When to investigate bleeding on HRT

Article summary

Did you find this summary helpful?

Thank you for your feedback

Unscheduled vaginal bleeding is common in the first 3 months of starting HRT.
Combined sequential regimes should produce a regular withdrawal bleed beginning towards the end of the progestogen phase.
Continuous combined regimes commonly produce irregular breakthrough bleeding or spotting in the first 4–6 months of treatment.
If unscheduled bleeding persists beyond 6 months, becomes heavier, or occurs after a time of no bleeding, referral for further investigations should be arranged to exclude endometrial pathology.
In patients with risk factors for endometrial cancer, or where there are concerns, there should be consideration for earlier investigation.
Investigation should include a transvaginal ultrasound scan assessment of the endometrial cavity and an endometrial biopsy where appropriate.

Unpredictable or unexpected bleeding may also be due to non-adherence with treatment, and this should be asked about.
Cervical smear history should always be checked.

Further Information:

Was this article helpful?