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

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

Panay N., Ang S.B., Cheshire R., Goldstein S.R., Maki P., Nappi R.E.; International Menopause Society Board. Menopause and MHT in 2024: addressing the key controversies - an International Menopause Society White Paper. Climacteric. 2024; 27(5): 441-57. https://dx.doi.org/10.1080/13697137.2024.2394950
Ашрафян Л.А., Балан В.Е., Баранов И.И., Белая Ж.Е., Бобров С.А., Воронцова А.В., Дубровина С.О., Зазерская И.Е., Иловайская И.А., Карахалис Л.Ю., Лесняк О.М., Мазитова М.И., Подзолкова Н.М., Протасова А.Э., Серов В.Н., Сметник А.А., Сотникова Л.С., Ульрих Е.А., Чернуха Г.Е., Юренева С.В. Алгоритмы применения менопаузальной гормональной терапии у женщин в период пери- и постменопаузы. Совместная позиция экспертов РОАГ, РАМ, АГЭ, РАОП. Акушерство и гинекология. 2021; 3: 210-21. [Ashrafyan L.A., Balan V.E., Baranov I.I., Belaya Zh.E., Bobrov S.A., Vorontsova A.V., Dubrovina S.O., Zazerskaya I.E., Ilovayskaya I.A., Karakhalis L.Yu., Lesnyak O.M., Maznyak O.M., Mazitova M.I., Podzolkova N.M., Protasova A.E., Serov V.N., Smetnik A.A., Sotnikova L.S., Ulrikh E.A., Chernukha G.E., Yureneva S.V. Algorithms for menopausal hormone therapy during the period of peri- and postmenopause. Joint position statement of RSOG RAM, AGE, RAOP experts. Obstetrics and Gynecology. 2021; (3): 210-21 (in Russian)]. https://dx.doi.org/10.18565/aig.2021.3.210-221
Министерство здравоохранения Российской Федерации. Клинические рекомендации. Менопауза и климактерическое состояние у женщины. ID:117. https://cr.minzdrav.gov.ru/schema/637_1 [Ministry of Health of the Russian Federation. Clinical guidelines. Menopause and climacteric state in women. ID:117. https://cr.minzdrav.gov.ru/schema/637_1 (in Russian)].
ACOG. Management of menopausal symptoms (Practice Bulletin No. 141). 2014. Available at: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2014/01/management-of-menopausal-symptoms
Baber R.J., Panay N., Fenton A.; IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric. 2016; 19(2): 109-50. https://dx.doi.org/10.3109/13697137.2015.1129166
NICE. Menopause: identification and management (NICE Guideline NG23). Last updated: 07 November 2024. Available at: https://www.nice.org.uk/guidance/NG23
The Menopause Society (NAMS). The 2022 hormone therapy position statement of the Menopause Society. Available at: https://www.menopause.org/professional-resources/position-statements
FSRH. Statement on NICE Menopause Guideline 2015. Available at: https://www.fsrh.org/documents/ceu-statement-nice-menopause-guidelines-2015-november-2015/
FIGO. New FIGO position paper on how to address the benefits and risks of menopause hormone therapy published in IJGO. 2024. Available at: https://www.figo.org/news/new-figo-position-paper-how-address-benefits-and-risks-menopause-hormone-therapy-published
Сметник А.А., Иванов И.А., Урмакова Е.И., Табеева Г.И. Особенности использования МГТ в России: результаты масштабного опроса женщин в пери- и постменопаузе. Акушерство и гинекология. 2025; 8: 196-208. [Smetnik A.A., Ivanov I.A., Ermakova E.I., Tabeeva G.I. Characteristics of menopausal hormone therapy use in Russia: results of a large-scale survey of peri- and postmenopausal women. Obstetrics and Gynecology. 2025; (8): 196-208 (in Russian). https://dx.doi.org/10.18565/aig.2025.200
Юренева С.В. Менопаузальная гормональная терапия – индивидуализированный подход с позиции эффективности и безопасности: обзор международных рекомендаций. Акушерство и гинекология. 2024; 9: 36-46. [Yureneva S.V. Efficacy and safety of personalized menopausal hormone therapy: a review of international guidelines. Obstetrics and Gynecology. 2024; (9): 36-46 (in Russian)]. https://dx.doi.org/10.18565/aig.2024.224
Менопауза и МГТ в 2024 году: решение ключевых противоречий – проектный документ Международного общества по менопаузе. Доступно по: https://www.imsociety.org/wp-content/uploads/2024/10/Russian-Menopause-and-MHT-in-2024_final.pdf [Menopause and MHT in 2024: solving key contradictions - a project document of the International Menopause Society. Available at: https://www.imsociety.org/wp-content/uploads/2024/10/Russian-Menopause-and-MHT-in-2024_final.pdf (in Russian)].
