Breakthrough Bleeding on HRT
Why does bleeding happen on HRT?
- Irregular bleeding is common during the first 3–6 months after starting HRT
- Bleeding may also occur when changing the type or dose of HRT
- Some HRT preparations are designed to cause a predictable, cyclical bleed, which is expected and normal
For the majority of women, there is no underlying serious cause.
When should bleeding be checked?
You should seek medical advice if:
- Bleeding persists beyond 6 months
- Bleeding becomes heavy or unpredictable
- Bleeding starts after a period of no bleeding on continuous HRT
Your GP or healthcare practitioner may recommend:
- A pelvic ultrasound scan
- Further investigations such as an endometrial biopsy, if needed
It is also important to:
- Remain up to date with cervical screening
- Have a clinical examination where appropriate
In some cases, if the lining of the uterus appears thickened, a hysteroscopy may be recommended to identify the cause of bleeding.
How is breakthrough bleeding managed?
In most women, bleeding can be managed by adjusting HRT, including:
- Altering the dose
- Changing the route of administration (tablet, patch, gel, etc.)
Some women may notice an improvement by:
- Increasing the progesterone dose
- Reducing the oestrogen dose
Progesterone can also be delivered via a hormonal intrauterine system (Mirena® coil), which is often associated with less bleeding and provides effective endometrial protection.
Choosing the right type of HRT
During the early stages of menopause, sequential (cyclical) HRT is often recommended. This produces a regular, predictable bleed.
Later, switching to continuous combined HRT can help avoid irregular bleeding patterns and is usually better tolerated once menopause is established.