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Management of bleeding in women on HRT

02 December 2020
9 min read
Volume 31 · Issue 12


Bleeding while on hormone replacement therapy is common. Debby Holloway explains the causes of this, investigations needed, and how to tailor treatment to the individual if no pathology is found

Bleeding while taking hormone replacement therapy (HRT) is a relatively common problem. The majority of women with post-menopausal bleeding – on and off HRT – will have either no cause or a benign cause, but about 10% of women will have endometrial cancer. Post-menopausal bleeding is defined as unscheduled vaginal bleeding that occurs a year after the last natural menstrual period or any breakthrough bleeding on cyclical HRT or breakthrough bleeding after 6 months on continuous combined therapy when there has been established amenorrhoea. Practice nurses must be aware of the problem of bleeding on HRT and each individual needs to be assessed for pathology. If no pathology is found, treatment should be tailored to the individual to overcome the bleeding issues.

The aim of this article is to cover the causes of post-menopausal bleeding and irregular bleeding for women taking hormone replacement therapy (HRT) and how to manage it. Bleeding while on HRT is common and if once investigated no cause has been found, then the HRT prescribed may need to be changed.

Bleeding while taking HRT is a common problem and in the Women's Health Initiative trial 40% women were unblinded due to vaginal bleeding (Rossouw et al, 2002). It is estimated that 38% of women using sequential HRT and 41% of women on continuous combined HRT (CCT) attend clinics with bleeding (Hickey et al, 2009). Problems with bleeding do lead to the discontinuation of therapy and expensive and invasive tests to exclude cancer and pathology, and this may affect the acceptability of treatment for women.

The majority of women with post-menopausal bleeding on and off HRT will have either no cause or a benign cause, but about 10% of women will have endometrial cancer (Scottish Intercollegiate Guidelines Network [SIGN], 2002). Endometrial cancer accounts for 1 in 18 of all female cancers and is increasing due to multiple factors (Bray et al, 2005), the most prominent being obesity.

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