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[Panicked]

I have a diagnosis of Anxiety Disorder (many years ago and it got worse with time) and now I am in complete terror over a possible bad uterine diagnosis.
 
This past October I reached menopause officially (12 months since last menstrual period) and a month later I began HRT - 0.075 estradiol patches and 200 mg oral progesteron. I had very light spotting soon after starting the HRT but I assumed it must be related to that since I had zero spotting/bleeding the previous 13 months. I did report it to the dr and she said I should let them know if it happens again. It stopped soon and all was good until February 11 when I began to bleed.
I reported it and she called me in for an ultrasound.
The Endometrial thickness was 8.9 and the dr. said it's in the gray area (slightly thick for menopause) - so she decided for a biopsy. In the meantime, the bleeding seemed to have stopped altogether as I became diligent about taking the progesterone at the same time before bed.

However, the next day after I got the ultrasound result and the recommendation for biopsy I stopped the HRT cold turkey - and a few days later the bleeding started again. It's almost as if there is a pattern of bleeding when the estrogen gets skipped or stops. 

I had the biopsy today but it will take 1-2 weeks to get the results and this will be a nightmare wait with my anxiety disorder.

She said the chances for a bad result are below 10-15% and it is "probably" fine, but I wish she had been more emphatic. It still sounds terrifying to me.

I told her I may have inadvertently skipped a couple of progesterone pills here and there but she said this would probably not be enough to thicken the endometrium.
I also wonder if the estradiol dose she prescribed may have been too high. I mean, isn't it likely the endometrium would thicken on hormones?
Either way, she did not say anything about how being on HRT is likely to cause bleeding the first 6 months. Other than the very light spotting back in November right after starting (and which stopped right away), the bleeding happened in the 4th month since starting HRT.   
 
As far as personal sk factors, I do have some: I had rather short cycles for most of my reproductive life (22-23 days, sometimes 21), age at first period was only 3 weeks after turning 12,  I entered menopause at almost 51 (last period), and my BMI has fluctuated between barely normal and 27 all the way since my teen years. I was pregnant twice and had two children, whom I breastfed for about 1 year each or a bit less. That was my break from estrogen. Otherwise, I was never on birth control pills.

I would appreciate any words of reassurance as I have moments of complete panic.   
   
Thank you so much.

[CLKD]

....... and breath.  Some GPs panic and insist that women stop HRT, however, it probably isn't necessary.  The idea is to get a scan of the womb so that there is a base line from which to work.

Bleeding is normal if replacement is removed from the system.  Messy if you've been without for over 12 months 

Medics are often less than empathetic as they are giving out these types of info every day.  Many times I had to speak with patients after the Consultant with whom I worked, taking shorthand notes; because he hadn't been clear enough  .  a) I knew what he was talking about and b) they could ask questions from me rather than The Big Man 

What triggers your anxiety disorder and R U on any medication?  My 1st panic attack was at age 3 and I've had various meds since the 1980s to ease symptoms.  As well as what is the worst that could happen?

You've done nothing 'wrong', your situation is usual for many when replacement is introduced to the body.  MayB keeping a mood/food/symptom diary may be useful for a few months to chart progress.

[bombsh3ll]

Please do not make yourself ill worrying about this.

It is incredibly unlikely to be endometrial cancer.

Hormone therapy can lead to endometrial thickening if the progestogen is not sufficient to oppose the particular level of estrogen in that individual.

And of course you will bleed if you stop the treatment - that's called withdrawal bleeding.

Whilst this does need to be investigated, this is very common on hormone therapy, especially when micronised progesterone is used, which is the least potent of all available progestogens and doesn't do a brilliant job at inducing a quiet endometrium in all women.

IF there was any sign of atypical cells, it will have been caught at a very early stage with the biopsy.

Early hyperplasia can even be treated with a mirena IUS, which is what they are likely to suggest even with a clear result.

This can be a great option but if it's not for you there are multiple oral progestins that can be used.

[Panicked]

Thank you kindly, CLKD and bombsh3ll, for the time you took to reply.

"Incredibly unlikely" is what I was desperately looking for as I ravaged the Internet looking for peer-reviewed medical articles (I have a PhD in a social science, so unfortunately I can read those, understand them pretty well, and make myself sick in the process).
With my specific symptoms (PMB a few months after official menopause, endometrial thickness 8.9) and personal risk factors (52 yo, a bit overweight, BMI 26-28 cycling since teen years, irregular periods during perimenopause ... which came further and further apart, until I had only about 4 the last year) - the risk seems to be at about 10-15% - unless UNLESS the coincidence with HRT means something, which should make it much lower - but my dr. didn't think much about that. She is an OBGYN, not a GP. 
 
She said 'less than 10-15%' where I had hoped for "incredibly unlikely" from her too. Maybe she wants to cover her bases and go by the official 

I also read that while bleeding within the first 6 months of HRT is common, if a period of no bleeding had already been established, then it can be more worrisome. I was bleed-free from late November to February 11 (the first 2-3 months of HRT after the initial very light spotting)...so I am not sure what this means.
The only HRT-related explanation might be that missing some progesterone pills may have triggered the bleeding. But she said this is unlikely to have caused the thickening. And if it's HRT related, what exactly may have caused it? Maye the bleeding - but can the HRT cause the endometrium to thicken from a normal of 3-4 for menopause to 8.9 in 3 months or so?
 
