Can you still experience bleeding while on hormone replacement therapy (HRT) with cyclic progesterone (a progestin hormone)?

From the Guidelines

Yes, you can still experience bleeding while on hormone replacement therapy (HRT) with cyclic progesterone, as this is a normal and expected outcome of this treatment regimen. Typically, cyclic progesterone in HRT involves taking estrogen continuously and adding progesterone for 10-14 days each month, which often results in a withdrawal bleed when the progesterone is stopped, similar to a menstrual period 1. The bleeding occurs because the progesterone stabilizes the uterine lining built up by estrogen, and when progesterone is withdrawn, the lining sheds, causing bleeding.

Common regimens include:

• Estradiol 1-2 mg daily (oral or transdermal)
• Micronized progesterone 200 mg daily for 12-14 days each month, as recommended by recent studies 1 It's essential to note that while this bleeding is expected, any unusual or heavy bleeding should be reported to your healthcare provider. Additionally, some women may prefer continuous combined HRT to avoid monthly bleeding, but this should be discussed with a doctor, considering the potential benefits and risks, including the impact on cardiovascular health and venous thromboembolism 1.

The choice of progestin is also crucial, with micronized progesterone being a preferred option due to its favorable safety profile and lower risk of cardiovascular disease and venous thromboembolism 1. Other progestins, such as medroxyprogesterone acetate and dydrogesterone, may also be used, but their safety profiles and potential effects on lipid metabolism and androgenic activity should be considered 1.

In cases of unusual or heavy bleeding, medical treatment can be considered, including nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal treatment with combined oral contraceptives or estrogen 1. However, it's crucial to evaluate for underlying conditions and treat or refer for care if necessary. Ultimately, the management of bleeding irregularities while using HRT should be individualized, taking into account the woman's medical history, preferences, and values.

From the FDA Drug Label

If you have a uterus, talk to your healthcare provider about whether the addition of a progestin is right for you The addition of a progestin is generally recommended for a woman with a uterus to reduce the chance of getting cancer of the uterus (womb) See your healthcare provider right away if you get vaginal bleeding while taking PREMARIN Less serious, but common side effects include: ... Irregular vaginal bleeding or spotting

Yes, you can still experience bleeding while on hormone replacement therapy (HRT) with cyclic progesterone (a progestin hormone) 2.

• Vaginal bleeding is a possible side effect of HRT, even with the addition of a progestin.
• It is recommended to see a healthcare provider right away if vaginal bleeding occurs while taking HRT.

From the Research

Hormone Replacement Therapy and Bleeding

• Women on hormone replacement therapy (HRT) with cyclic progesterone can still experience bleeding, as evidenced by studies 3, 4, 5, 6, 7
• Breakthrough bleeding is a common problem in postmenopausal women taking HRT, and is often a factor that deters women from continuing or starting HRT 3
• The mechanisms underlying unscheduled bleeding in women on HRT are not well understood, but may be related to vascular changes caused by progestogen-only contraceptives or HRT 3

Types of HRT and Bleeding

• Cyclic HRT regimens, which involve taking progesterone for a certain number of days each month, can cause bleeding in some women 4
• Continuous combined HRT regimens, which involve taking both estrogen and progesterone every day, can also cause bleeding, although the risk may be lower than with cyclic regimens 4, 7
• The risk of bleeding with HRT may decrease over time, especially with continuous combined regimens 4

Management of Bleeding with HRT

• Abnormal bleeding with HRT can be managed by changing the progestogen, adjusting the dose of estrogen or progesterone, or switching to a different regimen 6
• Identifying women at higher risk of bleeding and tailoring the HRT regimen to their individual needs can help minimize the occurrence of abnormal bleeding 6
• New agents may be developed as adjuvant therapies to decrease abnormal bleeding in women on HRT, but more research is needed 6

Risk of Endometrial Cancer with HRT and Bleeding

• Women on HRT who experience bleeding are at a lower risk of endometrial cancer than those who do not use HRT 5
• The risk of endometrial cancer with HRT may increase with longer duration of use, but this is not statistically significant 5
• Unopposed estrogen therapy can increase the risk of endometrial hyperplasia and cancer, but the addition of progestogen can reduce this risk 7