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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

Women presenting with unscheduled bleeding on HRT should have an initial clinical assessment in primary care including vaginal examination to establish the location of bleeding.

Ultrasounds that show an endometrial polyp in the context of unscheduled bleeding on HRT should be referred on the USCP pathway.

Endometrial Cancer risk factors

Major

Minor

BMI >40

Genetic predisposition e.g. Lynch or Cowden syndrome

Estrogen-only HRT for >6months in women with a uterus

Tricycling HRT (quarterly progestogen) for >12months

Prolonged sequential HRT regimen: use for >5years when started in women aged ≥45

≥12months of inadequate progestogen cover* within sequential HRT

BMI 30-39

Unopposed estrogen >3months (<6months)

Tricycling HRT (quarterly progestogen) for >6months but <12 months

>6months (<12 months) of inadequate progestogen* with sequential HRT

Disproportionate progestogen to estrogen dose for >12 months (including >5years 52mg LNG-IUD)

Diabetes

Anovulatory cycles, including PCOS

* Women using sequential HRT should have a minimum

10 days of norethisterone or medroxyprogesterone acetate per month

12 days of micronized progesterone per month

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, with appropriate urgency.

Pelvic ultrasound:

NBT - A direct access pelvic ultrasound (TVUSS) request should be made with appropriate urgency as per above flowchart.
- Urgent Suspicion of Cancer (USC) ultrasound AND a USC pathway referral.
- Urgent ultrasound request (6weeks) as per unscheduled bleeding on HRT pathway

NB: October 2024 – the NBT referral ultrasound referral pathway has been updated and clinicians in primary care can and should directly request an ultrasound with appropriate urgency +/- make an USC pathway referral. – not ready to update yet, this will be the new wording once NBT confirm, which they haven’t….

UHBW - A direct access pelvic ultrasound (TVUSS) request should be made with appropriate urgency as per above flowchart.
- Urgent Suspicion of Cancer (USC) ultrasound AND a USC pathway referral. 
- Urgent ultrasound request (6weeks) as per unscheduled bleeding on HRT pathway

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.