Continuous vs Sequential HRT: Which Regimen Is Right for You?
Continuous and sequential HRT suit different stages of the menopause transition. Learn who each is for, how bleeding patterns differ, and how to switch.
Why HRT Regimen Type Matters
Not all HRT is the same. The regimen, meaning how oestrogen and progestogen are combined and timed, is chosen based on where you are in the menopause transition. Choosing the wrong regimen can lead to unpredictable bleeding, endometrial risk, or simply a worse symptom experience than necessary. Understanding the difference between sequential (also called cyclical) HRT and continuous combined HRT, and why one tends to suit perimenopause while the other suits postmenopause, helps you have a more productive conversation with your prescriber.
Sequential HRT: Designed for Perimenopause
Sequential HRT gives oestrogen continuously throughout the month and adds progestogen for a set number of days, typically 12 to 14 days. This mimics the natural hormonal cycle. When progestogen is withdrawn, the uterine lining sheds and a withdrawal bleed occurs, usually predictable in timing and lighter than a typical period. This scheduled bleed is normal and expected. Sequential HRT is recommended for women who are still having periods, however irregular, because their natural cycle means the endometrium is not in a stable state. Using continuous combined HRT in a woman who is still cycling or only recently menopausal increases the risk of irregular, unpredictable bleeding and may be less effective at protecting the uterine lining.
Continuous Combined HRT: Designed for Postmenopause
Continuous combined HRT delivers both oestrogen and progestogen every day without a break. Over time, this keeps the uterine lining thin and inactive, so no withdrawal bleed occurs. Most women find the absence of any monthly bleed a significant quality-of-life benefit. However, in the early months on continuous HRT, particularly if started too soon after the last period, irregular spotting or breakthrough bleeding is common as the endometrium adjusts. Continuous HRT is recommended for women who have been postmenopausal for at least twelve months and are not having periods. The standard guidance is to wait until a woman has had no periods for a year before switching from sequential to continuous.
Breakthrough Bleeding: What Is Normal and What Needs Checking
On sequential HRT, a regular withdrawal bleed is expected and not a concern. Bleeding that is very heavy, occurs at unexpected times in the cycle, or does not follow the progestogen withdrawal is worth reporting to your prescriber. On continuous HRT, irregular spotting in the first three to six months is common and often settles as the endometrium thins. Bleeding that persists beyond six months, becomes heavier, or begins after a period of being bleed-free on continuous HRT warrants investigation, including a transvaginal ultrasound, to rule out endometrial pathology. Spotting and irregular bleeding should always be assessed rather than assumed to be benign.
How to Transition from Sequential to Continuous HRT
The transition from sequential to continuous HRT is typically made after twelve months of no natural periods, though in practice this can be difficult to determine when periods have been irregular for some time. Your prescriber may use a combination of age, symptom pattern, and FSH levels to judge the right time. The switch itself is usually straightforward: your prescriber changes the prescription to a continuous combined preparation. Some women experience a period of spotting during the adjustment. If you are unsure whether you have reached postmenopause, your prescriber can advise on timing. Switching too early is the main reason women experience problematic bleeding on continuous regimens.
Progestogen Scheduling and Endometrial Protection
The progestogen component of HRT is essential for any woman with a uterus. It protects the endometrium from the proliferative effects of oestrogen, which without opposition would increase endometrial cancer risk. In sequential HRT, progestogen is given for at least 12 days per month to ensure adequate protection. Shorter durations increase risk. In continuous HRT, the daily progestogen dose is lower but given every day, maintaining a thin endometrium. The specific progestogen used also matters: body-identical micronised progesterone (Utrogestan) has a more favourable profile than older synthetic progestogens for cardiovascular and breast tissue considerations, and many prescribers now prefer it. Discussing which progestogen you are prescribed and why is worthwhile.
Discussing Your Regimen with Your Prescriber
Before your next prescription review, it is helpful to know your current bleeding pattern, how long it has been since your last natural period, and any side effects you are experiencing. If you are on sequential HRT and your periods stopped more than a year ago, ask whether it is time to consider switching. If you are on continuous HRT and having persistent breakthrough bleeding, ask for an assessment of the endometrium. Tracking your bleeding dates, symptoms, and progestogen timing in an app like PeriPlan helps you bring accurate data to these conversations rather than relying on memory. HRT regimens are not set in stone, and adjustments based on your evolving perimenopausal status are a normal part of ongoing care.
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