Help! I’m Bleeding on HRT: Immediate Next Steps

🔺 Bleeding Management Support

Breakthrough bleeding is common during the first 3–6 months of starting or adjusting HRT. To support you, we’ve developed a structured Bleeding Management Pathway to guide next steps if bleeding occurs.

Help! I've woken up with a bleed!

If you wake up with a bleed, stop the progesterone, continue estrogen, and resume progesterone when the bleeding stops. This may take 2–3 days to settle. Notify your doctor as soon as possible. Your doctor may need to lower the estrogen dose or change the progesterone dose or route.

The following is a guide. It is not prescriptive; it requires your doctor’s input and oversight. The purpose of this guide is to reduce the panic that can be associated with the first sign of bleeding on HRT.

With a doctor’s guidance, if Step 1 does not resolve the issue, simply move to Step 2 and continue through the pathway as needed. Most cases are due to hormonal adjustment and will settle with appropriate changes. Always notify your doctor as soon as bleeding occurs. It is important that your doctor knows what is happening so they can provide you with targeted advice.

For my patients: Please notify us of any bleeding so we can update your medical records accordingly. If your concern is urgent, please use the Urgent Troubleshooting option on our homepage (https://www.purity.health/book-online). This service is available daily except Friday, Saturday, and Sunday. It will trigger an urgent phone call from Dr Purity. Note: These appointments are reserved strictly for urgent medical concerns. For non-urgent troubleshooting, you can attend the fortnightly webinar or request a video review with Dr Purity by phone.

Please note: Vaginal use of Prometrium (oral capsule inserted vaginally) is an off-label application, used to optimise endometrial protection.

Our goal is to ensure your safety, maintain symptom control, and support your peace of mind throughout HRT.

Persistent Bleeding → Requires clinical evaluation and possible referral.

Definition of Persistent Bleeding in the Context of HRT

• Breakthrough bleeding is common in the first 3–6 months after starting or changing HRT. This is usually due to hormonal adjustment and often settles with minor changes.

• Persistent bleeding means:

  • Any bleeding that continues beyond 6 months after starting or adjusting HRT, or

  • New-onset bleeding that develops after a period of stability on HRT, or

  • Heavy, prolonged, or irregular bleeding that does not improve with the initial steps of the Bleeding Management Pathway.

    
    

Persistent bleeding always requires a clinical review to exclude endometrial pathology and may involve referral for further investigation (e.g., ultrasound, biopsy, gynaecology input).

Step 1: Continuous Oral Progesterone Regimen. This is the usual daily regimen.

Estrogen Gel

• Women aged over 45 years: 2 pumps daily, applied through the skin.

• Women under 45 years: usually do better starting with 1 pump daily. I advise them to understand their cycles and use estrogen according to their symptoms. For more details, see this simplified blog: Perimenopause – Master the Signature of Your Hormones and Titrate Your HRT According to Your Symptoms.

Progesterone

• 100 mg orally at night, taken continuously.

• If you are perimenopausal, stop when your period starts and resume promptly afterwards.

• If you track your cycle, stop progesterone when your period is due.

  
  

If Step 1 is not effective, move to Step 2 and continue down sequentially to Step 6.

Important Notes for my Patients

• Please notify me of any bleeding so we can update your medical records.

• If your concern is urgent, please use the Urgent Troubleshooting option on our homepage. This will trigger an urgent phone call from Dr Purity (not available Fridays or weekends). These appointments are reserved strictly for urgent medical concerns.

• Dr Purity will guide you regarding bleeding and HRT management. This framework outlines the process, but a doctor’s guidance and further investigation may be required.

Step 2: Cyclical Oral Regimen (for menopausal women)

• Estrogen gel: 2 pumps daily, applied through the skin

• Progesterone: 100 mg orally at night, Days 1–25, then take a 3-day break. This helps reset receptor sensitivity

  
  

Step 3: Vaginal Progesterone (for menopausal women)

• Estrogen gel: 2 pumps daily, applied through the skin

• Progesterone: 100 mg vaginally at night, Days 1–25, then take a 3-day break. Provides enhanced local effect with fewer systemic side effects

  
  

Step 4: Increased Progesterone Dose

• Estrogen gel: 2 pumps daily, applied through the skin

• Progesterone: 200 mg vaginally, continuous. Used for persistent bleeding

• Tip: If progesterone improves sleep, use one capsule orally and one vaginally at night

  
  

Step 5: Lower Estrogen

• Estrogen gel: reduce to 1 pump daily, applied through the skin

• Progesterone: maintain 200 mg. This balances endometrial stimulation

  
  

Step 6: 14-Day Regimen

• Estrogen gel: 1–2 pumps daily, applied through the skin

• Progesterone: 200 mg orally or vaginally for 14 days per month (Days 15–28). This means 2 weeks on, 2 weeks off. Suitable in selected cases, such as perimenopause, women who prefer monthly bleeds, or for endometrial re-challenge

  
  

Step 7: Slinda Option (off-label use for problematic bleeding)

• Estrogen gel: 1–2 pumps daily, applied through the skin

• Slinda (drospirenone 4 mg): taken once daily, continuous use (no breaks)

• Purpose: Provides stronger endometrial suppression when bleeding persists despite adjustments in progesterone type, dose, or regimen

• Notes:

  • This is an off-label use and requires informed consent

  • Can be considered if Steps 1–6 do not resolve problematic bleeding

  • Always under a doctor’s guidance, with investigations (e.g., ultrasound, biopsy) if bleeding continues

Persistent Bleeding → Requires clinical evaluation and possible referral.

Notes:

• Sandrena 1 mg ≈ Estrogel 2 pumps

• Micronised progesterone = safer, bioidentical - monitor if high estrogen

• CAUSES OF BLEEDING ON HRT

  1. Hormonal Causes (Most Common)

  • Regimen instability (recent changes in estrogen/progesterone)

  • Missed doses or inconsistent use

  • Progesterone resistance or receptor desensitisation

  • Estrogen dominance (excess estrogen relative to progesterone)

  • Starting new HRT or medications

  2. Lifestyle & Physiological Triggers

  • Travel across time zones (circadian disruption)

  • Stress or major lifestyle shifts

  • Weight changes or BMI extremes

  3. Structural Causes

  • Uterine fibroids

  • Endometrial polyps

  • Adenomyosis

  • Thickened endometrial lining (hyperplasia)

  4. Pathological or Rare Causes

  • Endometrial hyperplasia (with or without atypia)

  • Endometrial cancer (always rule out if persistent or heavy bleeding)

  • Cervical pathology (e.g. ectropion, polyps, malignancy)

  
  

Supporting women through all hormonal seasons and beyond

Dr Purity Menopause Clinic

www.purity.health