Yorkshire Menopause Group
HRT - Troubleshooting guide

1. Poor control of symptomsCheck compliance Increase oestrogen dose Change oestrogen type Change route
2. PMS type symptomsReduce progestogen dose Change progestogen type e.g. to dydrogesterone / MPA Change progestogen route e.g. to vaginal gel / IUS Change to continuous-combined if appropriate
3. Skin reaction to patches'air dry' before applying Change site daily Change to gel

4. Bleeding problems:

Cyclical HRT-
4.1 Heavy / Painful bleedingIncrease progestogen dose Reduce oestrogen dose Add NSAID / Tranexamic acid Consider continuous-combined / Tibolone if appropriate Refer for investigation if problem persists
4.2 Bleeding early in cycle(before day 10 of progestogen on oral E or day 8 on transdermal)

Increase progestogen dose

Refer for investigation if persists

4.3 Unscheduled / intermenstrual bleedingIncrease oestrogen dose Refer for investigation if persists beyond 3 months
4.4 Change in bleeding pattern once established on HRTRefer
4.5 No withdrawal bleedNo action required - reassure
4.6 Dislike of monthly bleedsConsider Tridestra if cycle infrequent Consider continuous-combined or Tibolone if appropriate

Continuous-combined HRT/ Tibolone

4.7 Persistent but reducing spottingRefer for investigation at 12 months
4.8 Persistent bleedingRefer for investigation at 6 months
4.9 Recurrence of bleeding after amenorrhoeaRefer for investigation immediately
4.10 Increasingly heavy/frequent bleedingRefer for investigation immediately