Latest / The Dr Louise Newson Podcast / 57 – Bleeding on HRT: what’s normal and what’s not

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57 – Bleeding on HRT: what’s normal and what’s not · The Dr Louise Newson Podcast

• 0:00
  Today on my podcast, I've got Mr. Zami Naji.
• 0:03
  He is a gynecologist in London and also a great friend.
• 0:06
  We talk a lot about bleeding on and off HRT because it's one of
• 0:11
  the most common side effects of taking hormones.
• 0:14
  It's one that causes a lot of confusion and sometimes concern.
• 0:18
  So we have a very reassuring chat about this topic.
• 0:23
  So Zama, you're here in real life.
• 0:25
  We've I've done 2 podcasts with you before, but remote.
• 0:29
  So we're in Jack's lovely studio.
• 0:32
  You're feeling relaxed. Very nice place.
• 0:34
  In fact, yes, thank you very much for having me.
• 0:36
  No. Well, you're one of my favourite
• 0:38
  gynecologists, such a really, and not just mine, but lots of
• 0:41
  women and lots of my colleagues as well.
• 0:44
  So you're in the hot seat. So I think I can just ask you a
• 0:47
  few questions because I am not a gynecologist, which is fine.
• 0:52
  I don't have anything against gynecologists.
• 0:54
  Very good gynecology knowledge. I have to say yes.
• 0:57
  But it's interesting, isn't it? Because, you know, I specialized
• 1:00
  in women's humans. They're made in the ovaries, but
• 1:03
  they're also made in the adrenal glands and they're made in the
• 1:05
  brain. But somehow a lot of
• 1:08
  gynecologists, not you, I hasten to add, feel that the menopause
• 1:12
  and hormone problems has to belong to gynecologists.
• 1:15
  Whereas in my mind, gynecologists like yourself
• 1:19
  specialized in the, the womb, the the ovaries, the
• 1:23
  reproductive organs, if you like, or the gynecological
• 1:26
  organs, because if there's a disease, that's what you treat.
• 1:31
  Whereas you don't want to be treating a hormonal issue that
• 1:34
  we're hormones all around our body.
• 1:35
  So it's a, it's a weird concept really, isn't it?
• 1:38
  Absolutely. Absolutely.
• 1:39
  Quite often I when we see patients whenever the
• 1:43
  consultation started to to divert towards HRTI always
• 1:48
  explain HRT is not only about prescribing medications, it's a
• 1:52
  complete different scope of of consultation.
• 1:55
  It requires having a extremely detailed history.
• 1:59
  We discuss lifestyle, we discuss sleep, diet, exercise, sports
• 2:05
  and then HRT comes as an additional.
• 2:07
  So it does require a more detailed consultation to give it
• 2:11
  justice, yeah. And so I mean, I'm very
• 2:15
  comfortable obviously prescribing hormones, assessing
• 2:17
  the person, looking at all the organs, because I've been
• 2:20
  trained in a very general way, as you know.
• 2:22
  But one of the commonest side effects of HRT is bleeding.
• 2:27
  And I know myself, when I started HRT 10 years ago,
• 2:31
  obviously I knew it was bleeding, but I got really heavy
• 2:33
  bleeding quite quickly. And I thought, gosh, no wonder
• 2:36
  women are scared. My periods have always been
• 2:39
  quite light. They've sort of come and go.
• 2:41
  They weren't really a big deal and other than when I was a
• 2:43
  teenager I suppose, but when they were very heavy I was quite
• 2:47
  worried. But I knew that is a common side
• 2:50
  effect, especially when you start taking hormones.
• 2:53
  So I just waited a few weeks and after about 8 weeks it settled
• 2:56
  down and it was fine. But it is common and it's one of
• 2:59
  the commonest reasons that we refer patients to you for
• 3:02
  bleeding. And there are lots of reasons
• 3:05
  for bleeding. And I wouldn't mind just
• 3:06
  spending a bit of time just sort of educating people about
• 3:10
  bleeding, not just on HRT, but in general, because, you know,
• 3:14
  it's quite alarming if you're not expecting bleeding.