Could it be too much estrogen in those patches (0.075 patch dose) - especially made unopposed by a few days of missed progesterone? 

Sometimes I fear the thicker endometrium may have been there before the HRT and then I wonder what this could mean.
I was also told in the past at an OB visit (when I saw them for some irregular bleeding when I still had my periods) that my uterus was slightly enlarged but they didn't seem to be worried.

 The endometrial thickness of 8.9 frightens me more than the bleeding itself - and I am not sure what to think of it. I understood that sometimes this can be called proliferative endometrium - it just gets thucker than on other women because of extra estrogen - and Lord knows I've had more than the average woman over the years.

I wonder what e-thickness most cancerous biopsies have?

Thank you for any specific insights you might have around these questions.

[bombsh3ll]

I don't have the specific reference to hand but read recently that less than 1% of endometrial biopsies in postmenopausal women on hormone therapy being investigated for bleeding were cancerous.

This particular article did not reference any specific endometrial thickness.

Guidelines that have been relied on for years that postmenopausal endometrial thickness should be 4mm or less are based on women not using HRT. These women can be expected to have a thin atrophic lining.

No normative values have been established for those on treatment, however experts have postulated values up to 11mm for those taking hormone therapy.

It is much less worrying that this is occurring in the context of hormone therapy.

[Panicked]

Thank you bombsh3ll!

I read this study too - it's one of those I am trying to hang on to until I get the results. They say only 1 in 200 biopsies of women on HRT turn out cancerous. What's difficult is that my dr doesn't seem so convinced the HRT would necessarily be the culprit. I also had established a no bleed period of almost three months when the bleed began on Feb 11 - and I read this too can be a cause for concern.

Do you know of other people who started bleeding during the first 6 months of HRT but after some established time of no bleeding?

'On the other hand, I went back to examine my Progesteron compliance since starting in November and it looks like I may have skipped anywhere between 5-10 pills from my first 90 pill bottle (prescribed to last three months). I would go to bed later and just forget to take one, though I am not sure if I ever skipped two in a row.  I wonder if these skipped pills altogether might have triggered the break-through bleeding due to not enough opposing progesterone overall.

I am also thinking that if she had done an ultrasound on my annual last March, before I started the HRT, and assuming the thickening of 8.9 would have veen found then incidentally as a pre-existing condition, this would have made me asymptomatic since I had no complaints at the time.
This too would have come with very low odds even at with an 8-11 acceptable cut off point for ET. Throw in the PMB, and it's a different story. The question is what caused it?

She ordered the ultrasound when I reported the bleeding this February - so all the worry started after I began the HRT in Nov.
Two weeks after starting I had experienced some very light bleeding which I reported, but she was not concerned and told me to let them know if it happens again.

And yet it seems so difficult to believe the HRT had nothing to do with the thickening and the bleeding.

The dr. reassured me but when I asked her about problematic odds, she said "less than 10-15%," which still sounds very high to my ears.
After the ultrasound, her reply to some questions I sent on the portal was:

"Not to worry - we will get it all worked out!  You can continue your HRT until our appointment or stop if you would rather.  This is nothing to fear just something that we need to work through. Here is a great website to review but please don't stress - we will get it all worked out and most of the time this is nothing bad!"

https://www.acog.org/womens-health/faqs/perimenopausal-bleeding-and-bleeding-after-menopause

Other drs I talked to over the phone said the odds are even lower because she is giving me the official range without controls for age, and in early 50's it's still on the young side, they said, and mostly uncommon.
 

Now I live in constant fear because my mind grips on the bad odds instead of focusing on the good ones.
Health anxiety has terrorized me through my 30's and 40's when I had various scares whose odds were an absolute joke compared to this one now.

So I am hoping the HRT-related odds (1/200) still apply, even with a period of established no bleeding within the first 6 months.

I quit HRT cold turkey as soon as I heard the ultrasound findings and that triggered bleeding again 4 days later. Now I seem to be at the tail end of it and it's almost going away, but I have been off HRT for soon to be a week.

I don't experience any symptoms for quitting - except the terror from this US/biopsy scare. 

I am concerned I will panic too badly when I get the results.
     
 

[Panicked]

For others who might be in a similar situation in the future and Googling desperately like I did, just reporting results were benign. No hyperplasia either.

[CLKD]

.... and breath. And keep off GOOGLE?

What's the next step?

[Panicked]

I have an appointment with my Gyno to decide whether I should stay on HRT or not. I still would like to see that endometrium thickness go down, so probably she will prescribe some progesterone.

[bombsh3ll]

You would probably be best with a synthetic progestin, which have a much more potent endometrial effect.

In fact most/all of the data about women on combined HRT having lower risk of endometrial cancer dates from before the use of micronised progesterone when synthetic progestins were universally used.

The mirena IUS is a really good option for bleeding and endometrial thickness. It is probably what your gynaecologist will suggest.

If this is unsuitable for you there are multiple oral synthetic progestins that you could take alongside transdermal estrogen.