Unscheduled Bleeding in Women Using HRT

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1 Background Information / Scope of Pathway

These pathways were developed to guide clinicians when managing unscheduled bleeding in women using HRT
The pathways are not provider specific and so the guidance and forms apply to all providers.

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2 Information Resources for Patients and Carers

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3 Development and Updates to this Pathway

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4 Referral Forms

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5 Patient presents with unscheduled bleeding (using HRT)

  1. Sequential/Cyclical HRT – it is normal to have a withdrawal bleed once a month
  2. Unscheduled bleeding is common up to 6 months after starting HRT
  3. Unscheduled bleeding can occur as a result of a women’s own endogenous ovarian activity that can be intermittent in the perimenopause
  4. The risk of unscheduled bleeding is greater if continuous combined HRT is started after less than 1 year of the LMP – so start sequential HRT instead – see Management of Menopause pathway
  5. Poor compliance with HRT can result in unscheduled bleeding

At any point GPs can seek advice from or refer to a healthcare professional with expertise in managing menopause using eReferral.

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6 Take History

    • When was the HRT started?
    • Check whether continuous combined or sequential HRT (as women may not know that they have a monthly withdrawal bleed with sequential HRT)
    • LMP before HRT was started?
    • Bleeding pattern before HRT was started?
    • Check for irregular intermenstrual bleeding or post coital bleeding before HRT was started

    Ask about missed HRT tablets

    History suggestive or malabsorption or history of malabsorption

    History suggestive of gastrointestinal upset

    Check medication and interactions – enzyme inducing medication can result in irregular bleeding as oestrogen is metabolised more quickly.

    • Check for the possibility of pregnancy – use of contraception where appropriate
    • Sexual history ?STI
    • Date of last smear
    • Assess risk of endometrial malignancy (obesity, diabetes, nulliparity, history or chronic anovulation, history of polycystic ovarian syndrome, late menopause, FH of hereditary nonpolyposis colorectal, endometrial or ovarian cancer)

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7 Examination

  • Inspect the vulva for skin lesions
  • Speculum to examine the vagina and cervix
  • Bimanual examination to assess uterine size
  • BMI

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8 Investigations

  1. There is no Ix needed if abnormal bleeding occurs up to 6 months of starting HRT as long as there is no suspicion of pelvic pathology from history or examination. This includes any bleeding on continuous combined HRT and prolonged or unscheduled bleeding on sequential HRT. Investigate abnormal bleeding with sequential HRT if bleeding was previously to schedule.

  2. Consider swabs or pregnancy test if appropriate from the history

  3. If there is no suspicion of pathology from history or examination, you can discontinue the HRT for 6 weeks. If bleeding persists after 6 weeks, refer as per the Abnormal Bleeding (post-menopausal) pathway. If bleeding stops, restart HRT, but consider using a different HRT to previous (see points on management below.)

    If bleeding recurs try changing the HRT as per boxes 10 and 11. If bleeding continues seek advice from gynaecology via eReferral Advice and Guidance.

    Similarly, if the irregular bleeding is associated with sequential HRT, see the comments below.

    If the patient does not want to stop HRT try changing the HRT as per boxes 10 and 11. If bleeding persists beyond 6 months – refer to gynaecology.

  4. Consider investigation of the endometrium where the risk of endometrial carcinoma is raised, even if less than 6 months of starting HRT – refer if in doubt.

  5. US can assess the thickness of the endometrium. On continuous combined HRT, the endometrium should be thin because of the continual effect of progestogens. On sequential HRT, the endometrium will vary according to where she is in the pack. Measuring the thickness is therefore less useful and the thickness can be similar to pre-menopausal levels.

    A post-menopausal cut off of 4mm does not apply as the patient is taking hormones.

    Pipelle of hysteroscopy is indicated if the endometrium looks abnormal, is significantly thickened or hyperplastic, or if it cannot be clearly defined.

  6. Vaginal bleeding of new onset while established on HRT, or persistent vaginal bleeding needs US and referral to gynaecology for consideration of hysteroscopy.
  7. Refer to gynaecology 2 week wait if any abnormalities found on examination – e.g. abnormal looking cervix, pelvic mass.

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10 Sequential/Cyclical HRT

  1. Irregular or heavy bleeding with sequential HRT
    • Double the dose of progestogen
    • Change the type of progestogen
    • Increase the duration to 21 days
    • Consider LNG-IUS as the progesterone combined with oral or transdermal oestrogen.
  2. Bleeding early in the progesterone phase – increase the dose or change the type of progesterone
  3. Lack of withdrawal bleed can result from an atrophic endometrium. Exclude pregnancy if peri-menopausal. Ensure compliance.

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11 Continuous Combined HRT

  1. Can try reverting back to sequential HRT
  2. Consider changing the continuous combined HRT
  3. Try increasing the progestogen
  4. Consider IUS plus transdermal or oral oestrogen
  5. Try tibolone

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12 Seek advice or refer to LTHT gynaecology single point of access

At any point GPs can seek advice from or refer to a healthcare professional with expertise in managing menopause using eReferral.