Bleeding on HRT Action Plan

🔺 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.

If Step 1 does not resolve the issue, simply progress to Step 2, and continue through the pathway as needed. Most cases are due to hormonal adjustment and resolve with appropriate changes.

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. This will trigger an urgent phone call from Dr Purity. Note: these appointments are reserved strictly for urgent medical concerns.

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.

Step 1: Continuous Oral Progesterone Regimen

• Estrogen gel: 2 pumps daily →Through the skin

• Progesterone: 100 mg orally at night, continuous

Step 2: Cyclical Oral Regimen

• Estrogen gel: 2 pumps daily →Through the skin

• Progesterone: 100 mg orally, Days 1–25 + 3-day break→ Resets receptor sensitivity

Step 3: Vaginal Progesterone

• Estrogen gel: 2 pumps daily →Through the skin

• Progesterone: 100 mg vaginally, Days 1–25 + 3-day break→ Enhanced local effect, fewer systemic side effects

Step 4: Increase Progesterone Dose

• Estrogen gel: 2 pumps daily →Through the skin

• Progesterone: 200 mg vaginally, continuous→ For persistent bleeding

Step 5: Lower Estrogen

• Estrogen gel: Reduce to 1 pump →Through the skin

• • Progesterone: Maintain 200 mg vaginally→ Balances endometrial stimulation

Step 6: 14-Day Regimen

• Estrogen gel: 1 or 2 pumps daily →Through the skin

• Progesterone: 200 mg orally/vaginally for 14 days per month (day 15-25), 2 weeks on, 2 weeks off→ Suitable in selected cases, e.g., perimenopausal, those who prefer monthly bleeds or for endometrial re-challenge

  
  

  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