Question 58 - 38 Year Old With Need For Appropriate Diagnoses And Management Of Libido Problems And Undiagnosed Abnormal Vaginal Bleeding
(Posted August 7, 2000)

Dr N,

I am 38 years old and was recently placed on a regime of premarin .625 every day dropping every third day and replacing it with es estratest hs along with medroxyprogesterone 2.5. I take 5 days off at the end of the cycle.

Symptoms that my physician felt warranted HRT at such a young age included: severe bleeding with severe clots (periods lasting about 10 days 5 of which would be heavy with usually 2 days restricting ability to leave the house), severe cramping, spotting through the rest of the month with only about one week in a 25 day cycle without some type of flow, and a complete lack of libido. This bleeding pattern had been occurring for 2 years. There is a history of early menopause in my mother's family with some complete by 40. No fibroids or cancer of the endometrium were present. Hormone levels were not measured before HRT was started. The bleeding has reduced with only small clotting and what I would consider a normal period, but the anxiety, agitation, and a general lack of a sense of mental well being has accompanied the use of the progesterone causing more problems that I think the HRT is worth. My instinct is to drop the meds so I can feel sane.

What steps would you take to assess appropriate treatment for someone my age?

Hi,

Ok ...

The first thing that would try to do is attempt to elicit the cause of the abnormal bleeding. The 2 most possible categories, would be (1) bleeding associated with an abnormal hormonal cycle, resulting in failure to ovulate and (2) bleeding from an abnormality of the lining, or the body of the uterus. There are some other considerations, but they would be a less frequent cause of this sort of problem.

Diagnostic tests and procedures would include but not be limited to:

Blood tests for menopause, hypothyroidism and coagulation disorders. Pelvic Ultrasound, pap smear and pelvic exam, sampling of the uterine lining and hysteroscopy (visualization of the inside of the uterus with a scope). In addition, if endometriosis is suggested, laparoscopy would be a consideration.

If the cause is found too be a hormonal problem that requires no specific treatment, the most reasonable initial therapy at age 38 would seem to be an oral contraceptive. If the blood tests show unequivocally that you are menopausal, you might consider transdermal estrogen, either a patch, or a gel and I would do this 365 days a year. In view of your libido problem, I would also add some testosterone, either in gel form combined with the estradiol, or by an injection of 50 mg of depo testosterone monthly. I would agree that you are having symptoms associated with progestin intolerance and if it turns out that you experience similar symptoms with oral contraceptives, another treatment strategy will be needed. If post menopausal HRT is instituted, I would use a progestin, most likely Prometrium for 10 days a month following which you would have a scheduled withdrawal bleeding. Prometrium, seems to be responsible for fewer progestin symptoms, however, it may not be potent enough to regulate your bleeding and if this is the case, a more potent progestin will be needed. If the cause is an abnormality of the uterus, appropriate therapy would depend on its nature.

These are some general thoughts that come to mind based on your history. However, I think that the first thing you need to do is find a doctor who you feel is competent to manage this problem. If you were comfortable with your present physician's management, you probably wouldn't be sending me this email. If you have difficulty finding someone, you could consider making an appointment with the gynecology department at a university medical center.

If you read the sections of the web site under the HRT and Sex headings, they may provide additional insight.

Please let me know what and how you do.

Dr N