Mead R. Menopause is having a moment. The New Yorker. March 3, 2025.
Liss J., Chesnokova A., Allen J.T. Unspoken and untaught: addressing the gap in menopause education. Curr. Obstet. Gynecol. Rep. 2024; 13: 281–288. https://dx.doi.org/10.1007/s13669-024-00404-y
Cano A., ed. Menopause: a comprehensive approach. Springer Nature; 2025.
Улумбекова Г.Э., Худова И.Ю. Оценка демографического, социального и экономического эффекта при приеме менопаузальной гормональной терапии. ОРГЗДРАВ: новости, мнения, обучение. Вестник ВШОУЗ. 2020. 6(4): 23-53. [Ulumbekova G.E., Khudova I.Yu. Demographic, social and economic effects of menopause hormonal therapy. Healthcare management: news, views, education. Bulletin of VSHOUZ. 2020; 6(4): 23-53 (in Russian)]. https://dx.doi.org/10.24411/2411-8621-2020-14002
Harlow S.D., Gass M., Hall J.E., Lobo R., Maki P., Rebar R.W. et al.; STRAW 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012; 19(4): 387-95. https://dx.doi.org/10.1097/gme.0b013e31824d8f40
Vitale S.G., Watrowski R., Barra F., D'Alterio M.N., Carugno J., Sathyapalan T. et al. Abnormal uterine bleeding in perimenopausal women: the role of hysteroscopy and its impact on quality of life and sexuality. Diagnostics (Basel). 2022; 12(5): 1176. https://dx.doi.org/10.3390/diagnostics12051176.
Verrilli L., Berga S.L. What every gynecologist should know about perimenopause. Clin. Obstet. Gynecol. 2020; 63(4): 720-34. https://dx.doi.org/10.1097/GRF.0000000000000578
Dreisler E., Frandsen C.S., Ulrich L. Perimenopausal abnormal uterine bleeding. Maturitas. 2024; 184: 107944. https://dx.doi.org/10.1016/j.maturitas.2024.107944
Tallova A.O., Martinez Aguilar R., Maybin J.A., Critchley H.O.D. Pre-clinical models to study abnormal uterine bleeding (AUB). EBioMedicine, 2022; 84: 104238. https://dx.doi.org/10.1016/j.ebiom.2022.104238
Thoprasert P., Phaliwong P., Smanchat B., Prommas S., Bhamarapravatana K., Suwannarurk K. Endometrial thickness measurement as predictor of endometrial hyperplasia and cancer in perimenopausal uterine bleeding: cross-sectional study. Asian Pac. J. Cancer Prev. 2023; 24(2): 693-9. https://dx.doi.org/10.31557/APJCP.2023.24.2.693
Tian Y., Bai B., Wang L., Zhou Z., Tang J. Contributing factors related to abnormal uterine bleeding in perimenopausal women: a case-control study. J. Health Popul. Nutr. 2024; 43(1): 52. https://dx.doi.org/10.1186/s41043-024-00540-4
Bassette E., Ducie J.A. Endometrial cancer in reproductive-aged females: etiology and pathogenesis. Biomedicines. 2024; 12(4): 886. https://dx.doi.org/10.3390/biomedicines12040886
Kitahara Y., Hiraike O., Ishikawa H., Kugu K., Takai Y., Yoshino O. et al. National survey of abnormal uterine bleeding according to the FIGO classification in Japan. J. Obstet. Gynaecol. Res. 2023; 49(1): 321-30. https://dx.doi.org/10.1111/jog.15464
Молотков А.С., Ярмолинская М.И., Цыпурдеева А.А. Оптимизация подходов в лечении пациенток с аномальными маточными кровотечениями. Акушерство и гинекология. 2024; 1: 140-52. [Molotkov A.S., Yarmolinskaya M.I., Tsypurdeeva A.A. Optimizing treatment approaches for patients with abnormal uterine bleeding. Obstetrics and Gynecology. 2024; (1): 140-52 (in Russian)]. https://dx.doi.org/10.18565/aig.2023.301
Министерство здравоохранения Российской Федерации. Клинические рекомендации. Аномальное маточное кровотечение. 2024. [Ministry of Health of the Russian Federation. Clinical guidelines. Abnormal uterine bleeding. 2024. (in Russian)].
