In short
Overview
Bleeding on HRT is common in the first months and harmless in most women, but some patterns need a check of the womb lining. This page shows which.
Direct Answer
Bleeding on HRT is expected with cyclic regimens and common in the first 6 months of continuous regimens. Monthly withdrawal bleeds occur in 80 to 90 percent of women on cyclic HRT, 8 to 9 in 10.
Bleeding that continues beyond 6 months of continuous HRT, becomes heavier, or starts after a bleed-free period leads to an assessment of the womb lining, according to clinical guidance and the British Menopause Society (BMS guideline).
Who This Applies To
- Women on HRT with bleeding outside the expected pattern.
- Women unsure whether their regimen is cyclic or continuous.
- Women with bleeding after months without any.
- Women using vaginal oestrogen only who notice bleeding.
Option Comparison / Decision Criteria
Which bleeding on HRT is expected?
Expected bleeding on HRT depends on the regimen. The table sets out the patterns.
| Pattern | What it means |
|---|---|
| Monthly bleed on cyclic HRT | Expected withdrawal bleed |
| Irregular spotting in the first 6 months of continuous HRT | Common, usually settles |
| Bleeding beyond 6 months of continuous HRT | Assessment of the womb lining |
| Heavier bleeding or bleeding after a bleed-free period | Assessment of the womb lining |
| Any bleeding on vaginal oestrogen alone | Assessment |
Why an In-Person Physician Review Matters
What does a review of bleeding on HRT involve?
A review of bleeding on HRT checks the regimen, missed doses and the bleeding diary, then decides on an examination and a test of the womb lining. A persistent bleed leads to an endometrial biopsy, a small sample of the lining, even when an ultrasound looks normal. Dr Felix works with a gynaecologist for the biopsy.
Frequently Asked Questions
Yes, irregular bleeding is common in the first 6 months of continuous HRT, and monthly bleeds are expected on cyclic HRT.
Bleeding beyond 6 months of continuous HRT, heavier bleeding, or bleeding after a bleed-free period leads to an assessment.
No, a change follows a review of the whole regimen and the bleeding pattern.
No, persistent bleeding leads to a biopsy of the womb lining whatever the ultrasound shows.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
- Management of unscheduled bleeding on hormone replacement therapy (HRT)
- Menopause: identification and management (NG23)
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.