Algorithms for prevention, diagnosis, and management of unplanned bleeding in women undergoing menopausal hormone therapy

DOI

https://dx.doi.org/10.18565/aig.2025.221

Podzolkova N.M., Dubrovina S.O., Enkova E.V., Karakhalis L.Yu., Korennaya V.V., Maltseva L.I., Protasova A.E., Smetnik A.A., Tapilskaya N.I., Ulrikh E.A., Yureneva S.V., Yarmolinskaya M.I.
1) Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia, Moscow, Russia; 2) Botkin Moscow Multidisciplinary Scientific-Clinical Center, Moscow City Health Department, Moscow, Russia; 3) Rostov State Medical University, Ministry of Health of Russia, Moscow, Russia; 4) N.N. Burdenko Voronezh State Medical University, Voronezh, Russia; 5) Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia; 6) Kazan State Medical Academy – Branch of the Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia, Kazan, Russia; 7) St. Petersburg State University, St. Petersburg, Russia; 8) Academician V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, Moscow, Russia; 9) D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, St. Petersburg, Russia; 10) Almazov National Medical Research Center, Ministry of Health of Russia, St. Petersburg, Russia; 11) I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, St. Petersburg, Russia

Given the rapid growth in the number of women aged 40–60 (more than 850 million, with a forecast of over 1 billion in the coming years), the issues of effective management of menopausal symptoms are becoming particularly important. In 85% of women, the cessation of menstruation is accompanied by severe psycho-vegetative, somatic, and metabolic disorders, which significantly reduce the quality of life.
In the Russian Federation, the use of menopausal hormone therapy (MHT) has increased fivefold over the past five years, reaching 6.5% among women aged 45–69 years [10]. This reflects the active involvement of the medical community in supporting informed patient choice and ensuring the safe and clinically appropriate use of MHT. Nevertheless, the use of MHT in the Russian Federation remains lower than in a number of developed countries in Europe and North America, where it exceeds 15%.
Key limiting factors include the legal vulnerability of physicians and insufficient training in therapy individualization, particularly in managing adverse events such as unplanned uterine bleeding (UUB), which occurs in 40% of women during the first six months of therapy.
The article emphasizes the need for personalized MHT, considering age, stage of climacteric, clinical response, comorbidities, and the dynamic balance of benefit/risk. It presents algorithms for the diagnosis, treatment, and prevention of UUB that were developed on the basis of current scientific evidence, international and national clinical guidelines. A number of key points are based on the consensus opinion of experts, which reflects the practical significance and clinical experience in the context of a limited evidence base on certain aspects of therapy.
The algorithms include the assessment of risk factors and principles of MHT adjustment in UUB; counseling and management of patients with UUB; bleeding control during cyclic MHT; management of bleeding during continuous MHT; approaches to patients using LNG-IUD; principles of preventing UUB during MHT.
Special attention is given to step-by-step clinical actions for excluding hyperplastic and neoplastic processes, which are critical for continuing therapy. The tables serve as practical tools for education and clinical decision-making support.
Conclusion: The use of these algorithms may contribute to timely diagnosis of UUB causes, the choice of optimal management strategies, reduction in the frequency of unjustified invasive interventions and MHT discontinuation. This, in turn, can improve the quality of life of patients and achieve better medical and social outcomes.

Authors’ contributions: Podzolkova N.M., Dubrovina S.O., Enkova E.V., Karakhalis L.Yu., Korennaya V.V., Maltseva L.I., Protasova A.E., Smetnik A.A., Tapilskaya N.I., Ulrikh E.A., Yureneva S.V., Yarmolinskaya M.I. – developing the concept of the study, collecting the information, writing the article.
Conflicts of interest: The authors declare no potential conflict of interest in the research, authorship, and/or publication of this article.
Funding: The study was conducted without sponsorship.
Methodology Statement: All stages of the research, including data collection, analysis, and interpretation, were performed without the use of AI tools.
For citation: Podzolkova N.M., Dubrovina S.O., Enkova E.V., Karakhalis L.Yu., Korennaya V.V., Maltseva L.I., Protasova A.E., Smetnik A.A., Tapilskaya N.I., Ulrikh E.A., Yureneva S.V., Yarmolinskaya M.I. Algorithms for prevention, diagnosis, and management of unplanned bleeding in women undergoing menopausal hormone therapy.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2025; (8): 230-246 (in Russian)
https://dx.doi.org/10.18565/aig.2025.221

menopausal hormone therapy

menopause

hormone therapy

uterine bleeding

endometrial cancer

Full text (in Russian)

