Unscheduled Bleeding While Using Hormone Replacement Therapy (HRT): Causes, When to Seek Help, and how to stop

Unscheduled bleeding is a common concern for women using hormone replacement therapy (HRT), particularly during the initial months of treatment. While it can be unsettling, understanding the causes, when to seek help, and how to manage it can provide reassurance and improve your experience with HRT.

Unscheduled bleeding on HRT - how to manage

What Is Unscheduled Bleeding?

Unscheduled bleeding refers to any bleeding or spotting that occurs outside of the expected pattern for women on HRT. The pattern of bleeding often depends on the type of HRT prescribed:

• Sequential HRT: Involves monthly bleeding resembling a light period, expected at the end of the progestogen phase.

• Continuous Combined HRT: Typically results in no bleeding after the first few months, as the regimen is designed for postmenopausal women to achieve an absence of periods.

• Oestrogen-Only HRT: Prescribed for women without a uterus, where any bleeding is unexpected.

  
  

Causes of Unscheduled Bleeding

Unscheduled bleeding can occur for various reasons, some of which are benign and temporary, while others may warrant further investigation:

1. Adjustment to HRT:

   • In the first 3–4 months of starting or changing HRT, irregular bleeding is common as your body adjusts to the hormonal fluctuations.

     
     

2. Incorrect HRT Regimen:

   • Using an HRT formulation unsuited to your stage of menopause can lead to irregular bleeding. For instance, continuous combined HRT may cause bleeding in women who are not yet fully postmenopausal.

     
     

3. Hormonal Imbalance:

   • Insufficient progestogen or fluctuating oestrogen levels can affect the stability of the uterine lining, leading to irregular bleeding.

     
     

4. Breakthrough Bleeding:

   • Occurs when the uterine lining sheds unpredictably due to inconsistent hormone levels or absorption.

     
     

5. Uterine or Vaginal Causes:

   • Polyps, fibroids, or atrophic vaginitis (thinning of vaginal tissue) can lead to bleeding.

     
     

6. Underlying Conditions:

   • Rarely, bleeding may indicate endometrial hyperplasia (thickening of the uterine lining) or endometrial cancer.

     
     

When to Seek Medical Help

While most cases of unscheduled bleeding are benign, there are certain situations where medical investigation is necessary:

• Prolonged or Heavy Bleeding: Bleeding that persists beyond 6 months after starting HRT or is heavier than your normal periods.

  
  

• Postmenopausal Bleeding: Any bleeding occurring after more than 12 months of no periods before starting HRT.

  
  

• Recurrent Bleeding After Stabilisation: If bleeding resumes after an initial adjustment period.

  
  

• Associated Symptoms: Pelvic pain, bloating, or an unusual discharge alongside bleeding.

  
  

We may recommend investigations such as an ultrasound scan or an endometrial biopsy to rule out underlying conditions.

How to Remedy Unscheduled Bleeding

1. Adjust Your HRT Regimen:

   • WE may adjust the type, dose, or route of HRT. For instance, increasing the progestogen dose or switching to a different transdermal (patch, gel, or spray) formulation.

     
     

2. Optimise Progestogen Protection:

   • Ensuring adequate progestogen levels can help stabilise the uterine lining. There are different types of progesterone and progestogens and some are more effective at protecting the endometrium and stopping irregular bleeding. You may a dose adjustment of your current treatment.

     
     

3. Address Absorption Issues:

   • For women using transdermal HRT, absorption may vary. Switching between gels, sprays, or patches might improve hormone stability.

     
     

4. Treat Vaginal Atrophy:

   • Vaginal oestrogen creams, pessaries, or rings can improve local tissue health, reducing bleeding due to atrophic changes.

     
     

5. Investigate Structural Causes:

   • Conditions such as fibroids or polyps may require treatment, ranging from monitoring to surgical removal.

     
     

Summary of unscheduled bleeding when using HRT

Unscheduled bleeding can be a normal part of the adjustment process with HRT, particularly in the early months. By working closely with your healthcare provider, your treatment can be tailored to minimise these side effects while maximising the benefits of symptom relief and long-term health protection.

If you are concerned about bleeding while using HRT, don’t hesitate to seek professional advice. Prompt evaluation and adjustment of your therapy can ensure that your journey through menopause is as smooth and comfortable as possible.

This article is based on the latest British Menopause Society guidelines and supports the importance of individualised HRT care to ensure optimal outcomes.

We can help you adjust your HRT to control your unscheduled bleeding.

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