• 3:17
  And there are more serious causes and less serious causes.
• 3:21
  Sometimes we can try and tease it out from a history and often
• 3:24
  we have to think about investigations.
• 3:27
  Indeed, yeah. So what are the commonest causes
• 3:30
  of bleeding in a woman? Just generally.
• 3:32
  Quite often. Most of the times the causes are
• 3:34
  reassuring and non concerning. It's a functional, transient or
• 3:39
  longer term hormonal imbalance and sometimes can be triggered
• 3:42
  by pathology. And that's why to stress the
• 3:45
  fact that you said the extraction the of the knowledge
• 3:48
  and the information from the history is crucial on this
• 3:50
  matter. But when it comes to HRT, we try
• 3:55
  to mimic what happens in the nature and often we get it
• 3:58
  right. Yes, often the case of this
• 4:01
  scenario, it requires a little bit of more reassurance to the
• 4:05
  patients to tell them it is expected or not uncommon to have
• 4:10
  a little bit of unscheduled bleeding at the start.
• 4:12
  It's often the body trying to adjust accordingly to these
• 4:16
  extra hormones and hopefully most of the times it does the
• 4:20
  job itself without a necessary. So the reassurance within at
• 4:24
  least three to six months of starting, it is not uncommon to
• 4:28
  expect some form of bleeding. But in this scenario of starting
• 4:33
  to become worrying in the form of the menstrual flow or in the
• 4:37
  form of the pattern, if there is any associated other symptoms,
• 4:41
  then it may warrant a little bit a closer look to see if there
• 4:44
  are other causes can be minimized or mitigated during
• 4:47
  the starting process at least. Yeah.
• 4:49
  And it's, it's really interesting because often it's
• 4:52
  asking the right questions, you know, as you know, as a doctor
• 4:55
  and I've spoken about it before in this podcast, it's, it's
• 4:58
  asking the right questions and the patients often know.
• 5:01
  So with lots of women who talk to me have had some bleeding,
• 5:04
  there's usually they know there's a reason behind it.
• 5:07
  So some women, for example, are perimenopausal when they start
• 5:10
  HRT, so they're still having their own hormones as well.
• 5:14
  And then some women say to me, I had some bleeding that's
• 5:17
  irregular, but around the time of bleeding, I've also had some
• 5:20
  breast tenderness and bloating. And I think, well, that's
• 5:23
  probably more hormonal. It only lasted for two or three
• 5:26
  days and now they haven't had it for weeks.
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  And that's very unlikely to be anything serious, isn't it?
• 5:31
  Unlikely at all. Look also in the in the form of
• 5:34
  the history backing how how important is the history is to
• 5:38
  to engage the woman herself and she will express her concerns
• 5:44
  about this complaint in a little bit more details.
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  And in fact, also stressing the fact whether any are there any
• 5:51
  other risk factors that could probably invite a little bit of
• 5:56
  a closer look. Very importantly as well,
• 5:58
  whether the body weight is optimized or not, smoking,
• 6:02
  alcohol, diabetes, hypertension, previous pregnancy or not.
• 6:08
  It's a previous history of common gynecological
• 6:10
  pathologies. Fibroids, adenomyosis,
• 6:13
  endometriosis, a little bit of a detailed gynecological history.
• 6:16
  That's really important as well, looking at risk factors because
• 6:19
  you know, we've only got limited resources, NHS and privately we
• 6:23
  don't want to be over investigating people but we
• 6:26
  don't want to be missing things as well.
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  And obviously everyone who has bleeding back of their mind,
• 6:31
  could it be a cancer? And that's the big thing that
• 6:33
  people worry about. But actually the risk is
• 6:35
  incredibly low. Endometrial cancer isn't a
• 6:39
  really common cancer, but it is a very treatable cancer if it if
• 6:43
  it's picked up early. Curable, in fact.
• 6:45
  Yes, yeah. Absolutely.
