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How do you manage unscheduled bleeding on HRT?
Unscheduled bleeding is common for women who take hormone replacement therapy (HRT) for the menopause. But new guidance suggests dose changes may be needed for those experiencing unscheduled bleeding, or on a high dose of oestrogen. Here, I outline the new guidance, and explain what unscheduled bleeding is and how to manage it.
British Menopause Society guidance
New guidance has been released by the British Menopause Society. It covers the use of HRT for menopause symptoms. The guidance, outlined below, applies to anyone taking combined HRT. It also applies to those with unscheduled (unexpected) bleeding on HRT.
- If you take a high dose of oestrogen (100 mcg patch or 4 pumps of Oestrogel, for example), you should take a higher dose of micronised progesterone (Utrogestan) than previously recommended.
- This change in dose applies however you take progesterone (orally or vaginally).
- It’s important to get the balance of oestrogen and progesterone right. If you have a womb (uterus), the progesterone protects against cancer of the lining of the womb (endometrial cancer). It also reduces unscheduled bleeding.
If this affects you, it’s a good idea to discuss this with a GP at your next HRT review appointment.
What is unscheduled bleeding on HRT?
Unscheduled bleeding is often a normal part of the adjustment period when starting HRT. There are different doses, regimens (HRT plans), and types of HRT available. A GP will discuss what the best method is for you.
If you have a womb, it’s recommended you take combined HRT, where you take progesterone and oestrogen.
Some women will take monthly cyclical (also known as sequential) HRT. This is where you have a scheduled period-like bleed every month. With other regimens of combined HRT, such as continuous combined HRT, you won’t have a scheduled bleed.
Unscheduled bleeding is when you have:
- unexpected bleeding after starting HRT that doesn’t have a scheduled bleed
- unexpected bleeding after changing a dose or type of HRT that doesn’t have a scheduled bleed
- unexpected bleeding outside of your scheduled bleed, if taking HRT where you have a scheduled bleed
It’s common to have unscheduled bleeding within the first 6 months of starting HRT for the first time. Or within three months of changing your dose or type if you’re already taking HRT.
How do I manage bleeding on HRT?
To manage your unscheduled bleeding, a GP may suggest a change in your HRT dose or type.
For example, if you’re on a high dose of oestrogen, it’s likely you’ll need to increase your dose of progesterone. Balancing the dose of each hormone will help to reduce unscheduled bleeding and protect you against the risk of endometrial cancer.
Unscheduled bleeding could be a sign of endometrial cancer or another issue if:
- you have unscheduled bleeding for over 3 months after changing HRT. Or if the unscheduled bleeding starts after this time
- you have unscheduled bleeding for over 6 months after starting HRT
So, it’s important to book an appointment with a health care provider if your bleeding lasts longer than expected.
What are the risk factors for endometrial cancer?
Your risk of endometrial cancer may increase if:
- you have a body mass index (BMI) of 40 or above
- Lynch or Cowden syndrome runs in your family
- you have a womb, and you’ve used oestrogen-only HRT for more than 6 months
- you don’t get regular periods, such as with polycystic ovary syndrome
- you have diabetes
Your risk may also increase depending on the specific type or regimen of HRT you take. If you’re unsure, ask a GP for advice.
When should I seek medical advice for bleeding on HRT?
If you have unscheduled bleeding for longer than expected, it’s important to book an appointment with a GP.
Unscheduled bleeding can sometimes indicate endometrial cancer. But it could also be a sign of other issues, such as sexually transmitted infections or vaginal atrophy (thinning of the vaginal walls).
The GP will ask you questions about your bleeding pattern and how you use HRT, for example. They may also ask to examine you.
If you have risk factors for endometrial cancer, the GP may recommend that you have more investigations, such as an ultrasound. They should explain to you which types are available, and their risks and benefits.
For most women on combined HRT, the risk of endometrial cancer is small. But if there is cancer, it’s important to catch it early. Over 9 in 10 women will survive their cancer for 5 years or more if it's found at its earliest stage.
So, if you’ve been having unscheduled bleeding on HRT – book an appointment today. A GP can help to manage your bleeding and check that everything’s okay.
If you’re experiencing menopause symptoms, you don’t have to face them alone. With a Bupa Menopause Plan, you can discuss symptoms with a specially trained GP, get a personalised care plan based around your needs with access to 24/7 support via Anytime HealthLine.
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Sources Sources
- Progestogens and endometrial protection. British Menopause Society. thebms.org.uk, published October 2021
- Management of unscheduled bleeding on hormone replacement therapy (HRT). British Menopause Society. BMS Guideline. thebms.org.uk, published April 2024
- HRT – types, doses and regimens. British Menopause Society. thebms.org.uk, published September 2021
- Survival for womb cancer. Cancer Research UK. cancerresearchuk.org, last reviewed March 2024
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