How should I adjust the HRT regimen when bleeding occurs within the first six

In patients without endometrial cancer risk factors, adjust the progestogen or HRT preparation for a total of 6 months if unscheduled bleeding occurs within 6 months of starting HRT or persists 3 months after a dose or preparation change NICE CKS.

• Check adherence and correct use, particularly the progestogen dose and duration; consider a combined patch or pill to reduce administration errors NICE CKS.
• Ensure the progestogen dose is proportionate to the oestrogen dose; with high-dose oestrogen, consider increasing continuous micronised progesterone from 100 mg to 200 mg daily for adequate endometrial protection NICE CKS.
• Offer a 52 mg LNG-IUD, which reduces unscheduled bleeding compared with other preparations NICE CKS.
• Consider oral rather than transdermal HRT if there are no thrombosis risk factors, because oral preparations produce higher rates of amenorrhoea NICE CKS.
• Add vaginal oestrogen if examination identifies atrophy NICE CKS.

If bleeding persists after 6 months of adjustments, discuss urgent transvaginal ultrasound within 6 weeks versus weaning off HRT and considering non-hormonal alternatives NICE CKS.

Investigate rather than simply adjusting HRT if bleeding is heavy or prolonged, or first presents more than 6 months after starting HRT or more than 3 months after a change: arrange urgent transvaginal ultrasound within 6 weeks NICE CKS.