Bleeding problems with HRT

• Perform vaginal and speculum examination and then refer as Urgent
• Sequential therapy - change in pattern of bleeding including increased duration, frequency and/or heaviness, and irregular bleeding.
• Continuous combined therapy or tibolone - if still bleeding after 6 months of therapy or if bleeding occurs later after a spell of no bleeding.
• Only use Urgent, suspicion of cancer, option if concerns on examination, eg suspicion of cervical cancer
• Incidence of endometrial cancer in patients with bleeding problems on HRT is extremely low, unless unopposed estrogen taken, or regimens with high dose estrogen and inadequate progestogen
• No need to advise stopping HRT prior to appointment, but OK to do so if patient wishes to stop

Most common reason for referral is unscheduled bleeding on continuous combined HRT. Bleeding problems can be reduced by

• When starting HRT, start with low dose and aim for lowest effective dose
• Consider oral continuous combined HRT if no VTE or cardiovascular risk factors, since chance of amenorrhoea is higher than with transdermal continuous combined HRT Postmenopause : Menopause Matters
• If transdermal continuous combined HRT indicated, offer off license half continuous combined patch, rather than medium dose (Evorel conti or Femseven conti) to offer low dose when possible Postmenopause : Menopause Matters
• If higher dose estrogen required (after giving any type of HRT at least 3 months to show effect, addressing other factors contributing to symptoms, eg diet and lifestyle, patch adherence..) increase progestogen proportionately
• Try to avoid the need for regimens taking estrogen and progestogen separately, since progestogen can be missed leading to higher chance of endometrial stimulation and hence bleeding. The need for separate progestogen is inevitable if using estrogen gel or spray, since these are estrogen only, but these should be a later option, not offered first line
• Uterine bleeding with hormone therapies in menopausal women: a systematic review. J H Pickar1 2, D F Archer 3, S R Goldstein et al. Climacteric 2020 Dec; 23(6):550-558