Differing responses in blood pressure over 24 hours in normotensive women receiving oral or transdermal estrogen replacement therapy.

OBJECTIVE: To examine the effects of oral and transdermal estrogen replacement therapy (ERT) on ambulatory 24-hour blood pressure (BP) recordings. METHODS: In a nonrandomized, prospective study, 90 normotensive, oophorectomized women, ages 30-59 years, underwent ambulatory 24-hour BP measurements at study entry and after 3 and 6 months of either oral (n = 50) or transdermal (n = 40) ERT. RESULTS: In the women receiving transdermal estrogen, we observed a change in mean nighttime systolic BP of -4.2 mmHg (95% confidence interval [CI] -7.7, -0.7; P = .039) after 6 months, treatment. There was a change in mean daytime diastolic BP after 3 months (-3.3 mmHg; 95% CI -5.5, -0.9; P = .016) and 6 months (-4 mmHg; 95% CI-6.8, -1.2; P = .014), and in mean nighttime diastolic BP after 3 months (-3.8 mmHg; 95% CI -6.6, -0.9; P = .027) and 6 months (-4.4 mmHg; 95% CI -7.1, -1.7; P = .005). No significant BP changes were observed in the women taking oral estrogen. Although the statistical power to detect a change of 4 mmHg at the 5% significance level was 90% for diastolic BP, it was weaker for systolic BP (63%) in this group. However, in more than one-third of the women receiving either treatment, a statistically significant increase in BP was observed. CONCLUSIONS: Transdermal ERT was associated with a reduction in mean ambulatory BP, whereas oral treatment did not alter BP. Although the overall effect of estrogen was to lower BP, individual responses were variable, and BP increased in more than one-third of the women on either treatment. Therefore, long-term monitoring of ambulatory measurements may be required.

Abnormal uterine bleeding on hormone replacement: the importance of intrauterine structural abnormalities.

OBJECTIVE: To examine the importance of submucous myomas and endometrial polyps before and after menopause and in abnormal withdrawal bleeding on hormone replacement therapy (HRT). METHODS: Between May 1991 and May 1993, women presenting with abnormal withdrawal bleeding on HRT (n = 106), menstrual problems in pre-menopause (n = 92), or postmenopausal bleeding (n = 33) underwent diagnostic outpatient hysteroscopy for the presence of intrauterine structural abnormalities. The findings were compared with a control group of post- and perimenopausal women without bleeding problems (n = 183). RESULTS: When compared with women who had normal uterine cavities, the presence of submucous myomas was associated with a threefold increase in the risk of abnormal menstrual bleeding in premenopausal women (odds ratio [OR] 3.34, 95% confidence interval [CI] 1.77-6.43; P < .001) and a twofold increase in the risk of abnormal withdrawal bleeding in post- and perimenopausal women (OR 2.4, 95% CI 1.25-4.53; P = .004). This did not seem to be related to the number of myomas detected. The frequency of endometrial polyps was not found to be significantly higher in women who had menstrual disorders or abnormal withdrawal bleeding on HRT. Postmenopausal bleeding without hormonal stimulation was not significantly associated with submucous myomas or polyps. CONCLUSION: As increasingly more women request HRT, bleeding problems presenting pre-menopause can no longer be expected to resolve "naturally" after menopause. In the presence of submucous myomas, these women will continue to have a higher risk of abnormal withdrawal bleeding when treated with hormone replacement, whereas endometrial polyps are not associated with an increased bleeding risk. Hysteroscopic assessment of the uterine cavity and subsequent counseling as to the risk of heavy or prolonged bleeding will be helpful in their future management and may improve compliance.