Your frequently asked questions

Why do I not have regular bleeds with cyclical HRT?

The bleeds you get on cyclical HRT may not be as regular as those you experienced before the menopause or if you were taking the combined oral contraceptive pill. They tend to occur towards the end of the combined phase or at the start of the oestrogen phase (the tablets are coloured differently depending on the phase, as the pack leaflet will explain).

Also, some women (about 5%) do not have a bleed at all when on cyclical HRT. This is nothing to worry about, since it simply shows that the lining of the womb (endometrium) is very thin. However, one thing to consider if you are not experiencing a bleed is whether you could be pregnant.


Why am I still bleeding with ‘period free’ HRT?

The thinning of the lining of the womb produced by taking oestrogen and progestogen every day can take a number of weeks, and during this time it is very common for women to experience some vaginal bleeding. This bleeding is likely to be irregular and unpredictable. It can vary from the odd spot to normal period-like bleeding on and off for the first three months of therapy, gradually becoming less and less. The bleeding should be minimal by three months and it should have completely stopped by six months.

It is important to persist with the HRT in the first few months, since it is only with persistence that the bleeding stops. However, if you have any worries or if you think your bleeding is more than described above, please contact your surgery.


My hot flushes have improved but my vagina still feels sore.

Hot flushes will normally start to improve after about one month of HRT, and you should have the full benefit after about three months. However, vaginal soreness can take much longer to resolve, sometimes up to six months. You can either wait or you may want some extra treatment. Oestrogens can be given locally to the vagina in the form of a low dose cream, pessary, tablet or ring. These preparations raise local hormone levels but do not affect the whole body. Low doses of natural oestrogens (eg estriol or estradiol) are often used for this form of treatment. Extra progestogen is not usually needed, since these local doses of oestrogen do not affect the endometrium when used in the short term. After a while, it may be possible to stop the local therapy because your HRT will be having its full effect. However, long-term treatment may be needed if symptoms return when treatment is stopped.

My breasts are particularly tender, what can I do about it?

Breast tenderness is very common in the first few weeks after starting HRT and should get better by three months. You might find it helpful to take Oil of Evening Primrose, but it does not work for everybody.

If matters have not improved at three months you may want to try a different HRT. Your doctor may suggest a different type of progestogen or taking HRT in another way such as through the skin with a patch. It is worth checking that you are on the lowest dose of HRT that is effective for you.

I have put on a few pounds.

In the first few months, you may notice some fluid retention, which can cause you to feel bloated, but studies have shown no evidence that HRT causes significantly more weight gain overall than taking a placebo (dummy treatment, with no active medicine). However, it is true that most women, whether or not they take HRT, put on some weight after the menopause.

Will HRT increase my risk of breast cancer?

Between the ages of 50 and 65, about 32 women in every 1000 not on HRT will develop breast cancer. After five years on combined HRT (oestrogen and progestogen), the risk of breast cancer does increase slightly – an extra six women in every 1000 will be diagnosed with breast cancer in women aged 50-65 years. You should discuss this with your doctor or nurse if you are planning to take HRT in the longer term.

Do I need to have a mammogram because I have started HRT?

You do not need to have a mammogram just because you have started HRT. There is also no need to have screening mammograms performed more often than every three years (the recommended interval between screens in the NHS Breast Screening Programme) if you are taking HRT. However, if you develop any new breast symptoms while taking HRT, it is important that you see your doctor.

Do I need to have a smear because I have started HRT?

There is no need to have a smear because you have started HRT. However you need to continue to have cervical smears (to detect abnormalities or cancer of the womb entrance or cervix) every 3-5 years up to the age of about 64. There is no need to have them more frequently or after the age of 64 if you are taking HRT.

What will happen if I stop taking HRT?

If you stop taking HRT after only a few weeks, it is very likely that your symptoms, such as hot flushes, will come back. They may come back within a few days or weeks and may be worse than before, since there will have been a sudden change in hormone levels. Vaginal dryness may also come back.

I suffer from vaginal dryness but I don’t want to take HRT.

If you prefer not to take systemic HRT, or are unable to take it due to contraindications, then you may want to try local oestrogen HRT. These HRT products provide oestrogen directly to the vaginal tissues, with minimal absorption into the bloodstream. If vaginal dryness and painful intercourse are your main worries, then local HRT may be a good alternative for you, but you should be aware that local oestrogen does not improve other menopausal symptoms such as hot flushes.

My vaginal oestrogen cream is very good but messy to apply.

Local oestrogen is available in different types of preparations, not just cream. Other possible forms of local HRT include tablets that are inserted with an applicator, pessaries and vaginal rings.

I’ve heard women should try to take a low dose HRT but how do I know if mine is low dose?
Following the media reports about HRT in the last few years, a general recommendation has emerged that suggests women should be prescribed the lowest effective dose of HRT. This makes good medical sense and may help reduce side effects in some women. It is best to discuss this with your doctor.

I’ve been on cyclical HRT for five years and I’m getting tired of having periods well into my fifties.
If you have been on HRT for five years, you may be post-menopausal. It is generally assumed that a woman is post-menopausal if she has not had any natural periods for over 12 months. However, as you are on cyclical HRT, it is difficult to judge when your last natural period was. Most women are post-menopausal by the time they are 54* so if you are close to that age, you may wish to consider moving to a continuous combined, ‘period-free’ HRT but you will need to discuss this with your doctor.
* McKinlay et al. Am J Human Biol 1992; 4: 37-46.