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  On this point, Claire, Louise, look again.
• 6:50
  HRT I have to say has been treated unfairly on the media as
• 6:54
  as a causing factor for in the material cancer.
• 6:56
  This type of cancer comes with other common risk factors like
• 6:59
  you, you, you mentioned categorically high, high higher
• 7:04
  body weight or higher BMI, the pregnancy status, diabetes,
• 7:08
  hypertension. In the absence of these factors,
• 7:10
  the women, they deserve some reassurance on this front in
• 7:13
  particular for sure. Absolutely.
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  If people are on continuous. So that's the progesterone every
• 7:18
  day with the estrogen, especially estradiol, then their
• 7:22
  risk of cancer of the lining of the womb is less than if they
• 7:25
  didn't have HRT. And a lot of people, I think
• 7:28
  even a lot of gynecologists and doctors don't realise that as
• 7:31
  well. Absolutely.
• 7:33
  So but a small period like bleed that lasts couple of days and
• 7:36
  doesn't happen again is very unlikely to be a cancer, isn't
• 7:40
  it? That's that's that's fairly
• 7:42
  true. I always also explain to
• 7:44
  patients, please listen to your to your to your feelings to your
• 7:48
  to always when you know something is not right.
• 7:52
  Often this is the case. It just deserves a little bit
• 7:55
  more attentive listening. Yes.
• 7:56
  And if the if the patient despite of that of the
• 8:00
  reassurance and is still concerned, it's our obligation
• 8:03
  and and duty to listen and and and engage and make sure she is
• 8:06
  reassured in the best possible way.
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  Quite often sometimes when we are when we work in a cancer
• 8:11
  exclusion clinic that we done our due diligence and our safety
• 8:17
  checks and we are satisfied at this stage that there is no
• 8:20
  immediate concern for cancer. And then we're obliged by the
• 8:23
  governance by the rules that we have to discharge these patients
• 8:26
  from the service. We always follow a safety
• 8:30
  netting approach that this is a snapshot assessment at this
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  moment in time we are satisfied not to not to concern you, but
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  we always invited to remain vigilant should the symptoms
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  recur back in three months time, in six months time or if you are
• 8:45
  have any other new concerns arising.
• 8:48
  Not necessarily unscheduled bleeds.
• 8:49
  Sometimes even cancers happen with very unusual symptoms or
• 8:53
  uncommon symptoms like pain like bloating.
• 8:56
  Just listen to yourself, listen to your body and report it back
• 8:59
  and we can be happy quite to investigate again.
• 9:02
  Most of the times patient they they just need this type of
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  reassurance and that they have somewhere to go back to at the
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  end. I think that's the big thing,
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  isn't it, If women are intuitive, but if they if they
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  think or have any concerns and then us as doctors need to
• 9:16
  listen to them. And that's part of the problem
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  sometimes is doctors don't always listen, but we should do.
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  The other thing is very interesting because a lot of
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  people think that estrogen is associated with endometrial
• 9:27
  cancer, cancer, the lining of the womb.
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  But it stems back from the 1970s when they were giving estrogen
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  only HRT because they didn't think about the womb.
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  They just knew the benefits of estrogen.
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  But the estrogen then was the conjugated equine estrogen.
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  So it was pregnant horses urine and with which has lots of
• 9:45
  chemicals, you know, lots of different estrogens, lots of
• 9:47
  different progestogens in it and goodness only knows what else it
• 9:50
  had in it as well. And then there's also ethanol.
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  Estradiol was sometimes used as HRT, which is a synthetic form
• 9:56
  of of estrogen. But I can't find any studies
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  anywhere that show that estradiol, which is the exact
• 10:03
  replica of our own estrogen, that's the beneficial
• 10:06
  anti-inflammatory type, is actually ever been linked with
• 10:09
  endometrial cancer. But, and we'll never have the
• 10:12
  studies because they certainly won't be done now, but when
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  people have cancer, it's a sort of multi hip process.
