Some unwanted effects of hrt: withdrawal bleeds

SOME UNWANTED EFFECTS oF HRT: WITHDRAWAL BLEEDS
If you have a uterus you will not necessarily experience withdrawal bleeds when you begin HRT. However, such bleeds (for a few days at a predictable time of the month) are more likely if progestogen is taken for ten to fourteen days a month along with daily oestrogen. In the case of a woman taking progestogen for the first twelve days each month, the withdrawal bleed typically starts between day twelve and day seventeen and occurs monthly. About half the women taking progestogen in this cyclical manner have withdrawal bleeds for ten years or more. In most cases the bleeds become progressively lighter. When HRT is discontinued, the bleeds stop.
Women taking progestogen each day in combination with oestrogen are less likely to have withdrawal bleeds as time goes by. Shirley was one of the 10 to 20 per cent of women using this format who have irregular spotting or bleeding six months to a year after starting. She found the irregular bleeding a nuisance but persisted with HRT because of a remarkable improvement in her vaginal symptoms and joint pain. Shirley's doctor suggested that continuation of the bleeding beyond twelve months should be investigated by endometrial biopsy or hysteroscopy and biopsy. By the time a year was up, all bleeding had stopped.
Whether you take progestogen for a part or all of a cycle, the first few withdrawal bleeds are likely to be the heaviest, particularly if you start on HRT around the time of menopause. At this stage there may be some endometrium left, and the initial courses of progestogen produce the first bleeds after several months of build-up.
Heavy withdrawal bleeding generally responds to an increase in the dosage or potency of the progestogen used to balance the oestrogen. If bleeding continues despite alterations in dosage, it suggests the presence of uterine fibroids or endometrial polyps. These should be investigated by hysteroscopy and biopsy, and may be removed subsequently along with most of the endometrium by techniques including endometrial ablation. Even after this therapy, women need to keep taking progestogen as it is impossible to remove all of the endometrium.
Women who do not start HRT until several years after the menopause usually have less endometrium than those at, or with a recently completed, menopause. If you are older than that, the amount of endometrium may be insufficient to produce any visible withdrawal bleed. The absence of a withdrawal bleed indicates that there is little endometrium to be shed.
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