Experiencing unexpected bleeding or changes in your bleeding whilst taking HRT is a very common occurrence. Your first thought might be that your HRT is at fault. That could be the case, or there could be an underlying condition that needs attention. Bleeding is always a sign to take seriously. So it's a good idea to let your doctor know, even if it seems minor.
That being said, bleeding while taking HRT is common and often not a cause for concern. In fact, up to 60% of women using HRT1 experience this no matter the type you’re using, so you’re not alone. It may help to understand more about when bleeding on HRT is considered normal and when it’s time to seek advice.
The focus here is on vaginal bleeding. If you notice blood in your urine or stool, it’s best to consult your doctor.
Is vaginal bleeding common on HRT?
The short answer is yes.
Most of the time, bleeding happens because the additional oestrogen from HRT stimulates the lining inside the uterus—the same lining that is shed during menstruation2. Bleeding can also happen when the dose of progesterone doesn’t adequately support the amount of oestrogen needed to manage symptoms. What constitutes a balanced dosage is highly individual, which is why it’s essential to keep an open dialogue with your doctor. If you need some initial guidance on HRT side effects, our menopause specialists are here to help.
The type and pattern of bleeding depend on several factors, such as the kind of HRT you’re using, your individual response to hormones, and other health considerations.
Sequential HRT involves taking oestrogen continuously and adding progestogen for part of the cycle, which triggers a shedding of the uterine lining, similar to a menstrual period3. 85% of women using this type of HRT experience this monthly withdrawal bleeding4 If you miss bleeds when on a sequential regime this shouldn’t cause concern and may signal that you are moving closer towards your menopause
If you’re on continuous combined HRT bleeding during the first few months of getting started is considered a normal side effect and should slowly settle down. Keeping a note of any bleeding can be helpful to report back to your doctor at your first review appointment. Continuous combined HRT involves adding progestogen alongside oestrogen continuously. For women who still have their uterus it is important that progestogen is given to counter oestrogen’s usual effects on the uterine lining, so there’s less bleeding over time and no increased risk of developing an overgrowth of the lining of the uterus. About 80% of people using this form of HRT report bleeding in the first month, no matter if taken orally or as transdermal methods (patches, gel or spray)5, 6. However, this number drops to 50% after 3 months of use and less than 10% after a year4. This goes to show how important it is to consider how long you’ve been on HRT and perhaps give your body time to adjust.
Does that mean HRT isn’t for me?
Not necessarily. Despite bleeding inconveniences, HRT offers significant long-term health benefits, such as supporting heart and bone health as well as improving menopausal symptoms. In order to continue HRT with less bleeding, your doctor might adjust things like the dosage. If you’re feeling overwhelmed, you can reach out to one of our menopause experts for personalised support.
Should I stop HRT if I have bleeding?
It’s tempting to stop altogether as bleeding unexpectedly can be upsetting. It’s best not to stop HRT abruptly without consulting your doctor, as bleeding may not be directly related to HRT. Stopping HRT too suddenly and without consulting can complicate the diagnosis or even the situation.
Is there any form of HRT that avoids bleeding?
Adding an intrauterine device (such as the Mirena coil) to an oestrogen-only regimen seems to reduce or eliminate bleeding. Your doctor will help you find an option that best suits your needs.
The different types of bleeding on HRT
You might experience two types of vaginal bleeding while on HRT:
- Scheduled bleeding: This type of bleeding occurs on a predictable schedule, usually if you are using sequential HRT; which is often recommended during the perimenopause when your body is still having periods and if you are still within a year of your last period. This bleeding tends to be lighter than a typical menstrual period, although not always the case, and is known as a withdrawal bleed.1.
- Unscheduled bleeding or breakthrough bleeding: (can also be referred to as “spotting”). This means any bleeding that happens outside your regular pattern and doesn’t need menstrual products. It’s pretty common during the first few months of starting HRT, no matter which type you’re using. While it can feel like a little surprise that catches you off guard, it’s usually nothing to worry about.
If you’re experiencing sudden bleeding after a long period of no bleeding, outside the typical scheduled bleeding phase, or seeing heavier-than-usual bleeding or passing clots, you should be discussed with your healthcare provider as soon as possible. For a first direction you can book a consultation with our Menopause Care team.
What should I do in case of irregular bleeding on HRT?
Monitor the bleeding and discuss it with your doctor. The key things to track are frequency of bleeding episodes, any potential triggers like intercourse, any associated symptoms such as pain, fever, or changes in bladder or bowel functions2. If the bleeding persists beyond the adjustment period or shows any concerning patterns, bring these observations to your doctor’s attention.
Possible causes of bleeding on HRT
Before diving into the possible reasons for vaginal bleeding, it’s worth first asking yourself: Am I sticking to my HRT regimen? Missing doses, particularly of progesterone, can sometimes lead to bleeding.
Assuming you’ve been following your routine and have been on HRT for more than six months, several reasons could explain why you're experiencing bleeding, ranging from common adjustments to more serious conditions. These issues are often linked to either a lack or an excess of oestrogen in the body, or a need for an adjustment to the progesterone. For some of these conditions, your doctor may refer you for tests, such as a transvaginal ultrasound (using a wand inserted into the vagina) to evaluate aspects like the thickness of the uterus lining or the size of any tissue growths.