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  It's not just one 'cause there's genetic changes, there's
• 10:23
  inflammation, there's other causes.
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  Genetics is now very much on the on the rise for for as a causing
• 10:30
  factor. And there is a space to be
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  washed over the coming years. That will be a huge implications
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  for genetic testing for for the material.
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  Cancer in fact, yes. So it's sort of a multi hit
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  really. It's just say as simply estrogen
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  causes endometrial cancer can't really be accurate because
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  that's not how he's just, you know, that's not how cancer
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  falls. And let you say other risk
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  factors as well. And and that is important.
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  And you know, the incidence of those risk factors is
• 10:59
  increasing. The incidence of obesity,
• 11:01
  diabetes, hypertension, all this inflammation increases.
• 11:05
  So there will be women and there might be women listening who
• 11:08
  have been on HRT and they've had endometrial cancer because of
• 11:12
  course that doesn't mean that the HRT has caused it.
• 11:15
  They might have had it anyway and actually it might be that
• 11:19
  those women who get a cancer that has developed when they've
• 11:22
  taken HRT, they have a better long term outlook as well.
• 11:27
  I often say that when women understand their hormones, they
• 11:30
  feel so much more empowered. That's why I developed my free
• 11:34
  Balance app. It gives you practical tools to
• 11:37
  track your symptoms and periods if you have them, access
• 11:41
  hundreds of evidence based articles and connect with a
• 11:44
  community of women who are navigating similar experiences.
• 11:48
  This isn't about quick fixes or vague Wellness advice.
• 11:52
  It's about real education grounded in science, so you can
• 11:56
  make informed decisions about your health and your treatment.
• 12:01
  Too many women are still being dismissed or misinformed.
• 12:05
  I want you to walk into appointments confident, prepared
• 12:09
  and heard. So if you want accurate
• 12:12
  information and support in one place, download My Balance app.
• 12:17
  It's free, it's independent, and it's built for women.
• 12:22
  We are unconsciously biased because we work in a cancer
• 12:25
  service. So we are seeing alarming trends
• 12:29
  of endometrial cancer on on the rise, but at also relatively
• 12:33
  young age. But if you also, like we said,
• 12:36
  look into the history that you always find a way in the history
• 12:39
  and. That's where progesterone can
• 12:41
  often come in. So we, a lot of women with PCOS,
• 12:43
  polycystic ovarian syndrome actually have quite low
• 12:46
  progesterone and they're not ovulating often and they're not
• 12:50
  producing enough progesterone. And so often giving, and this is
• 12:53
  the natural progesterone giving that can really make a huge
• 12:56
  difference to their bleeding and to their symptoms as well.
• 12:59
  And and that you say the the balance of hormones because
• 13:03
  absorption of estradiol through the skin, if we use it as a
• 13:06
  practical gel really varies. The dose of progesterone really
• 13:10
  varies according to their symptoms in bleeding.
• 13:12
  So I have some women who have a low dose of estradiol, but they
• 13:15
  need quite a higher dose of progesterone or the other way
• 13:18
  around, if someone's on a higher dose and they're not absorbing
• 13:20
  very much, then actually they don't automatically need a
• 13:23
  higher dose of progesterone. But looking at the the balance
• 13:27
  is really important because it makes the, the landing of the
• 13:30
  room a lot sort of more stable and a lot happier and less
• 13:33
  likely to bleed as well, doesn't it?
• 13:34
  And. That's the beauty of the human
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  Physiology and and this front. If there is a a size fit for
• 13:40
  all, yes it will be a safer and and and and more peaceful for
• 13:46
  all. But it might not be that
• 13:49
  rewarding to the clinicians and to the patients.
• 13:51
  So some some women, they respond totally differently to different
• 13:54
  type of medications. And we're all different, yeah.
• 13:57
  And like I say, if, if, if we're perimenopausal when we take
• 14:00
  hormones sometimes with my patients, I think great,
• 14:03
  everything's nice and stable. And then they have their own
• 14:05
  hormones that come into play and can interfere and and sort of
• 14:08
  destabilize things as well. So it's always this balance,
• 14:12
  but, and so if someone has bleeding on HRT and as, as
• 14:16
  clinicians, we want them to have further investigations.
