Womens Health

Expected Bleeding from Continuous HRT

Frederick R. Jelovsek MD

When your doctor recommends hormone replacement therapy (HRT) after menopause, do visions of menses forever appear? How much bleeding should you expect? There are two basic dose frequencies -- sequential estrogen followed by progesterone and continuous estrogen and progestin (synthetic progesterone). With the sequential regimen there is almost always some menstrual bleeding or spotting just like with birth control pills. The continuous regimen is much better however, with many women having no bleeding at all.

Recent Research

In a recent article, Nand et al: Bleeding pattern and endometrial changes during continuous combined hormone replacement therapy. Obstet Gynecol 1998;91:678-84, investigated estrone 1.25 mg (Ogen®) with 3 different doses of medroxyprogesterone acetate (Provera®) 2.5 mg, 5.0 mg and 10mg. They recorded how much bleeding 568 women had over 2 years on the different regimens.

Interestingly, the investigators didn't find a significant difference between the three different progestin doses as to a lower incidence of bleeding on the higher doses. At the end of 3 months of therapy 58% of women were amenorrheic while 42% still had some bleeding. At 6 months, 75-80% of women had no vaginal bleeding at all. By 24 months, 90-94% of women were amenorrheic. Almost 10% of women had bleeding no matter what dose of progestin they were taking.

How Much Bleeding

The study also tells us that the average number of days of any bleeding on these hormonal regimens started out from 6-9 days per month at the beginning of therapy and declined to about 3 days of bleeding per month after 2 years. There were no cases of endometrial cancer or hyperplasia that occurred during the study period.

The lessons to learn from this are:

  • even though many women don't have bleeding on this continuous regimen, some do no matter how long they take the medication.
  • raising the progestin dose is unlikley to lessen the bleeding for most women who are having it
  • women should expect bleeding problems for the 1st 6-9 months on this regimen

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Bleeding While on Hormone Replacement
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