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It's normal to experience some vaginal bleeding when taking Hormone Replacement Therapy (HRT) during the menopausal transition. This may be due to the hormonal changes that hormone therapy treatment triggers. In some cases, especially during the initial stages of HRT or when the dosage of HRT is adjusted, breakthrough bleeding or spotting may occur as the body adjusts to the new hormone. Just to note, sometimes Hormone Replacement Therapy is also called Menopause Hormone Therapy.

While this is not a serious cause for concern for the majority of people, it is important to be aware of any changes in bleeding or spotting that occur during the course of HRT.

Breakthrough bleeding can be a sign of a hormonal imbalance or another underlying issue that should be looked into with your doctor. If you experience irregular bleeding, contact your doctor or Fertifa Patient Advisor to discuss further testing and potential treatments.

If there is a sudden change in menstrual pattern, intermenstrual bleeding (bleeding between periods), menopause symptoms, postcoital bleeding (bleeding after sex), or postmenopausal bleeding, we would recommend contacting your doctor or gynaecologist as soon as possible.

The side effects of taking HRT

It's recommended that the lowest dose of HRT should be taken, for the shortest time possible. Remember that each person is different, and each person may experience their own side effects of HRT that are unique to them. In addition to breakthrough bleeding, some people may experience side effects while taking HRT. These common symptoms can include:

- hot flushes (or hot flashes)

- night sweats

- mood swings

- changes in libido (sex drive)

- decreased libido (sex drive)

- vaginal dryness

- changes in skin health

- acne or thinning hair

As we know, these are some of the symptoms that are commonly experienced during menopause and perimenopause - and are often the reason people start HRT in the first place! People on HRT may also experience other symptoms such as headaches, nausea, dizziness, and fatigue. These can be caused by a variety of factors including the dosage of hormones or other medications taken in conjunction with HRT.

While these symptoms may be uncomfortable or even disruptive to everyday life, they usually get better over time as your body adjusts to the new hormone levels while taking HRT. Remember, HRT might not work for everyone and if the side effects of HRT are particularly difficult or persistent, it is important to speak to your doctor to discuss other possible treatment options.

What does breakthrough bleeding on HRT look like?

Vaginal bleeding whilst taking HRT may look like occasional spotting or brown discharge. There's often only a small amount of blood, knowing as 'spotting'. Remember, it's normal to see this whilst taking HRT.

The potential causes of postmenopausal bleeding

It is important to remember that vaginal bleeding during menopause is usually not a sign of serious medical concern. However, any changes in bleeding should be discussed with your healthcare provider to ensure that the correct treatment is being used.

Abnormal vaginal bleeding or painful bleeding in postmenopausal people can be a sign of cancer - such as gynaecological cancer, cervical cancer, uterine cancer, breast cancer, endometrial cancer or ovarian cancer. However, it is far more likely to be a menopausal symptom, or caused by other conditions caused by lower oestrogen levels. If you're experiencing abnormal bleeding, irregular bleeding, or heavy bleeding, don't panic. Book in an appointment with your doctor or Fertifa Patient Advisor who can decide what the best next steps are for you.

Potential causes of postmenopausal bleeding include:

• Inflammation and thinning of the vaginal lining (atrophic vaginitis) or womb lining (endometrial atrophy) – caused by lower oestrogen levels.
• Cervical or womb polyps – growths that are usually non-cancerous. Getting a pelvic ultrasound should help to identify if any polyps (womb polyps are also called endometrial polyps or uterine polyps as they grow inside the uterus) are contributing to bleeding.
• A thickened womb lining (endometrial hyperplasia) – this can be caused by hormone replacement therapy (HRT), high levels of oestrogen, or being overweight, and can lead to womb cancer.
• Ovarian, womb or endometrial cancer - unscheduled bleeding in postmenopausal can be an indication of endometrial cancer. This can include bleeding between menstrual periods, heavy or prolonged menstrual bleeding, or bleeding after menopause.

Speak to your doctor to determine the cause of unscheduled bleeding, and try not to worry as other factors like hormonal imbalances or benign conditions are much more likely to be the cause. Your doctor might want to look into your family history, take your blood pressure, and run some blood tests. At the appointment, you can also expect a physical examination including a pelvic exam, a transvaginal ultrasound to see your uterus, cervix, and ovaries better and possibly taking a tissue sample to check for cervical cancer cells or other abnormalities. Don't worry too much about these steps; your doctor or Patient Advisor can walk you through what to expect during these tests.

Bleeding in postmenopausal people taking HRT

People on Hormone Replacement Therapy may have an increased risk of experiencing bleeding depending on how it is taken. For example:

• Sequential/cyclical HRT: If you are taking progesterone for 12 days out of the month (known as sequential/cyclical HRT), your monthly menstrual period will continue.
• Combined hormone treatments: By contrast, combined menopausal hormone treatment, which uses both oestrogen and progesterone, is designed to stop vaginal bleeding entirely. Even so, irregular bleeding, unscheduled bleeding, or even heavy bleeding can be common up to 6 months after starting HRT.
• Oestrogen only HRT: People taking oestrogen only tablets will carry an increased risk of cancer, although this increase is minimal. This form of HRT is typically recommended to people who have had their womb removed, or who use an intrauterine system (IUS/coil). It is important for people taking HRT to be aware of the risks associated with bleeding. If you experience any unexpected or unscheduled bleeding, speak to your healthcare provider or doctor and let them know. They may suggest switching to another type of hormone replacement therapy or stopping use altogether.

Bleeding with HRT is caused by varying hormone levels, and so changing the dose of oestrogen levels and progesterone levels can help some people with this unexpected bleeding. Chat with your doctor or Fertifa Patient Advisor about what might be the best treatment for postmenopausal bleeding for you.

It's important to be aware of these potential side effects of HRT. These symptoms usually improve over time as the body adjusts to the new hormone levels but can be uncomfortable and disruptive in the meantime. If these side effects are impacting your daily wellbeing and comfort and continue to persist after months of treatment, we recommend speaking to your doctor or Fertifa Patient Advisor, who may want to look into a more detailed health history or family or medical history to try and find the root of abnormal bleeding and chat about alternative treatment options.

We know this can be a difficult topic, but remember, you're not alone 💜