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The endometrium and hormone replacement: Safety and bleeding

6 Introduction The response of the endometrium is of prime importance in hormone replacement therapy (HRT). The main concern is safety and that the preparation should not induce endometrial malignancy or a premalignant hyperplasia. Bleeding is a key issue in stopping HRT and for medical consultation.1,2,3,4,5 Recent surveys show that the main intolerable side effect of HRT is heavy bleeding, especially in older women.2,3,4 A study conducted in 590 women found that among women using cyclic HRT for the first time 38.3% had one or more visits for unexpected bleeding and 12.3% had one or more endometrial biopsies. Among women starting continuous combined HRT, 41.6% had one or more visits for unexpected bleeding and 20.1% had one or more endometrial biopsies.5 Human endometrium is a mucosa served by a microvascular blood supply that undergoes the unique process of benign angiogenesis under the control of ovarian steroids during reproductive life. This process is thought to continue in women taking HRT, and to be involved in any bleeding induced.