- Thinning of the uterine lining (Atrophic Endometrium), a natural change during menopause which happens when the uterine lining becomes very thin due to a lack of oestrogen8.
- Cervical or uterine polyps: Tissue growths, which is mostly benign, that typically develop in the uterine lining or around the cervix, potentially causing irregular bleeding.
- Fibroids: These are another type of tissue growth, forming within the muscle walls of the uterus.
- Thickened uterine lining (Endometrial Hyperplasia): In some cases, oestrogen can cause the uterine lining to thicken, also resulting in unexpected bleeding. This may require further investigation and treatment.
- Inflammation and thinning of the vulva or vagina (Atrophic Vaginitis): Lower hormone levels can lead to thinning and inflammation of the vaginal lining, which may cause spotting or light bleeding8. This is a frequent cause of vaginal spotting and can often be supported by topical vaginal oestrogens.
- Side effects of certain medications: Medications, anticoagulants, and some herbal or dietary supplements may contribute to bleeding.
- Missing a dose of HRT: Missing a dose can sometimes cause spotting. Follow your doctor’s guidance on missed doses, and contact them if the bleeding is heavy or persists.
- Infection: of any of the reproductive organs can cause inflammation and bleeding, requiring medical treatment.
- Factors like obesity: Excess fat in the body can contribute to elevated oestrogen levels, which may affect the uterine lining and lead to bleeding. Bleeding problems in people carrying extra body fat are more common and may require higher doses or different progesterone doses to manage.
- Ovarian, uterine, or endometrial cancer: In rare cases, unexplained or persistent bleeding may indicate a more serious condition, such as cancer. To put things into perspective, the risk of cancer in women experiencing vaginal bleeding while on HRT is significantly lower than in those who are not on HRT. To confirm such a diagnosis, your doctor may refer you for further testing, including taking tissue samples.
If you’re concerned, keep monitoring the bleeding, as this will be helpful information for your next doctor’s review. If you need reassurance, you can also book a personalised support session with our Menopause experts.
How to stop bleeding on HRT
Taking HRT doesn’t mean you have to accept unwanted and unpredictable bleeding. There are solutions to be found and it starts by clearly identifying the underlying reason together with your doctor. Once any serious issues are ruled out, several options may help reduce the bleeding.
Opting for sequential HRT
Doctors often prescribe this regimen in the first two years after menopause and during the perimenopause. With sequential HRT, you’ll likely experience scheduled bleeding, which may help you anticipate and gain back a sense of control.
Opting for continuous combined HRT
Typically prescribed one or two years after menopause or switched to from sequential HRT after several years or when withdrawal bleeds have started to reduce or disappear. For the majority of people, there are less bleeding episodes over time on continuous combined HRT.
Modifying timing, dosage, or preparation
Your doctor might adjust the timing, change the type or dosage of progesterone with the hope to stabilise and reduce unwanted bleeding. They can suggest lowering the oestrogen dose 5 or having a hormone releasing coil (also known as intrauterine system or IUS) placed inside the uterus. This IUS would release low-dose progestogen locally, which can help prevent thickening of the uterine lining that causes bleeding. Note that most adjustments would likely happen after your initial six months on HRT, as the body usually needs time to adapt.
Consulting regularly with your doctor
Have regular reviews to make sure that your HRT remains both effective and safe. Your specialist can recommend alternative approaches tailored to your needs and discuss the risks and benefits of HRT. Surgery might be suggested when all other options have failed.
When should I see a doctor?
It’s always wise to be on the side of caution when it comes to unexpected bleeding. Consider consulting with your doctor if:
- There is worsening pain or discomfort associated with the bleeding
- Bleeding occurs 6 months after starting HRT, even if it happens only once
- You notice bleeding 3 months after modifying your HRT
- You experience bleeding outside the expected timeframe when on sequential HRT
- You notice sudden or new bleeding after a period of no bleeding
It’s natural to feel concerned about bleeding on HRT, but remember that many causes are temporary and treatable. Spotting is often part of the adjustment process. If you have any concerns, our Menopause Care Consultation team is here to offer you some personalised guidance and reassurance.
¹Hormone replacement therapy and irregular bleeding Hickey et al. (2001)
²Clinical management of vaginal bleeding in postmenopausal women Carugno J. (2020)
³⁴Management of bleeding problems with hormone replacement therapy Hillard T.(October 2002)
⁵Unscheduled bleeding with hormone replacement therapy Gajjar et al (January 2019)
⁶Abnormal bleeding during menopause hormone therapy: insights for clinical management de Medeiros et al.(January 2013).
⁷Management of women with postmenopausal bleeding: evidence‐based review, Bakour et al.(October 2012)
⁸Postmenopausal Bleeding - Disorders of menstruation Bradshaw (March 2011)
⁹Hormone replacement therapy and bleeding disorders. Römer T. (February 2006)
¹⁰Postmenopausal vaginal bleeding in women using hormone replacement therapy Burbos et al. (February 2012)
¹¹¹²¹³Postmenopausal Bleeding NHS (May 2023)
¹⁴Management of unscheduled bleeding on hormone replacement therapy (HRT) British Menopause Society (April 2024)
