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Appendix 8 – Bleeding Patterns

View HRT Guidance Flow Chart

Perimenopausal Bleeding Patterns

Menopausal symptoms can occur at any time during the decline of ovarian function (Climacteric) and may be present with apparently normal regular menstrual cycles. The pattern and symptoms can be identified by using a menstrual chart.

Symptoms that are due to estrogen deficiency will be present throughout the cycle. For those only occurring in the premenstrual phasae, consider treating as for the premenstrual syndrome (PMS). Dysfunctional uterine bleeding is common during the perimenopause when the bleeding pattern can be so variable in frequency and heaviness, but if there is concern, consider referral for gynaecological opinion.

In order to minimise the chance of breakthrough bleeding, continuous combined therapy should be reserved for women who are at least 12 months post-menopause. By age 54 years, 80% of women will be 12 months post-menopausal, when a change from sequential to continuous therapy, or Tibolone, can be tried if a period-free method is preferred.

When changing from sequential to continuous combined therapy, breakthrough bleeding may be a problem. This may be reduced by stopping all HRT for up to two weeks at the end of the sequential cycle, before initiating the continuoue combined treatment.

Bleeding Patterns on HRT

Carry out a pelvic examination to exclude local genital tract pathology.

  • Heavy/prolonged bleeds – increase progestogen/change progestogen
  • Painful bleeds – change progestogen
  • Bleed too early – increase progestogen
  • Spotting early in cycle – increase estrogen
  • 28 day sequential regimens should produce regular, predictable and acceptable bleeds, starting during or soon after progestogen phase
  • Irregular/heavy bleeding may respond to change of regimen or increase of progestogen and/or estrogen.
  • Timing of the bleed is no guide to adequacy of progestogen of endometrial safety.
  • Investigate persistent/abnormal bleeding.

Bleeding Pattern Investigations

  • Endometrial biopsy
  • Ultrasound scan
  • Hysteroscopy

Break-through bleeds on long cycle/quarterly bleed and period-free regimens are common in first 3-6 months when no particular invesitgation is necessary.

Persistent bleeds, or bleeding starting after a long spell of amenorrhoea, requires investigation as for post-menopausal bleed. Refer patient.

Surgical options include:

  • Endometrial ablation/resection (but subsequent HRT still needs to contain a progestogen)
  • Intrauterine system
  • Hysterectomy