Bleeding on HRT

While the impact of menopause can vary significantly among individuals, one aspect many women anticipate is the cessation of menstrual periods. However, this transition isn’t always straightforward, and some may continue to experience unexpected vaginal bleeding.

Vaginal bleeding during perimenopause and even post menopause can be sporadic and unpredictable. Is this normal? When should you seek advice from a healthcare provider, and what role does Hormone Replacement Therapy (HRT) play in this context?

Unexpected bleeding is a common occurrence in women during or after the menopause phase, regardless of whether they are using HRT. In most cases, the underlying cause is not typically a major concern. However, each situation should be assessed individually. 

Understanding vaginal bleeding after menopause...

Similar to the variability of menstrual periods among women, bleeding patterns around the time of menopause can also differ significantly.

Menopause is officially defined as the absence of menstruation for 12 consecutive months. The period leading up to menopause, known as perimenopause, can last for several years and is characterised by changes in menstrual cycles. During this phase, your periods may become irregular in terms of frequency and duration. It is not uncommon for periods to become heavier or lighter during this transitional period.

Early in perimenopause, fluctuating oestrogen and low progesterone levels can lead to heavier and more frequent periods. Later in perimenopause, as oestrogen levels consistently decrease, periods may become less frequent and lighter. Some women may experience a pattern of missing one or two periods and then having a heavier, longer one. The unpredictability and fear of heavy bleeding can pose challenges in various aspects of life and potentially lead to health issues, such as anaemia.

Sometimes, factors other than hormonal changes can contribute to bleeding irregularities during perimenopause, such as changes in contraception or the presence of uterine fibroids. Therefore, it is essential to discuss any bleeding concerns with your healthcare provider, as “normal” should not preclude addressing the issue.

For women who have reached menopause (12 months without a period), any bleeding—whether heavy or light—is considered “post-menopausal bleeding” and is not normal. Hormonal changes, such as fluctuations in oestrogen levels, are a common cause of such bleeding. However, other factors, such as fibroids, polyps, or abnormalities in uterine cell growth, can also contribute. In rare cases, changes in uterine cell lining may become cancerous.

Given the potential range of causes, it is crucial to consult with a healthcare provider if you experience unexpected post-menopausal bleeding.

Healthcare providers consider various factors when evaluating the cause of vaginal bleeding and determining the appropriate course of action.

These factors may include:

  • weight;
  • history of diabetes or polycystic ovarian syndrome;
  • personal or family history of gynaecological issues;
  • pelvic pain;
  • pain or bleeding related to sexual intercourse;
  • risk of sexually transmitted infections;
  • cervical screening (smear test) history; and
  • current medications.

It is also important to distinguish between vaginal bleeding and bleeding from the rectum or urethra, as these have different causes and treatments. Keeping track of when and how much you bleed can be helpful if further investigations are needed.

HRT is administered in two main regimens depending on whether you are perimenopausal or menopausal.

  • Cyclical or Sequential HRT: This regimen, often used for perimenopausal women, involves scheduled breaks in the progesterone component to induce a withdrawal bleed each month. Occasionally, unexpected bleeding may occur.
  • Continuous Combined HRT: This regimen, typically used for menopausal women, consists of taking estrogen and progesterone continuously without breaks, aiming to eliminate bleeding. Any bleeding while on this regimen may raise concerns and should be discussed with a healthcare provider.

Regardless of the HRT regimen, vaginal bleeding can be common, especially during the initial months of HRT use. Factors such as changes in hormone doses, the method of administration, or irregular medication schedules can contribute to bleeding. Inform your menopause clinician about any bleeding, especially if it persists beyond the adjustment period.

If you are postmenopausal (12 months without a period) and not on HRT, any vaginal bleeding should be reported to your healthcare provider for evaluation.

If you recently started HRT (within the past 3 months), it is common to experience unscheduled bleeding, which should be discussed with your menopause clinician at your 3-month review appointment. For heavy bleeding or persistent concerns, it’s advisable to seek medical attention sooner.

Adjustments to HRT, such as changing the estrogen dose, progesterone component, or method of administration, may help resolve bleeding issues. Some individuals may benefit from using a Mirena coil, which can act as both an HRT component and a treatment for bleeding, while also providing contraceptive benefits.

Patience is key as finding the right balance of hormones is a personalized process. Assess the bleeding in conjunction with improvements in other menopausal symptoms, as it may be acceptable to tolerate occasional light bleeding if other symptoms have significantly improved. Always communicate any bleeding issues with your healthcare provider, even if you’ve been stable on HRT for some time.

Healthcare providers may conduct further investigations to determine the cause of vaginal bleeding. This may include ultrasound scans to measure uterine lining thickness, referral to a gynaecologist, hysteroscopy (a procedure involving a small camera), or blood tests to assess for anaemia, iron levels, hormone levels, and other factors.

The vast majority of women who experience post-menopausal bleeding, especially those on HRT, do not have serious underlying conditions. Nonetheless, it is essential to address and investigate any bleeding concerns with your healthcare provider for a thorough evaluation and appropriate guidance.