What Your Doctor is Really Thinking #7: You’ve been on cyclical HRT for 3 years and you want to switch to a continuous regime

You’ve been on HRT for three years and you want to switch to continuous HRT. Loads of your friends are on HRT that means they no longer have to put up with a monthly bleed, yet here you are - still going through the motions like a teenager.

I get it. There’s one silver lining to menopause and that’s the end of the dastardly periods. Yet here you are, hot flushes and acne in full swing, anxiety like you’re about to bungee-jump from the Eiffel Tower, you have no idea where you’ve left your glasses, and every month you get kicked in the guts with yet another period.

Where is the justice?

Every HRT journey is different. The theory is simple, yet the application of it can be a very different story. The theory is built on scenarios involving hypothetical, uncomplicated women with a medical history that features little more than a bout of chicken pox as a child.

You are very likely not that woman!

To work out what might be possible, I need to know the details of what came before, what’s happened since, and what other considerations there might be for you.

• How long ago did you start on HRT and how old are you now?

• What was happening before you started on HRT?

• How frequent and/or regular were your periods?

  • Had you had a few months without any bleeding at all before your doctor put you on this god-forsaken regime that brought back a monthly bleed that you thought you were getting rid of?

• What has your bleeding been like on your current regime?

• What is you current HRT regime - what type and formulation of oestrogen and what type and formulation of progestin?

I’m not trying to be obstructive with my gazillion questions, I just need to understand all of this before we can have a sensible discussion about what might come next.

The timing of a switch from cyclical to continuous HRT is notoriously tricky.

Get it right and you sail off into the deep blue, post-menopausal yonder, period-free.

Get it wrong and you’ll have unscheduled bleeding that sees you whisked off down a route of transvaginal ultrasounds and endometrial biopsies, that may be entirely appropriate, but possibly could have been avoided.

The aim is to make the switch when you are truly postmenopausal (ie. One year after the cessation of your natural periods). The fly in the ointment is that we’ve been messing with the system, meaning your bleeding pattern alone won’t always point to the answer.

Blood tests are rarely give us the whole answer because the exogenous hormones (the one’s in we’ve been giving you) artificially influence the lab results.

Not usually.

It’s one area where medicine really is more art (a dark one at that!) than science.

The plan depends on your situation. Here are three typical cases - hopefully you’ll recognise yourself in one of them:

You’re 52 and had been period free for 11 months before you started on HRT 3 years ago → It’s time to switch to continuous (probably could have done this after 12 months on a cyclical regime)

Your ovaries already had one foot out the door three years ago - they are very likely tucked up in bed by now. The party’s over.

You’re 46 and were having very regular heavy periods when you started on HRT 3 years ago. You’ve continued to have heavy bleeding on the cyclical regime → It’s a gamble.

You may well not be postmenopausal yet and there isn’t an easy way to tell. You could opt to stick with the predictable cyclical regime for another year or two, or risk the switch which may result in unscheduled bleeding and the subsequent disruption, anxiety and investigations that often triggers.

You’re 56 and were still having regular periods when you started HRT 3 years ago. You still have a very light bleed each month on your cyclical regime → Time to switch.

At 56, it’s highly likely that you are post-menopausal based on age alone. Not a guarantee, but a pretty safe bet.

As you can see, it is far from straight-forward. You might feel, after all that questioning, that I should have a definitive answer for you, but midlife medicine is rarely like that. I already know you aren’t average, so the textbook plans for average women seldom apply.

Your plan will be one peppered with caveats and maybes and safety-netting. Sometimes you have to take a leap of (well-informed) faith and see what happens.

An important note: bleeding in the first three months of an HRT change is not uncommon. Bleeding after three months on a continuous HRT regime needs prompt investigation - don’t ignore it.

HRT is complicated.

You are not average.

And I’m not a wizard.

These three things mean there may be some to-ing and fro-ing when it comes the right time to make the switch from cyclical to continuous.

You will get there. Through all the chaos of menopause, at some point you will be period free - and what a liberating time that will be! Skinny dipping any time you damn-well like.

* The content of these emails/posts/publications/audio files is intended as general health and wellness information, not as individual medical advice. Please consult your own doctor for advice that is specific to you and your needs.