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Unscheduled bleeding on HRT (DRAFT)

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Unscheduled bleeding

The BMS definition is ‘Unscheduled bleeding on hormone replacement therapy (HRT) is defined as irregular bleeding which occurs after initiating, or changing, an HRT preparation which should be ‘bleed free’ – continuous combined hormone replacement therapy (ccHRT) or, which occurs, in addition to the scheduled monthly withdrawal bleed in persons taking sequential preparations (seqHRT).’

It is common to have unscheduled bleeding in the first 6 months of starting HRT or within 3 months of changing the dose or preparation of HRT. Bleeding outside of this should be investigated.

It is not normal to have heavy or prolonged bleeding on seqHRT i.e. bleeding most days of the month or withdrawal bleeds which last more than 7 days or are reported as flooding/clots. This should be investigated as unscheduled bleeding (see below). If women are presenting with these symptoms prior to commencing HRT, this should be investigated as appropriate before starting HRT. (Please see Remedy Guidelines: Abnormal vaginal bleeding)

The BMS has published detailed and helpful guidance on management of unscheduled bleeding on HRT which should be followed.

Management of unscheduled bleeding on hormone replacement therapy (HRT) - British Menopause Society (thebms.org.uk)

Investigations

Please see the attached flowchart for unscheduled bleeding on HRT.

Management

Adjusting HRT

The BMS guidance details full advice (summary copied above).

Assess adherence and understanding of how to use prescribed preparations, consider switching if likely to be beneficial (e.g. combined preparations rather than separate medications)

Ensure the progestogen dose is proportionate to the oestrogen dose (see dose section of HRT page)

Offer all eligible women a 52mg LNG-IUD as this is associated with the least amount of unscheduled bleeding

If eligible, oral preparations provide higher rates of amenorrhoea

Offer management for atrophy if present on examination (Genitourinary symptoms)

Referrals

Please refer to gynaecology at UHBW or NBT in line with local pathways, as per the flowchart above.

December 2024 - Please note the changes to local pathways.

NBT and WGH: Clinicians should now directly request ultrasound scans either as part of a USC referral or as an urgent scan within 6 weeks – see flow chart above.

UHB: For USC referrals, ultrasound scans will be arranged by Gynaecology and do not need to be requested by primary care. Urgent ultrasounds scan can still be requested by primary care – see flow chart

Resources

Patients Resources

Postmenopausal bleeding - NHS (www.nhs.uk)

Hysteroscopy - NHS (www.nhs.uk)

IUS (intrauterine system) or hormonal coil - NHS (www.nhs.uk)

Resources and References

Management of unscheduled bleeding on hormone replacement therapy (HRT) - British Menopause Society (thebms.org.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.