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Received 19.08.2025

Accepted 27.08.2025

Natalia M. Podzolkova, Dr. Med. Sci., Professor, Head of the Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia, 125993, Russia, Moscow, Barrikadnaya str., 2/1, bldg. 1; Leading Researcher, S.P. Botkin Moscow Multidisciplinary Scientific and Clinical Center, 125284, Russia, Moscow, 2nd Botkinsky Proezd, 5, +7(916) 488-87-55, podzolkova@gmail.com, https://orcid.org/0000-0001-8991-1369
Svetlana O. Dubrovina, Dr. Med. Sci., Professor, Chief Researcher, Obstetrics and Pediatrics Research Institute, Professor, Department of Obstetrics and Gynecology No. 1, Rostov State Medical University, Ministry of Health of Russia, 344022, Russia, Rostov-on-Don, Nakhichevansky per., 29, +7(918)558-51-13, s.dubrovina@gmail.com,
https://orcid.org/0000-0002-2400-9638
Elena V. Enkova, Dr. Med. Sci., Professor, Head of the Department of Obstetrics and Gynecology No. 2, N.N. Burdenko Voronezh State Medical University,
Ministry of Health of Russia, 394036, Russia, Voronezh, Studencheskaya str., 10, +7(950)796-74-00, enkova@bk.ru, https://orcid.org/0000-0001-8885-1587
Lyudmila Yu. Karakhalis, Dr. Med. Sci., Professor, Professor at the Department of Obstetrics, Gynecology and Perinatology No. 2, Kuban State Medical University,
Ministry of Health of Russia, 350063, Russia, Krasnodar, Mitrofana Sedina str., 4, +7(988)244-40-44, lomela@mail.ru, https://orcid.org/0000-0003-1040-6736
Vera V. Korennaya, PhD, Associate Professor at the Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education,
Ministry of Health of Russia, 125993, Russia, Moscow, Barrikadnaya str., 2/1, bldg. 1; Chief Freelance Specialist in Gynecology of the Moscow Healthcare Department;
Deputy Chief Physician for Prospective Development, City Clinical Hospital No. 52, Moscow, drkorennaya@mail.ru, https://orcid.org/009-0000-9612-454X
Larisa I. Maltseva, Dr. Med. Sci., Professor, Honored Scientist of the Russian Federation, Professor at the Department of Obstetrics and Gynecology, Kazan State Medical Academy - branch of the Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia, 420012, Russia, Kazan, Butlerova str., 49,
+7(842)236-06-23, laramalc@mail.ru, https://orcid.org/0000-0003-0999-4374
Anna E. Protasova, Dr. Med. Sci., Professor at the Department of Oncology, St. Petersburg State University, 199034, Russia, St. Petersburg, Universitetskaya emb., 7–9; Professor, Department of Obstetrics and Gynecology, V.A. Almazov National Medical Research Center, Ministry of Health of Russia,
197341, Russia, St. Petersburg, Akkuratova str., 2; Chief Physician, Oncology Clinic AVA-PETER Scandinavia, St. Petersburg, +7(921)919-84-24, protasova1966@yandex.ru,
https://orcid.org/0009-0001-3965-8876
Antonina A. Smetnik, PhD, Head of the Department of Gynecological Endocrinology, Associate Professor at the Department of Obstetrics and Gynecology, IPO,
Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia,
117997, Russia, Moscow, Ac. Oparina str., 4, +7(495) 31-44-44, a_smetnik@oparina4.ru, https://orcid.org/0000-0002-0627-3902
Natalya I. Tapilskaya, Dr. Med. Sci., Professor, Head of the Department of Reproductology, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology, 199034, Russia, St. Petersburg, Mendeleevskaya line, 3; Professor, Department of Obstetrics and Gynecology, St. Petersburg State Pediatric Medical University,
St. Petersburg, +7(921)933-61-26, tapnatalia@yandex.ru, https://orcid.org/0000-0001-5309-0087
Elena A. Ulrikh, Dr. Med. Sci., Professor, Chief Researcher at the Research Laboratory of Oncogynecology and Oncofertility, V.A. Almazov National Medical Research Center, Ministry of Health of Russia, 197341, Russia, St. Petersburg, Akkuratova str., 2; Professor, Department of Oncology, I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, 191015, Russia, St. Petersburg, Kirochnaya str., 41; Leading Researcher, N.N. Petrov National Medical Research Center for Oncology,
St. Petersburg, +7(921)740-06-18, elenaulrikh@mail.ru, https://orcid.org/0000-0002-2701-8812
Svetlana V. Yureneva, Dr. Med. Sci., Professor, Deputy Director for Research, Institute of Oncogynecology and Mammology, Professor at the Department of Obstetrics and Gynecology, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia,
117997, Russia, Moscow, Ac. Oparina str., 4, +7(916)179-74-00, syureneva@gmail.com, https://orcid.org/0000-0003-2864-066X
Maria I. Yarmolinskaya, Honored Scientist of the Russian Federation, Dr. Med. Sci., Professor, Head of the Department of Gynecology and Endocrinology,
Head of the Center for Innovative Methods of Diagnosis and Therapy of Endometriosis, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology, 1
99034, Russia, St. Petersburg, Mendeleevskaya line, 3; Professor at the Department of Obstetrics and Gynecology, I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, 191015, Russia, St. Petersburg, Kirochnaya str., 41, +7(921)916-63-09, m.yarmolinskaya@gmail.com, https://orcid.org/0000-0002-6551-4147

Algorithms for prevention, diagnosis, and management of unplanned bleeding in women undergoing menopausal hormone therapy

Podzolkova N.M., Dubrovina S.O., Enkova E.V., Karakhalis L.Yu., Korennaya V.V., Maltseva L.I., Protasova A.E., Smetnik A.A., Tapilskaya N.I., Ulrikh E.A., Yureneva S.V., Yarmolinskaya M.I.

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