From the FDA Drug Label
Common side effects include: ... Irregular vaginal bleeding or spotting The FDA drug label does not directly answer if bleeding is normal after starting HRT, but it does mention that irregular vaginal bleeding or spotting is a common side effect of estrogens, such as estradiol.
- It is recommended to talk with your healthcare provider if you have vaginal bleeding while taking estradiol tablets 1.
- Abnormal bleeding from the vagina is also listed as a warning signal to call your doctor immediately, as it could be a sign of possible uterine cancer 1.
From the Research
Bleeding can be a normal occurrence after starting hormone replacement therapy (HRT), particularly in the first few months as the body adjusts to the hormones. For those taking estrogen-progestin combinations, breakthrough bleeding or spotting is common during the initial 3-6 months of treatment 2. If you're on cyclic HRT (taking estrogen daily with progestin for 10-14 days each month), you may experience withdrawal bleeding similar to a period when you stop the progestin. For continuous combined HRT (taking both hormones daily), irregular spotting often occurs initially but should decrease over time. However, any heavy, prolonged, or unexpected bleeding should be evaluated by a healthcare provider, especially if it occurs after you've been on stable HRT for several months or if you're post-menopausal and weren't having periods before starting treatment.
The most recent and highest quality study on this topic is from 2022, which discusses the current recommendations for HRT use in menopausal women 3. This study highlights the importance of HRT in improving menopausal symptoms and its potential role in managing long-term sequelae. However, it also emphasizes the need for careful evaluation of any bleeding that occurs after starting HRT, especially in post-menopausal women who were not having periods before starting treatment.
Some key points to consider when evaluating bleeding after starting HRT include:
- The type of HRT regimen being used (cyclic or continuous combined)
- The duration of treatment
- The presence of any underlying medical conditions that may affect bleeding
- The severity and duration of the bleeding
It's essential to note that while bleeding can be a normal occurrence after starting HRT, it's crucial to consult a healthcare provider if you experience any heavy, prolonged, or unexpected bleeding. This is especially important for post-menopausal women who were not having periods before starting treatment, as any bleeding in this population should be thoroughly evaluated to rule out any underlying conditions such as endometrial cancer 2.
In terms of managing bleeding after starting HRT, the study from 2000 suggests that combined HRT regimens tend to be predominantly progestogenic, and there is increasing evidence to suggest that some of the vascular changes seen in women taking long-term, low-dose progestogen-only contraceptives may also occur in women taking HRT 2. Another study from 2001 found that micronized progesterone is a clinically effective, well-tolerated, and cost-comparable alternative to medroxyprogesterone acetate in HRT for nonhysterectomized, postmenopausal women 4.
Overall, while bleeding can be a normal occurrence after starting HRT, it's crucial to carefully evaluate any bleeding that occurs, especially in post-menopausal women who were not having periods before starting treatment. Any heavy, prolonged, or unexpected bleeding should be evaluated by a healthcare provider to rule out any underlying conditions.