How should persistent or breakthrough bleeding on hormone therapy be evaluated and managed?

Persistent or breakthrough bleeding on hormone therapy should always be evaluated to rule out serious causes and to ensure your treatment is optimized. Here at Alloy, we recommend the following approach, which is also supported by menopause experts:

1. Evaluation:

   • If you experience persistent or recurrent bleeding after the first 3-6 months of starting hormone therapy, it's important to see your healthcare provider.
   • Your provider may perform a transvaginal ultrasound to assess the thickness of the endometrial lining (the "endometrial stripe").
   • An endometrial biopsy may be done in the office to sample the uterine lining and rule out conditions like endometrial hyperplasia or cancer.
   • Other causes, such as polyps, fibroids, vaginal atrophy, or infections, may also be considered and evaluated.

2. Management:

   • If the bleeding is due to hormone therapy, your provider may adjust your estrogen or progesterone dose. Sometimes, reducing estrogen or ensuring adequate progesterone can help stabilize the uterine lining.
   • If a structural cause (like a polyp or fibroid) is found, specific treatment such as removal may be recommended.
   • If the bleeding is due to vaginal atrophy (thinning of vaginal tissues), adding or adjusting local vaginal estrogen may help.

3. When to Seek Help:

   • Any postmenopausal bleeding should be evaluated, especially if it persists or is heavy.
   • If you are perimenopausal, some irregular bleeding can be normal, but persistent or bothersome bleeding should still be discussed with your provider.

For a detailed discussion on evaluating and managing persistent or breakthrough bleeding, check out these helpful resources:

• Spotting During Menopause: Is It Normal?
• Bioidentical Hormone Replacement Therapy: Insiders' Guide

You may also find it helpful to watch the following YouTube chapters, which explain how persistent bleeding is evaluated and managed:

• Evaluating Persistent Vaginal Bleeding
• Managing Irregular Bleeding on Hormone Therapy

If you are looking for hormone therapy options or want to personalize your treatment, explore our estradiol patches, estradiol pills, or estradiol vaginal cream. You can also fill out our medical intake to receive a personalized menopause treatment plan from a menopause-trained doctor at Alloy.

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This answer was created using the following resources:

• Answering Your Perimenopause & Menopause Questions | Dr. Kudzai Dombo - Evaluating Uterine Lining Overgrowth on Hormone Therapy
• Vaginal Symptoms in Peri/Menopause | Dr. Darwana Ratleff Todd - Audience Q&A: Bleeding, Allergies, and Atrophy
• Hormone Therapy 101 (pt.3) | Dr. Corinne Menn - Managing Irregular Bleeding on Hormone Therapy
• Understanding Hormones During Menopause | Dr. Mary Jane Minkin - Adjusting Hormone Therapy for Persistent Symptoms
• Spotting During Menopause: Is It Normal?
• Catching Up with Dr. Darwana Ratleff-Todd | Alloy
• Bioidentical Hormone Therapy: Your Comprehensive Guide