Unscheduled bleeding on menopausal hormone therapy: when to investigate, adjust or reassure
Talat Uppal FRANZCOG, FAAQHC, FACHSM, DDU, Sneha Wadhwani MB ChB, FRACGP, MRCGP, DRCOG, DFFP, DCH, PgCert Med Ed
Abstract
Unscheduled bleeding is a common reason women stop menopausal hormone therapy. Most episodes are benign, but unscheduled bleeding in women using menopausal hormone therapy differs from postmenopausal bleeding in women not using hormone therapy, and this distinction should guide investigation.
Key Points
Unscheduled bleeding is common after starting or changing menopausal hormone therapy and is usually benign.
The timing and pattern of bleeding should be interpreted according to the menopausal hormone therapy regimen and time since the final menstrual period.
Endometrial cancer risk factors should be assessed alongside the bleeding history, examination findings and adequacy of endometrial protection.
Transvaginal ultrasound is a first-line investigation when indicated, with endometrial thickness thresholds differing between sequential and continuous combined regimens.
Optimising oestrogen and progestogen therapy can often control bleeding, but persistent, heavy or recurrent bleeding, abnormal imaging or inadequate sampling warrants further investigation.
