Unscheduled bleeding on HRT (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP
  • Primary & Secondary Care 
  • Adults only 

Introduction

Unscheduled bleeding is a common problem, affecting up to 38% of people using sequential hormone replacement therapy (HRT) and 41% using continuous combined HRT. It is a major factor leading to repeat consultations and cessation of HRT.

Unscheduled bleeding is defined as irregular bleeding that occurs more than six months after either initiating HRT or, changing the preparation or dose in women established on HRT.

When women present with unscheduled bleeding on HRT, assessment starts with a comprehensive, clinical assessment comprising of a thorough patient history; assessment for individual risk factors for cancer; abdominal & pelvic examination, including speculum examination.

Endometrial Cancer: major and minor risk factors

Major Risk Factors

Minor Risk Factors 

BMI ≥ 40

BMI 30 to 39

Genetic predisposition to endometrial cancer (eg, Lynch or Cowden syndrome)

Unopposed oestrogen for more than 3 months but less than 6 months, including expired 52mg LNG-IUD

Oestrogen-only HRT for more than 6 months in women with a uterus, including expired 52mg LNG-IUD

Oestrogen dose where the progestogen dose is not in proportion for more than 6 months but less than 12 months

Tricycling HRT (quarterly progestogen course) for more than 6 months

Prior or current history of anovulatory cycles, such as polycystic ovarian syndrome

Prolonged sHRT regimes: use for more than 5 years in women aged >50

Diabetes, Liver disease, Hypertension (each considered individual minor factors)

Reduced length of progestogen per month as part of sHRT (<10days for NET/MPA or <12 days for Utrogestan) for >6 months

Age >55
Oestrogen dose where the progestogen is not in proportion for >12 months

 

Abbreviations

Abbreviation  Meaning 
BMI  body mass index
ccHRT  continuous HRT
ET  endometrial thickness
HRT  hormone Replacement Therapy
LNG-IUD  levenogestrel Intrauterine device
MPA  medroxyprogesterone actetate
NET  norethisterone
sHRT  sequential HRT

Further information for Health Care Professionals

Editorial Information

Last reviewed: 11/04/2024

Next review date: 27/06/2024

Author(s): Sexual Health Department .

Version: 1

Approved By: Awaiting approval

Reviewer name(s): Hame Lata, Consultant .

Document Id: TAM630

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Further information for Healthcare Professionals