Choosing your HRT regimen: cyclical or continuous

If you have a womb and need HRT, oestrogen is taken alongside progesterone to protect the womb lining. There are two main patterns for how the progesterone is given, and which one suits you depends mostly on where you are in the menopause transition. This article explains the difference, when each is used, and how the decision is made.

Women who have had a hysterectomy and no longer have a womb do not need progesterone alongside their oestrogen, so the cyclical-versus-continuous question does not apply to them.

Cyclical, also called sequential

Cyclical HRT means oestrogen is taken every day, and progesterone is added for about twelve to fourteen days each month. Stopping the progesterone for the rest of the month triggers a withdrawal bleed, a few days of bleeding usually lighter than a natural period. This pattern is the default while you are still having natural periods or your periods stopped less than a year ago. It mimics the hormonal rhythm your body is still trying to produce, and the predictable bleed is part of why it works in perimenopause.

Continuous combined

Continuous combined HRT means both oestrogen and progesterone are taken every day, with no monthly break. The aim is no bleeding at all. Used in a post-menopausal woman, this pattern is the simpler one and the one most women settle into long term. It is the default once your periods have been finished for around a year, or you have completed about a year on cyclical HRT, or you are over 54.

Why the choice depends on where you are

If continuous combined HRT is given to a woman whose ovaries are still cycling, the body's own hormone activity collides with the steady daily dose, and the most common result is irregular, frustrating bleeding that is hard to investigate cleanly. Cyclical HRT works with that residual activity by giving a predictable monthly bleed. Once the ovaries have settled, the rationale flips: there is no residual cycle to work with, the aim is steady hormone levels with no bleeding at all, and continuous combined fits.

When to switch from cyclical to continuous

The usual triggers to move from cyclical to continuous combined are reaching about a year past your last natural period, completing roughly a year on cyclical HRT, or simply reaching an age (often 54) where post-menopause is the safe assumption. Done at the right time, the switch usually settles into a no-bleed pattern within a few months. Done too early, irregular bleeding is the typical result, which usually means going back to cyclical for a bit longer and trying again later.

The hormone-releasing coil as a third option

A hormone-releasing coil (such as the Mirena) sits in the womb and delivers progestogen directly to the lining. It provides the endometrial protection that an HRT regimen needs while also working as effective contraception, which matters in perimenopause because pregnancy is still possible. Used alongside transdermal oestrogen, a coil is a very practical regimen for many women: contraception, endometrial protection, and often lighter or absent periods, all in one device. It lasts several years before needing replacement.

What to expect about bleeding

Bleeding patterns are one of the things that often takes a few months to settle. On cyclical HRT, expect a regular monthly withdrawal bleed; missed or much heavier bleeds are worth flagging. On continuous combined, irregular bleeding in the first three to six months is common and usually settles to none. Bleeding that starts more than six months after a settled period of no bleeding, or that does not settle, should be checked rather than assumed to be the HRT.

How the choice gets made and revisited

At your assessment we choose the regimen that fits where you are, what you have tried before, and how you would prefer to manage bleeding. The choice is not final. Many women start on cyclical and switch to continuous combined when the time is right. Some change form (gel to patch, tablet to coil) over the years for practical reasons. The aim is the right regimen for now, reviewed and adjusted as you go, rather than something you commit to once and stick with regardless.

The honest summary

There is not a single best HRT regimen; there is the regimen that fits where you are. Cyclical for women still having periods or recently past them, with a predictable monthly bleed. Continuous combined once periods have settled, with the aim of no bleeding at all. A hormone-releasing coil is a practical third option that doubles as contraception. The regimen is reviewed and adjusted as your symptoms and stage change, and unexplained bleeding is always worth investigating rather than waiting out.

Ready to start?

If you want to move from reading to acting, the next step is a short assessment with a doctor on the GMC GP Register. It takes about ten minutes and tells you whether HRT is right for you.

Begin your assessment at this link. Online or in person at Westfield London.