Андреева Е.Н., Шереметьева Е.В., Прилепская В.Н. Национальные медицинские критерии приемлемости методов контрацепции 2023: фокус на сохранение репродуктивного здоровья женщин. Гинекология. 2023; 25(2): 124-32. [Andreeva E.N., Sheremetyeva E.V., Prilepskaya V.N. National medical eligibility criteria for contraceptive use 2023: focus on women's reproductive health: A review. Gynecology. 2023; 25(2): 124-32 (in Russian)]. https://dx.doi.org/10.26442/20795696.2023.2.202236
Jain V., Chodankar R.R., Maybin J.A., Critchley H.O.D. Uterine bleeding: how understanding endometrial physiology underpins menstrual health. Nat. Rev. Endocrinol. 2022; 18(5): 290-308. https://dx.doi.org/10.1038/s41574-021-00629-4.
Soontrapa N., Rattanachaiyanont M., Warnnissorn M., Wongwananuruk T., Indhavivadhana S., Tanmahasamut P. et al. The effectiveness of desogestrel for endometrial protection in women with abnormal uterine bleeding-ovulatory dysfunction: a non-inferiority randomized controlled trial. Sci. Rep. 2022; 12(1): 1662. https://dx.doi.org/10.1038/s41598-022-05578-0
Critchley H.O.D., Maybin J.A., Armstrong G.M., Williams A.R.W. Physiology of the endometrium and regulation of menstruation. Physiol. Rev. 2020; 100(3): 1149-79. https://dx.doi.org/10.1152/physrev.00031.2019
Дубровина С.О., Киревнина Л.В., Лесной М.Н. Аномальное маточное кровотечение: причины, диагностика и лечение. Акушерство и гинекология. 2021; 1: 170-7. [Dubrovina S.O., Kirevnina L.V., Lesnoy M.N. Abnormal uterine bleeding: causes, diagnosis, and treatment. Obstetrics and Gynecology. 2021; (1): 170-7 (in Russian)]. https://dx.doi.org/10.18565/aig.2021.1.170-177
Wang L., Guan H.Y., Xia H.X., Chen X.Y., Zhang W. Dydrogesterone treatment for menstrual-cycle regularization in abnormal uterine bleeding - ovulation dysfunction patients. World J. Clin. Cases. 2020; 8(15): 3259-66. https://dx.doi.org/10.12998/wjcc.v8.i15.3259
Lou Y.C., Zhou S., Liao J.B., Shao W.Y., Hu Y.Y., Ning C.C. et al. [Comparison of the effects and safety of dydrogesterone and medroxyprogesterone acetate on endometrial hyperplasia without atypia: a randomized controlled non-inferior phase III clinical study]. Zhonghua Fu Chan Ke Za Zhi. 2023; 58(7): 526-35. (in Chinese). https://dx.doi.org/10.3760/cma.j.cn112141-20230313-00118
Hamoda H.; BMS medical advisory council. British Menopause Society tools for clinicians: Progestogens and endometrial protection. Post Reprod. Health. 2022; 28(1): 40-6. https://dx.doi.org/10.1177/20533691211058030
Manley K., Hillard T., Clark J., Kumar G., Morrison J., Hamoda H. et al. Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time. Post Reprod. Health. 2024; 30(2): 95-116. https://dx.doi.org/10.1177/20533691241254413
Подзолкова Н.М., Подзолков В.И., Брагина А.Е. Современные возможности диагностики, лечения и профилактики возрастзависимых заболеваний у женщин. Менопаузальная гормональная терапия. Руководство для врачей. М.: ГЭОТАР-Медиа; 2025. 288 с. [Podzolkova N.M., Podzolkov V.I., Bragina A.E. Modern possibilities of diagnosis, treatment and prevention of age-related diseases in women. Menopausal hormone therapy. A guide for doctors. Moscow: GEOTAR-Media; 2025. 288 p. (in Russian)]. https://dx.doi.org/10.33029/9704-9411-0-2025-MGT-1-288
de Medeiros S.F., Yamamoto M.M., Barbosa J.S. Abnormal bleeding during menopause hormone therapy: insights for clinical management. Clin. Med. Insights Womens Health. 2013; 6: 13-24. https://dx.doi.org/10.4137/CMWH.S10483
Dave F.G., Adedipe T., Disu S., Laiyemo R. Unscheduled bleeding with hormone replacement therapy. The Obstetrician & Gynaecologist. 2019; 21(2): 95-101. https://dx.doi.org/10.1111/tog.12553
Schindler A.E. Pharmacology of progestogens. In: Carp H.J., eds. Progestogens in obstetrics and gynecology. Springer, Cham.; 2021. https://dx.doi.org/10.1007/978-3-030-52508-8_2
Armeni E., Lambrinoudaki I., Ceausu I., Depypere H., Mueck A., Pérez-López F.R. et al. Maintaining postreproductive health: A care pathway from the European Menopause and Andropause Society (EMAS). Maturitas. 2016; 89: 63-72. https://dx.doi.org/10.1016/j.maturitas.2016.04.013
Шляхто Е.В., Сухих Г.Т., Серов В.Н., Дедов И.И., Арутюнов Г.П., Сучков И.А. Российские критерии приемлемости назначения менопаузальной гормональной терапии пациенткам с сердечно-сосудистыми и метаболическими заболеваниями. Согласительный документ Российского кардиологического общества, Российского общества акушеров-гинекологов, Российской ассоциации эндокринологов, Евразийской ассоциации терапевтов, Ассоциации флебологов России. Акушерство и гинекология. 2023; 11: 211-32. [Shlyakhto E.V., Sukhikh G.T., Serov V.N., Dedov I.I., Arutyunov G.P., Suchkov I.A. Russian eligibility criteria for menopausal hormone therapy in patients with cardiovascular and metabolic diseases. Consensus document of the Russian Society of Cardiology, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Russian Phlebological Association. Obstetrics and Gynecology. 2023; (11): 211-32 (in Russian)]. https://dx.doi.org/10.18565/aig.2021.267
Tempfer C.B., Hilal Z., Kern P., Juhasz-Boess I., Rezniczek G.A. Menopausal hormone therapy and risk of endometrial cancer: A systematic review. Cancers (Basel). 2020; 12(8): 2195. https://dx.doi.org/10.3390/cancers12082195
Emons G., Steiner E., Vordermark D., Uleer C., Paradies K., Tempfer C. et al. Endometrial cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry Number 032/034-OL, September 2022). Part 1 with recommendations on the epidemiology, screening, diagnosis and hereditary factors of endometrial cancer, geriatric assessment and supply structures. Geburtshilfe Frauenheilkd. 2023; 83(8): 919-62. https://dx.doi.org/10.1055/a-2066-2051
Lindenfeld J., Jessup M. 'Drugs don't work in patients who don't take them' (C. Everett Koop, MD, US Surgeon General, 1985). Eur. J. Heart Fail. 2017; 19(11): 1412-3. https://dx.doi.org/10.1002/ejhf.920
Du Pasquier-Fediaevsky L., Tubiana-Rufi N. Discordance between physician and adolescent assessments of adherence to treatment: influence of HbA1c level. The PEDIAB Collaborative Group. Diabetes Care. 1999; 22(9):1445-9. https://dx.doi.org/10.2337/diacare.22.9.1445
Kisa A., Sabaté E., Nuño-Solinís R., Karkashian C. Adherence to long-term therapies. Evidence for action. WHO; 2003.