• 14:20
  We usually examine women, of course, but the next test really
• 14:24
  is usually an ultrasound scan, isn't it?
• 14:25
  That we do. And that's important because I
• 14:27
  see a lot of women who have a polyp, for example, and then
• 14:29
  they might come to you or another gynecologist, it's
• 14:31
  removed, bleeding settles and, and they sort of look back and
• 14:35
  think, oh, they might have had that for a while.
• 14:37
  But it's important to make sure that there isn't any other
• 14:41
  reason that's easily treatable. Indeed, absolutely.
• 14:43
  It's all part of the safety net. Some of the gynecologists are so
• 14:47
  incredibly scared of bleeding. That's how they focus whether
• 14:51
  HRT is suitable or not. And one of the criticisms I've
• 14:55
  had many times is that, Louise, too many women are taking
• 14:58
  hormones because too many women are having bleeding and it's
• 15:00
  clogging our clinics. And I feel that we should almost
• 15:03
  be taking a step back and and looking at the women with a
• 15:07
  higher risk. So they're usually, like you
• 15:09
  say, women who are overweight, diabetes, raise blood pressure,
• 15:13
  actually not taking hormones. You know, if someone's in their
• 15:16
  60s, never been on HRT and have bleeding, those women really
• 15:20
  need to be investigated. If a woman is 3540 maybe started
• 15:26
  some hormones perimenopausal and has bleeding, well her chances
• 15:30
  of anything, you know, bad like a cancer very low compared to
• 15:36
  the 60 year old. So there almost should be a sort
• 15:38
  of two tier system really. But the way the bottleneck of
• 15:42
  the NHS is often they all get referred to the same clinic and
• 15:45
  that's quite scary because it it's scary for the person
• 15:50
  because it's suspected cancer, two week referral clinic.
• 15:53
  But it also is a real demand for the services, isn't it for you
• 15:56
  to prioritise who to see and who to?
• 15:59
  To be honest, now, yes, we see them patients be when they when,
• 16:02
  when they they they come and show us the letters.
• 16:05
  It's in a bold under underline an italic text that is a cancer
• 16:10
  services the psychological morbidities after receiving such
• 16:14
  an invite. If I put myself in there, I
• 16:16
  receive how would how would I how would I react?
• 16:19
  So they're always come on the charge for for for this, for
• 16:23
  this. So therefore they're listening,
• 16:25
  they're engagement. It needs to it needs to take a
• 16:27
  lot of time. So I we we endeavoured several
• 16:31
  times in order to improve the communication behind this.
• 16:35
  But at the end of the day, it is a cancer exclusion clinic.
• 16:38
  The main job is to exclude cancer.
• 16:41
  We try to minimize the journey from the initial contact until
• 16:44
  the the until the the closing the episode as as shorter as
• 16:47
  possible. Sometimes possible, sometimes
• 16:50
  it's not. But we we try our best to
• 16:53
  reassure that most of the times patients come to this clinic
• 16:56
  with benign reasons and they leave with benign reasons.
• 16:59
  So hopefully cancer is still not the the we call it in a in a, in
• 17:05
  a very simpler terms, if we explain the cancer is the evil,
• 17:08
  yes, just like happening in the world now the world is going
• 17:12
  under very turbulent times. So still the good is better than
• 17:16
  the is more than the evil. So therefore the cancer is not
• 17:19
  is not winning. We are winning it a little bit
• 17:22
  of more positive encouragement about it and to reassure them
• 17:26
  bleeding, yes, can be a little bit alarming for for cancer, but
• 17:30
  it's not a causing factor for cancer.
• 17:33
  It can be for several other reasons.
• 17:36
  And that is important because I've had some patients who've
• 17:38
  been really scared, not just by the letter but by their doctors.
• 17:42
  And some of their doctors have said to them, well, just stop
• 17:45
  your HRT and then wait for the tests.
