Menopause is a time of change and for many women, Hormone replacement therapy (HRT) can be a game-changer in terms of managing their menopausal symptoms. However, for some, unexpected bleeding can be a real nuisance.
If you’re on HRT and experiencing bleeding, even after being told that ‘there’s nothing wrong’, it’s completely natural to feel concerned or even frustrated. Let’s take a closer look at what might be going on, and how I can help.
Is it normal to bleed on HRT?
Bleeding patterns can feel chaotic during menopause. In perimenopause—the years leading up to menopause—it’s not unusual for periods to become unpredictable. They might be heavier or lighter, come more frequently, or disappear for months only to return unexpectedly. It’s a confusing time, but these fluctuations are often linked to your hormones misbehaving.
Oestrogen levels can surge unpredictably in perimenopause, sometimes without enough progesterone to balance things out. This imbalance can lead to heavier, more frequent bleeding. Later on, as oestrogen levels drop, periods often become lighter and less regular before stopping altogether.
Once you’ve gone 12 months without a period, you’re ‘officially menopausal’, and any bleeding after that is considered abnormal. If you’re taking HRT, however, the story becomes a little more complicated.
How does HRT affect bleeding?
HRT works wonders for many women, but it can also cause unexpected bleeding. Whether you’re on a cyclical regime (designed for those still in perimenopause) or a continuous combined regime (more common for postmenopausal women), there’s always the possibility of spotting or bleeding—especially in the first few months.
For women on cyclical HRT, which mimics a monthly cycle, the aim is to have a predictable withdrawal bleed each month. But sometimes, bleeding doesn’t behave as expected—it might arrive early, late, or not at all. If you’re postmenopausal and taking continuous combined HRT, any bleeding at all can feel unsettling because this regime isn’t designed to cause a withdrawal bleed. However, irregular bleeding is still common, particularly during the transition from a cyclical to a continuous regime.
Changes in your HRT, such as an increased oestrogen dose or a switch in progesterone type, can also disrupt things. Life’s stresses, illnesses, or even a missed HRT dose can contribute to unexpected bleeding, but that doesn’t mean it should be ignored.
Should I be concerned if I’m bleeding whilst on HRT?
Bleeding on HRT often has a straightforward explanation. It could simply be your body adjusting to the hormones, particularly if you’ve only recently started or made changes to your HRT. This settling-in period can last three to six months, which it’s why it’s very important to have regular review appointments during this time.
But bleeding can also be a sign of something more concerning. Fibroids or polyps, which are generally non-cancerous growths, might be to blame. Sometimes, the lining of the womb (the endometrium) can become too thick, a condition called endometrial hyperplasia.
In rarer cases, postmenopausal bleeding may be caused by endometrial or cervical cancer. It’s important to remember that these causes are uncommon, but any unexpected bleeding should be checked out to rule them out.
What should I do if I’m unexpectedly bleeding whilst taking HRT?
If you’ve just started HRT, or recently changed your regime, some spotting or light bleeding is very normal in the first few weeks.
If the bleeding is heavy, persistent, or has started after six months of stable HRT use, it must be investigated. You will likely need a pelvic examination (and examination to look at the cervix) and an ultrasound to check the thickness of your womb lining or look for fibroids or polyps. Depending on the findings, you might be referred for a hysteroscopy—a procedure where a tiny camera is used to examine the inside of your womb and biopsies taken to rule out anything more serious.
It’s also a good idea to keep a record of your bleeding. Note when it happens, how heavy it is, and whether it’s accompanied by any other symptoms like pain or discomfort.
Should I stop taking progesterone if I’m bleeding on HRT?
This is a definite ‘No’. If you still have a womb, it’s really important that you don’t stop your prescribed progesterone medication, because it can put you at risk of endometrial cancer. Book an appointment, and let’s discuss it.
Can bleeding be managed without stopping HRT?
Many women come to see me because they have been started on HRT, experienced bleeding, have undergone a hysteroscopy – which found nothing concerning, but they were discharged from their gynae service but with no advice about what to do next.
Bleeding and spotting whilst on HRT can be really frustrating, and for most women, the thought of stopping HRT can be distressing, especially if it’s been helping managing hot flushes, low mood, and poor sleep. Thankfully, there are usually ways to adjust your HRT to reduce or stop the bleeding without abandoning it altogether.
Sometimes, tweaking the oestrogen or progesterone dose, switching the type of progesterone, or swapping from an oral regime to a transdermal one, is enough to make a difference. For some women, a Mirena coil can be an excellent option. This small device is placed in the womb and releases progesterone directly into the womb, helping to prevent bleeding while also serving as contraception if needed. It’s particularly effective for those who’ve struggled with bleeding on other HRT regimes.
Finding the right balance of hormones can take time and expert advice, which is where I come in.
If you’re experiencing bleeding and don’t know what to do next, don’t hesitate to book an appointment. Together, we can explore your options, investigate any potential causes, and find a solution that works for you.
If you’re struggling with bleeding whilst taking HRT, book an appointment today.
