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Bleeding patterns of the hormone replacement therapies in the postmenopausal estrogen and progestin interventions trial.

To the Editor: Lindenfeld and Langer provide helpful information differentiating types of progestins and regimens on bleeding patterns in women enrolled in the Postmenopausal Estrogen and Progestin Interventions trial. In particular, they report that cyclical micronized progesterone plus conjugated equine estrogens was superior to cyclical medroxyprogesterone acetate plus conjugated equine estrogens in a number of parameters associated with bleeding patterns including cumulative number of days, quantity, and episodes of bleeding However, our real concern is an apparent misinterpretation of results we reported on bleeding patterns. We found that the combination of 1 mg of norethindrone acetate and 5 g of ethinyl estradiol given continuously results in significantly less bleeding, as assessed by monthly incidence or cumulative frequency of bleeding or bleeding and/or spotting, when compared with continuous 2.5 mg of medroxyprogesterone acetate plus 0.625 mg of conjugated equine estrogens. Lindenfeld and Langer reference our report in the Discussion section but state that medroxyprogesterone acetate was associated with less bleeding than norethindrone acetate—a statement completely contrary to the findings in our study. Given the increasing number of studies reporting data on bleeding patterns with hormone replacement therapy, we feel it is important to clarify the effect of norethindrone acetate and ethinyl estradiol in this regard.