Will You Still Bleed Monthly on Oestrogel and Micronized Progesterone?
Yes, you will likely experience monthly withdrawal bleeding when using transdermal estradiol (Oestrogel) combined with micronized progesterone in a sequential regimen, though bleeding patterns typically become more predictable after the first 3–6 months of therapy. 1
Expected Bleeding Pattern with Sequential Hormone Therapy
Sequential regimens—where you take progesterone for 12–14 days each month—are specifically designed to induce regular withdrawal bleeding that mimics a menstrual period, occurring 2–3 days after you complete each progesterone course. 1
During the first 3–6 months of therapy, 10–20% of women experience breakthrough bleeding or spotting between withdrawal bleeds, but most of these irregular episodes resolve as the endometrium adapts to the hormone regimen. 2
By 6–12 months of continuous use, most women achieve predictable withdrawal bleeding that occurs only during or immediately after the progesterone phase, with minimal spotting at other times. 2, 3
Why Sequential Regimens Cause Bleeding
The 12–14 day progesterone exposure each month transforms the estrogen-stimulated endometrium into a secretory state, and when progesterone is withdrawn at the end of each cycle, the endometrial lining sheds—producing withdrawal bleeding similar to a natural menstrual period. 1, 4
This bleeding is not only expected but medically necessary: it prevents endometrial hyperplasia and reduces endometrial cancer risk by approximately 90% compared to unopposed estrogen. 1
Alternative: Continuous Combined Regimen to Avoid Bleeding
If you prefer to avoid monthly bleeding entirely, you can switch to a continuous combined regimen where you take both estradiol and progesterone every day without interruption. 1, 4
Continuous daily micronized progesterone (typically 100 mg/day) combined with transdermal estradiol leads to endometrial atrophy and amenorrhea (no bleeding) in most women after 6–12 months, though irregular spotting is common during the first 3–6 months of transition. 5, 6
The continuous regimen provides equally robust endometrial protection while eliminating withdrawal bleeding, making it the preferred choice for women who find monthly bleeding bothersome or who have completed their reproductive years. 1, 5
Practical Guidance on Bleeding Management
Expect some irregular spotting during the first 3 months of either sequential or continuous therapy—this is normal and typically resolves without intervention. 2, 3
If heavy or prolonged bleeding persists beyond 6 months, or if bleeding occurs at unexpected times despite adequate progesterone exposure (12–14 days per cycle), you should undergo endometrial assessment (transvaginal ultrasound or biopsy) rather than simply increasing the progesterone dose. 2
Vaginal administration of micronized progesterone (200 mg for 12–14 days per month) provides better bleeding control than oral administration at the same dose, with fewer episodes of spotting and higher treatment satisfaction, though oral micronized progesterone remains the guideline-recommended first-line option. 3