus appears to deteriorate in women using HRT. However, other studies suggest that biliary cirrhosis does not deteriorate in women on HRT. HRT is possible in women with chronic renal and bone diseases. The outlined management of uterine bleeding also applies to these women. Uterine bleeding may occur with use of tamoxifen and less frequently with raloxifene, which is approved for the prophylaxis and treatment of postmenopausal osteoporosis. Transvaginal sonography may identify women with uterine stimulation, as indicated by the presence of subendometrial cysts and thickened endometrium, and preselect patients for endometrial sampling to exclude hyperplasia and cancer. The sensitivity and specificity of a single measurement of endometrial thickness is limited and additional tests such as saline infusion sonography may enhance the predictive value of the ultrasound assessment. The baseline frequency of postmenopausal bleeding does not appear to be increased in women who use raloxifene. Preliminary data suggest that use of raloxifene is not associated with an increased risk of endometrial cancer as is tamoxifen. SERMs constitute a relative contraindication in women with severe impairment of liver function.