57 – Bleeding on HRT: what’s normal and what’s not

In this episode of The Dr Louise Newson Podcast, host Dr Louise Newson is joined by gynaecologist Mr Azami Najee to discuss the common and often alarming issue of bleeding while on Hormone Replacement Therapy (HRT). The conversation unpacks why bleeding occurs—especially during the initial months of HRT—as a normal physiological response to hormonal adjustment, rather than a sign of serious pathology. They emphasize that while bleeding can be distressing, it is frequently benign and linked to hormonal fluctuations, particularly in perimenopausal women. The doctors stress the importance of thorough history-taking, risk factor assessment, and context-specific evaluation, noting that cancer is extremely rare in this setting, especially when patients are on combined HRT with daily progesterone. They also challenge outdated myths about oestrogen causing endometrial cancer, clarifying that natural oestradiol is not linked to cancer and that continuous progesterone use actually reduces risk. The episode advocates for a nuanced, patient-centered approach to bleeding on HRT, urging clinicians to listen to patients’ concerns, avoid blanket advice like stopping HRT, and use tools like ultrasound to rule out treatable causes such as polyps. Dr Newson concludes by promoting her free Balance app as a resource for women to track symptoms and feel empowered in their healthcare decisions.