• 17:48
  If your bleeding settles, it's probably related to the
• 17:50
  hormones, but just stop and wait for the results.
• 17:53
  Now, a lot of people are on HRT because of their symptoms.
• 17:57
  So I've had two people in the last three weeks who've come
• 17:59
  back to me with very dark thoughts that have come back.
• 18:03
  They had them before they started their HRT and they've
• 18:06
  been forbidden to restart their HRT until they have their
• 18:10
  results. And that seems very unfair.
• 18:13
  It's always an informed choice and even I always think as a
• 18:16
  doctor I'm sure you think the same.
• 18:18
  Worst case scenario, what am I telling or what am I advising my
• 18:21
  patients? So if someone did have a cancer
• 18:25
  and they continued on their HRT until the diagnosis was made, it
• 18:28
  wouldn't change the outcome from that cancer at all.
• 18:31
  Pretty much. Absolutely.
• 18:32
  Yeah, Exactly. Yeah.
• 18:33
  But again, it's this uncertainty as well.
• 18:36
  Absolutely. And then in the end of the day,
• 18:39
  nobody would like to be to be 1, especially when it comes to
• 18:43
  cancer. Louise, I wouldn't like to to
• 18:46
  put a blame on any patients or or any system or any clinician.
• 18:51
  We are all doing our best and acting good in good faith.
• 18:54
  Yeah. But sometimes it's it is a still
• 18:56
  a large undertaking cancer process.
• 18:59
  And often people think that could this have been picked up
• 19:03
  early? Yeah.
• 19:04
  Could this has been diagnosed differently.
• 19:06
  So these these type of questions that you would probably trying
• 19:10
  to address with the patients at the earliest possible in order
• 19:13
  to minimize if there is a standard process within the NHS
• 19:17
  that you can indeed to be seen and investigated and get the
• 19:20
  results across the board. I would.
• 19:23
  I don't think we would be in this place, no.
• 19:26
  But we haven't got it, we might not have it.
• 19:28
  So in the meantime we just help our patients in an
• 19:30
  individualised way. So before we finish, I always
• 19:34
  ask, I've asked you before. So three take home tips.
• 19:38
  So three things, if people are listening and they might be
• 19:41
  concerned that they might have had some bleeding, what are the
• 19:45
  three things that you would recommend?
• 19:47
  So this is women who are taking hormones.
• 19:50
  So what are the three things that you would recommend?
• 19:53
  Number one, please take these concerns seriously to the
• 19:57
  patient. Do not be alarmed about it.
• 20:00
  It can be common. Sometimes it could translate a
• 20:03
  transient. An interpretation of your
• 20:06
  Physiology towards these hormones often associated with
• 20:09
  being maybe under certain type of stress, recently change in
• 20:13
  time zones, travels. These are manifestations of the
• 20:16
  hormones trying to do the job. In the end of the day,
• 20:19
  acknowledge these symptoms, just report them and have a sit down
• 20:22
  with your clinician to see is it worth investigating or not.
• 20:26
  Without necessarily to panic immediately about it, it's not a
• 20:29
  it's not a cause for concern #2 HRT is a medication that is
• 20:36
  destined to improve the well-being and the life of many
• 20:39
  women and have a good trust in these medications and the
• 20:45
  benefits and the vast majority of of the of the cases outweigh
• 20:49
  the less benefits. And finally, one in one in day
• 20:53
  investigations are required. Just please try to engage
• 20:57
  promptly in order to minimise the the uncertainty and the and
• 21:00
  the unpleasant time during these investigations.
• 21:02
  Yeah, it's so important. And to know that you can ask
• 21:05
  questions at any stage, which is really important.
• 21:07
  So yes, thank you so much for your time.
• 21:09
  Thanks for having me again today.
• 21:11
  Thank you. Thanks so much for listening.
• 21:15
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• 21:18
  it will really make a difference to grow numbers enable this to
• 21:22
  reach even more people. Thanks so much.