How to stop Hormone Replacement Therapy (HRT) bleeding?

Managing HRT-Related Bleeding

For women experiencing bleeding during Hormone Replacement Therapy (HRT), NSAIDs for 5-7 days is the recommended first-line treatment, followed by short-term low-dose combined oral contraceptives if bleeding persists. 1, 2

Initial Assessment

• Rule out underlying gynecological problems that could cause prolonged bleeding, including pregnancy, sexually transmitted infections, and pathologic uterine conditions (fibroids, polyps) 1, 2
• Document specific bleeding characteristics including frequency, duration, and amount of flow 3
• Assess pattern changes over time and presence of pain 3

Treatment Algorithm for HRT Bleeding

First-Line Treatment

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 1
  • Mefenamic acid 500 mg three times daily for 5 days 2
  • Celecoxib 200 mg daily for 5 days 2

Second-Line Treatment (if bleeding persists)

• Low-dose combined oral contraceptives for short-term treatment (10-20 days) if medically eligible 1, 2
• Consider a hormone-free interval of 3-4 days, which has been shown to improve bleeding patterns in clinical trials 1

For Continuous Combined HRT Regimens

• A short hormone-free interval (3-4 days) can help reduce bleeding, with studies showing an initial increase in flow followed by an abrupt decrease and eventual cessation of flow 11-12 days later 1
• Oral doxycycline (100 mg twice daily for 5 days) has not shown improvement in bleeding compared to placebo 1

Adjusting HRT Regimens

• Consider changing to a different formulation or route of administration if bleeding persists 4
• Oral formulations generally have better bleeding profiles than transdermal formulations:
  • Cumulative amenorrhea rates over one year range from 18-61% with oral HRT compared to 9-27% with transdermal HRT 4
  • Oral estradiol/progesterone combinations have lower bleeding rates and may be appropriate for women with bleeding concerns 4

Important Considerations

• Bleeding irregularities are generally not harmful and usually improve with persistent use of the hormonal method 1
• Amenorrhea rates and the mean number of bleeding/spotting days typically improve over time with continued use 4
• Low-dose therapies (0.5 mg oral estradiol, 0.3 mg oral conjugated equine estrogens, or 14 μg estradiol daily by transdermal patch) are associated with less bleeding and greater patient acceptability 5
• Intrauterine delivery of progestogen provides good endometrial suppression with lower circulating levels than other routes 5

When to Consider Alternative Approaches

• If bleeding persists despite treatment and the woman finds it unacceptable, counsel her on alternative contraceptive methods 1
• For refractory bleeding, consider endometrial biopsy, hysteroscopy, or referral to a specialist 6
• Endometrial ablation may be considered for women with refractory bleeding who have completed their family planning 6

Follow-up Recommendations

• Discuss expected timeline for improvement 3
• Explain potential side effects of treatments 3
• Schedule appropriate follow-up to monitor response to treatment 3
• Instruct when to seek urgent medical attention 3