5 Causes of Vaginal Bleeding on HRT

 



60% of menopausal women on HRT (no matter the type) experience vaginal bleeding. depends on the type of HRT a woman is taking:

  • If you're taking sequential HRT (estrogen daily and progesterone for part of the month), you'll likely experience withdrawal bleeding at the end of the progesterone cycle (similar to a period), lasting 3-7 days. Sequential HRT is recommended during perimenopause or in the first 2 years after menopause. This bleeding (withdrawal bleeding) is lighter than a typical menstrual period. This therapy has a scheduled bleeding and it’s ideal for women who want to take control of their period.
  • With continuous combined HRT (estrogen and progesterone daily), bleeding is less common as some women experience spotting or light bleeding in the first few months. This treatment is recommended 1 or 2 years after menopause. Some women switched from sequential HRT to continuous HRT because of less bleeding.

On average, vaginal bleeding or spotting starts after the first 3 to 6 months after starting HRT. It stops within that time frame. Women who still have their uterus are advised to take progesterone to counter estrogen’s effects on the uterine lining to avoid overgrowth and manage less bleeding. 


Bleeding Timeline


  • 80% of women on HRT experience bleeding in the first month.

  • 50% after 3 months of use

  • 10% after a year

Causes of Vaginal Bleeding on HRT

1. Endometrial Response to Estrogen - On average, 15%-30% of postmenopausal women on hormone replacement therapy (HRT) experience vaginal bleeding due to endometrial response. The endometrium (uterus lining) is sensitive to hormonal fluctuations and responds to HRT by thickening or thinning, leading to bleeding. 

Also, HRT changes the density, distribution, and structure of blood vessels in the endometrium contributing to vaginal bleeding. According to Menopause Expert, the endometrium takes around 3 to 6 months to adjust to hormone replacement therapy. 

2. Endometrial Hyperplasia - If estrogen levels are too high and progesterone is inadequate, the endometrial lining overgrows and increases the risk of spotting or heavy bleeding. 

Women taking unopposed estrogen HRT (estrogen without progesterone) increases the risk of endometrial hyperplasia. 2% to 20% of women taking this type of HRT develop endometrial hyperplasia. This condition sometimes develops into atypical endometrial hyperplasia (a precancerous condition) and potentially endometrial cancer. 

3. Atrophic Vaginitis (Vaginal Atrophy) - In some cases, vaginal bleeding isn’t from the uterus but from the vaginal walls. Estrogen deficiency causes vaginal thinning and dryness. It makes tissues weak and prone to bleeding after intercourse or minor irritation.

HRT helps menopausal symptoms, particularly vaginal dryness. However, 10% to 25% of women experience atrophic vaginitis even when taking systemic estrogen. As a result, some doctors prescribe vaginal creams, rings or tablets to treat vaginal problems specifically. 

4. Uterine Polyps or Fibroids - Pre-existing benign polyps or fibroids in the uterus react unpredictably with HRT. Additionally, HRT with higher doses of estrogen or using unopposed estrogen therapy stimulates the growth and number of polyps or fibroids. This leads to heavy menstrual bleeding and pelvic pain. 

5. Missed HRT - Some women are so busy that they often forget taking HRT. Experts noted that regular missed HRT dosage is the cause of spotting. Women are advised to contact their healthcare provider to tailor a scheduled medication that fits into their routine.

When to see a doctor

  • Pain or discomfort because of the bleeding

  • Bleeding after 6 months on HRT

  • Bleeding 3 months after modifying HRT

  • Bleeding outside the expected timeframe on sequential HRT

  • Sudden or new bleeding after a period of no bleeding

Doctors can adjust the timing, change the type or dosage of progesterone to stabilize and reduce unwanted bleeding, and lower estrogen dose or choose a hormone releasing coil (intrauterine system or IUS) placed inside the uterus. IUS releases low-dose progestogen locally and prevents uterus lining thickening that causes bleeding.

More importantly, schedule a regular check up with your doctor to ensure HRT therapy is safe and effective. 

Sources

Bleeding on Hormone Replacement Therapy (HRT)

Menopause Hormone Therapy: Does it cause vaginal bleeding?



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