Strategies to improve bleeding control on HRT

For information about when to investigate bleeding on HRT, see when to investigate section.

For the majority of women with unscheduled bleeding on HRT, modifying the progestogen intake will improve bleeding control. If symptoms are well controlled, reducing the oestrogen dose can also help.

Options include:

1. INCREASING THE PROGESTOGEN DOSE

• For sequential HRT, the dose of progestogen taken for 12–14 days in each cycle can be increased. For example, micronised progesterone 300mg taken for 12–14 days a month instead of 200mg.
• For continuous HRT, the dose of progestogen taken daily can be increased. For example, micronised progesterone 200mg daily instead of 100mg daily.

2. SWITCHING TO AN ALTERNATIVE PREPARATION

• Bleeding might be better controlled using a synthetic progestogen such as norethisterone, medroxyprogesterone, dienogest or desogestrel. These formulations are off-license and a higher dose of desogestrel compared to that used in contraception is recommended. For more information see prescribing information.
• The Mirena coil is a useful option given it is licensed for heavy menstrual bleeding.

3. INCREASING THE DURATION OF PROGESTOGEN INTAKE

• Progestogen intake in a sequential regime can be extended to 21 days rather than 14 days in each cycle.
• Taking micronised progesterone on days 1-25 of a cycle in a continuous regime can improve bleeding compared to daily use.

4. TAKING ADDITIONAL PROGESTOGEN

• Those who have the 52mg LNG-IUD in place could add in micronised progesterone, medroxyprogesterone, desogestrel or norethisterone to their regime.
• Consider adding a low dose progestogen to regime such as norethisterone 0.35mg or desogestrel 75mcg.

5. SWITCHING BACK TO A SEQUENTIAL REGIME

• If breakthrough bleeding occurs following a switch to continuous HRT and does not settle after 3–6 months, then the woman can be switched back to a sequential regime for at least another year. Unscheduled bleeding is higher with continuous combined HRT regimens.

6. REDUCING THE OESTROGEN DOSE

• Higher doses of oestrogen are more likely to stimulate bleed episodes.
• Doses can be reduced by cutting a patch (for example cutting a quarter off) or by applying half a pump of gel daily.