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Unexpected bleeding, known as breakthrough bleeding, can occur at any time of the month if you are taking both oestrogen and progestogen throughout your cycle. If you are on progestogen for only part of the cycle it can occur at times other than the end of the progestogen phase, and in such cases a thorough assessment by hysteroscopy is essential. If there is no problem with the endometrium, the dose of hormones is probably inadequate. The bleeding is usually stopped by alterations to the dose or potency of the oestrogen or progestogen.

If you do not want to have to cope with any bleeding, a change to the combined oestrogen and progestogen regimen may reduce breakthrough bleeding, or else you may consider having your endometrium removed. Paradoxically, although fewer women experience withdrawal bleeds with the combined format, about 10 per cent are still experiencing breakthrough bleeding a year later. The problem of breakthrough bleeding appears to be worse in women who are close to menopause or who have a recent history of disturbed bleeding, and it is for this reason that they are more likely to be given progestogen for part of the cycle rather than throughout it. Older women who are commencing HRT after several years without a bleed seem to have fewer problems with breakthrough bleeding.

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