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Why does HRT cause bleeding?

Any woman who still has her womb and takes HRT, is required to take a progesterone-like hormone to counteract the effects which oestrogen has on the endometrium (lining of the womb). Oestrogen causes the endometrium to increase in thickness and in cell number. As this happens, there is the possibility if any atypical cells are present, that these can eventually lead to cancer of the endometrium. The addition of progesterone to an oestrogen regimen prevents this from occurring.

But, unfortunately, progesterone negates certain of the beneficial effects of oestrogen. Not only do some women bleed, but they can also suffer from premenstrual tension. Progesterone can also weaken some of the beneficial cardiovascular effects of oestrogen. However, the protective action against cancer outweighs the disadvantages of progesterone, which is sufficient reason not to remove progesterone from HRT. This is different for women who have had a hysterectomy (removal of the womb) and who can take only oestrogen replacement therapy (ERT) without progesterone.

How can the problem of bleeding be overcome?

Most HRT regimens rely on a continuous dose of oestrogen. This needs to be “opposed” by the addition of progesterone in some form or another. What many regimens do is to add progesterone for 10 to 14 days each month. With this sequential administration, around 80% of women experience what is called a withdrawal bleed – similar to that experienced with the oral contraceptive pill.

One way of trying to overcome this is to give oestrogen and progesterone together continuously – called continuous combined therapy. In the first three to six months many women still have spotting and breakthrough bleeding, but this can settle down. In some lucky women, bleeding stops altogether, but in others, the spotting continues, but less frequently.

If, while on a continuous combined regimen, spotting continues to be a problem, then a change in treatment may help, although switching from one hormone combination to another one within a few months is usually not successful. The chance of bleeding cessation is greater in women who start with continuous combined therapy after having stopped menstruating already for over one year.

Read more:
Am I nearing menopause?
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