Gilbert J.R., Evans C.E., Haynes R.B., Tugwell P. Predicting compliance with a regimen of digoxin therapy in family practice. Can. Med. Assoc. J. 1980; 23(2): 119-22.
Asgary S., Karimi R., Momtaz S., Naseri R., Farzaei M.H. Effect of resveratrol on metabolic syndrome components: A systematic review and meta-analysis. Rev. Endocr. Metab. Disord. 2019; 20(2): 173-86. https://dx.doi.org/10.1007/s11154-019-09494-z
Chen L.R., Ko N.Y., Chen K.H. Isoflavone supplements for menopausal women: a systematic review. Nutrients. 2019; 11(11): 2649. https://dx.doi.org/10.3390/nu11112649
Crawford S.L., Jackson E.A., Churchill L., Lampe J.W., Leung K., Ockene J.K. Impact of dose, frequency of administration, and equol production on efficacy of isoflavones for menopausal hot flashes: a pilot randomized trial. Menopause. 2013; 20(9): 936-45. https://dx.doi.org/10.1097/GME.0b013e3182829413
Djapardy V., Panay N. Alternative and non-hormonal treatments to symptoms of menopause. Best Pract. Res. Clin. Obstet. Gynaecol. 2022; 81: 45-60. https://dx.doi.org/10.1016/j.bpobgyn.2021.09.012
Pickar J.H., Archer D.F., Goldstein S.R., Kagan R., Bernick B., Mirkin S. Uterine bleeding with hormone therapies in menopausal women: a systematic review. Climacteric. 2020; 23(6): 550-8. https://dx.doi.org/10.1080/13697137.2020.1806816
Ferenczy A., Gelfand M.M., van de Weijer P.H., Rioux J.E. Endometrial safety and bleeding patterns during a 2-year study of 1 or 2 mg 17 beta-estradiol combined with sequential 5-20 mg dydrogesterone. Climacteric. 2002; 5(1): 26-35.
Isaacson K. Office hysteroscopy: a valuable but under-utilized technique. Curr. Opin. Obstet. Gynecol. 2002; 14(4): 381-5. https://dx.doi.org/10.1097/00001703-200208000-00004
Preis K., Zielinska K., Swiatkowska-Freund M., Wydra D., Kobierski J. The role of elastography in the differential diagnosis of endometrial pathologies-preliminary report. Ginekol. Pol. 2011; 82(7): 494-7.
Dreisler E., Poulsen L.G., Antonsen S.L., Ceausu I., Depypere H., Erel C.T. et al.; European Menopause and Andropause Society. EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women. Maturitas. 2013; 75(2): 181-90. https://dx.doi.org/10.1016/j.maturitas.2013.03.011
Morrison J.M., Clark T.J. Ultrasound and blind endometrial sampling for detection of endometrial cancer in women with postmenopausal bleeding. Cochrane Database Syst. Rev. 2022; 2022(6):CD009457.
Timmermans A., Opmeer B.C., Khan K.S., Bachmann L.M., Epstein E., Clark T.J. et al. Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. Obstet. Gynecol. 2010; 116(1): 160-7. https://dx.doi.org/10.1097/AOG.0b013e3181e3e7e8
PDQ Screening and Prevention Editorial Board. Endometrial Cancer Screening (PDQ®): Health Professional Version. 2025 Apr 10. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002–.
Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021; 28(9): 973-97. https://dx.doi.org/10.1097/GME.0000000000001831
Abraham C. Proliferative endometrium in menopause: To treat or not to treat? Obstet. Gynecol. 2023; 141(2): 265-7. https://dx.doi.org/10.1097/AOG.0000000000005054
Furness S., Roberts H., Marjoribanks J., Lethaby A., Hickey M., Farquhar C. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database Syst. Rev. 2004, 3: CD000402. https://dx.doi.org/10.1002/14651858.CD000402.pub2
Stute P., Neulen J., Wildt L. The impact of micronized progesterone on the endometrium: a systematic review. Climacteric. 2016; 19(4): 316-28. https://dx.doi.org/10.1080/13697137.2016.1187123
Di Carlo C., Sammartino A., Di Spiezio Sardo A., Tommaselli G.A., Guida M., Mandato V.D. et al. Bleeding patterns during continuous estradiol with different sequential progestogens therapy. Menopause. 2005; 12(5): 520-5. https://dx.doi.org/10.1097/01.gme.0000178450.29377.c9
Mazur M., Kurman R.J. Diagnosis of endometrial biopsies and curettings: A practical approach. Springer Science & Business Media; 2005.
Xia E., Yu D. Diagnostic hysteroscopy. In: Xia E., eds. Practical manual of hysteroscopy. Springer, Singapore; 2022. https://dx.doi.org/10.1007/978-981-19-1332-7_8
Юренева С.В., Ильина Л.М. ЛНГ-ВМС в помощь врачу в наиболее сложный период репродуктивного старения женщин. Проблемырепродукции. 2016; 22(1): 79-86. [Yureneva S.V., Il'ina L.M. LNG-IUS for helping a doctor during the most difficult period of women’s reproductive aging. Russian Journal of Human Reproduction. 2016; 22(1): 79-86. (in Russian)]. https://dx.doi.org/10.17116/repro201622179-86
Инструкция по медицинскому применению лекарственного препарата Мирена - П N014834/01 от 29.01.2021. [Instructions for the medical use of the medicinal product Mirena - P N014834/01 dated 29.01.2021. (in Russian)].
Suhonen S.P., Allonen H.O., Lähteenmäki P. Sustained-release estradiol implants and a levonorgestrel-releasing intrauterine device in hormone replacement therapy. Am. J. Obstet. Gynecol. 1995; 172(2 Pt 1): 562-7. https://dx.doi.org/10.1016/0002-9378(95)90573-1
Chen L., Bao R., Tian X. Safety profile of levonorgestrel intrauterine system: Analysis of spontaneous reports submitted to FAERS. Heliyon. 2024; 10(17): e37112. https://dx.doi.org/10.1016/j.heliyon.2024.e37112
Depypere H.T., Hillard T., Erkkola R., Lukkari-Lax E., Kunz M., Rautiainen P. et al. A 60-month non-comparative study on bleeding profiles with the levonorgestrel intrauterine system from the late transition period to estrogen supplemented menopause. Eur. J. Obstet. Gynecol. Reprod. Biol. 2010; 153(2): 176-80. https://dx.doi.org/10.1016/j.ejogrb.2010.08.017
Sørdal T., Inki P., Draeby J., O'Flynn M., Schmelter T. Management of initial bleeding or spotting after levonorgestrel-releasing intrauterine system placement: a randomized controlled trial. Obstet. Gynecol. 2013; 121(5): 934-41. https://dx.doi.org/10.1097/AOG.0b013e31828c65d8
Madden T., Proehl S., Allsworth J.E., Secura G.M., Peipert J.F. Naproxen or estradiol for bleeding and spotting with the levonorgestrel intrauterine system: a randomized controlled trial. Am. J. Obstet. Gynecol. 2012; 206(2): 129.e1-129.e1298. https://dx.doi.org/10.1016/j.ajog.2011.09.021
Приказ Министерства здравоохранения Российской Федерации от 20.10.2020 № 1130н «Об утверждении Порядка оказания медицинской помощи по профилю "акушерство и гинекология" (зарегистрирован в Минюсте РФ 12.11.2020 № 60869). [Order of the Ministry of Health of the Russian Federation of 20.10.2020 No. 1130n "On approval of the Procedure for the provision of medical care in the field of obstetrics and gynecology" (registered with the Ministry of Justice of the Russian Federation 12.11.2020 No. 60869). (in Russian)].
World Cancer Research Fund. Endometrial cancer statistics. 2022. Available at: https://www.wcrf.org/preventing-cancer/cancer-statistics/endometrial-cancer-statistics/

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

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

Keywords

References

About the Authors

Similar Articles