If you're navigating perimenopause or menopause, hormone replacement therapy (HRT) can be a powerful way to manage symptoms like hot flushes, night sweats, mood swings and brain fog.
However, when it comes to HRT and periods, things can get confusing. You might be wondering whether you have to wait for your periods to stop before starting treatment or if starting HRT can cause your periods to return.
In this article, we answer common questions about HRT and periods, from how different HRT types affect bleeding patterns to what’s normal and when to speak to your doctor.
Can I start HRT if I'm still having periods?
You don’t have to wait until your periods have stopped to start HRT. Many women begin treatment during perimenopause, the transitional stage before menopause, when hormone levels start to fluctuate and periods become irregular. For many women, perimenopausal symptoms can be more intense than those experienced after periods stop, which makes starting HRT earlier pivotal to symptom relief.
During this phase, your doctor may prescribe sequential combined HRT, which mimics your natural cycle and includes progesterone for the end of your cycle [1]. This usually leads to a regular withdrawal bleed similar to a period, though it may be lighter or shorter.
Does HRT stop periods?
HRT may stop periods, but not always. It depends on the type of HRT regimen you're using and whether you're still in perimenopause or postmenopausal.
Sequential combined HRT
Sequential combined HRT (also known as cyclical combined HRT) is recommended if you’re still having periods or it's been less than a year since your last one.
It contains oestrogen and progesterone, with the hormones taken in a way that emulates the natural menstrual cycle. Over a 28-day cycle, you take oestrogen every single day and progesterone (such as Utrogestan) is added in for 10-14 days. This HRT cycle then starts again, without a break.
This causes a regular withdrawal bleed, where the lining of the womb is shed. This typically occurs at the end of each course of progesterone, but this isn’t a ‘true’ period [1].
Continuous combined HRT
Continuous combined HRT is usually prescribed if you’re postmenopausal (it’s been more than 12 months since your last period). It contains oestrogen and progesterone and is taken daily, without a break.
With this form of HRT, there should be no menstrual bleeding as your periods should have stopped beforehand. However, it can cause some irregular bleeding in the first three to six months of usage [1].
If you experience heavy bleeding, it continues for more than six months, or you suddenly begin bleeding after months with no bleeding, you should speak to your doctor.
Mirena coil
If you’re using a Mirena coil as the progesterone part of HRT, it can make them lighter or shorter, or even stop them altogether.
However, it’s not uncommon for your periods to become longer, irregular or more frequent within the first three to six months after having a Mirena coil fitted, as your body becomes accustomed to the progesterone being released [2].
Can HRT cause periods?
HRT can’t make your periods come back or delay when they naturally end. However, many women will experience some temporary spotting or irregular vaginal bleeding within the first few months of starting HRT [3]. This is because it can take some time for your body to adjust to the increased levels of oestrogen and progesterone.
Sequential combined HRT
If you are prescribed sequential HRT, you will likely have a withdrawal bleed every month. Around 85% of women experience this type of regular bleeding, though it may be lighter than natural periods [4].
Continuous combined HRT
Research shows that up to 80% of women experience breakthrough bleeding in the first month after starting continuous combined HRT, and up to 50% may still have some irregular bleeding after six months [5].
This usually settles with time, but if vaginal bleeding persists for more than six months or becomes heavy, you should speak to your GP as you may need to change the dosage or type of HRT you are taking.
Can HRT cause heavy periods?
HRT can sometimes make bleeding heavier, especially in the early stages, although this is typically a temporary side effect. If you’re experiencing heavy periods on HRT, or if you have irregular bleeding or spotting that becomes heavier than expected, speak to your doctor. You might need a change in dose, a different type of HRT, or investigations to rule out other causes.
What if I don’t get a bleed on cyclical HRT?
If you're using sequential combined HRT but notice no period 7 days after stopping progesterone, it isn't necessarily a cause for concern. Bleeds may become lighter or even stop as your body moves closer to menopause. However, it’s important to let your doctor know so they can assess whether any changes are needed.
When should I switch from sequential to continuous HRT?
The switch to continuous combined HRT is usually made when you’ve been period-free for at least 12 months [1], but it isn’t always straightforward. Some women stop bleeding naturally while still on sequential HRT, making the timing less clear. Others may continue to have regular withdrawal bleeds even though their natural periods have ended.
General advice is to avoid staying on sequential HRT for more than five years, due to a slightly increased risk of endometrial cancer [6]. The British Menopause Society recommends that women over the age of 45 taking sequential HRT should be offered a change to continuous combined HRT after 5 years or when they reach 54 (whichever comes first) [6]. If you switch to continuous HRT and bleeding returns, you may need to go back to the cyclical form for a while longer.
Can HRT regulate periods?
HRT isn’t designed to regulate natural menstrual cycles in the same way as hormonal contraception. However, sequential HRT can offer a more predictable bleeding pattern during the unpredictability of perimenopause. Some regimens may also help with heavy or erratic bleeding, but treatment should always be tailored to your individual needs.
It’s also important to remember that HRT won’t restore periods or extend your fertility, nor does it act as a contraceptive, even if it stops your periods.
If you are seeking a way to regulate your periods rather than alleviate menopause symptoms, other hormonal treatments, such as the combined contraceptive pill or the Mirena coil, may be more appropriate.
HRT can be a highly effective way to manage perimenopausal and menopausal symptoms, and with the right support, you can find a regimen that works for you, whether your periods have stopped or not.
¹National Institute for Health and Care Excellence. Menopause: Identification and Management (NG23).
Updated 7 Nov 2024. https://www.nice.org.uk/guidance/ng23
²Faculty of Sexual & Reproductive Healthcare (FSRH). FSRH Guideline: Intrauterine Contraception. Dec 2023. https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf
³British Menopause Society & Women’s Health Concern. 2020 Recommendations on HRT in Menopausal Women (updated Sept 2023). https://thebms.org.uk/publications/consensus-statements/bms-whcs-2020-recommendations-on-hormone-replacement-therapy-in-menopausal-women/
⁴British Menopause Society.Management of Unscheduled Bleeding on Hormone Replacement Therapy (HRT). November 2024. https://thebms.org.uk/wp-content/uploads/2024/12/01-BMS-GUIDELINE-Management-of-unscheduled-bleeding-HRT-NOVEMBER2024-A.pdf
⁵Lou, Ying Ying, Jeyanthan Kannappar, and Sahathevan Sathiyathasan. “Unscheduled Bleeding on HRT – Do We Always Need to Investigate for Endometrial Pathology?” The Obstetrician & Gynaecologist, vol. 21, no. 4, 2019, pp. 271–78. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/tog.12553
⁶British Menopause Society. Progestogens and Endometrial Protection. 2023. https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf
