Continuous vs Cyclical HRT for Perimenopause: Which Regimen Suits You?

Same Hormones, Different Schedules

You have decided to explore hormone replacement therapy, or your doctor has recommended it. Then the next layer of questions appears: continuous or cyclical? Combined or sequential? Bleed or no bleed?

The terminology can feel like a puzzle when you are already navigating a lot. But the distinction between continuous and cyclical HRT is a practical one that matters to how you feel day to day and what you can expect physically.

This article explains both approaches clearly so you can have a more productive conversation with your provider.

What Is Cyclical HRT?

Cyclical HRT, also called sequential HRT, involves taking estrogen every day while taking progestogen for only part of the month, typically 10 to 14 days. During the days when progestogen is not taken, a withdrawal bleed usually occurs.

This mimics the hormonal pattern of a natural menstrual cycle, with a built-in bleed phase. It is most commonly recommended during perimenopause, when periods are still occurring, even if they have become irregular.

Cyclical HRT is generally the preferred starting approach for people who are still having periods, because it is designed to work alongside a body that still expects a cycling hormonal pattern.

What Is Continuous Combined HRT?

Continuous combined HRT means taking both estrogen and progestogen every day without any breaks. Because progestogen is present continuously, the uterine lining does not build up, and no withdrawal bleed occurs.

This approach is typically recommended for women who have been postmenopausal for at least one year, meaning periods have completely stopped for 12 consecutive months. Starting continuous HRT too early, while the body still expects a cycle, can lead to irregular or unpredictable spotting.

Continuous HRT is simpler to manage for many people because there is no cycling schedule to track. It also avoids the regular bleed that cyclical HRT involves, which many people prefer in the longer term.

Key Differences in Practical Terms

The most obvious practical difference is bleeding. Cyclical HRT produces a regular, predictable withdrawal bleed each month. Continuous HRT, once the body adjusts, typically results in no bleeding at all, though irregular spotting is common in the first few months.

Hormone stability differs as well. Cyclical HRT involves fluctuating progestogen levels that may cause some symptoms to vary across the cycle, particularly in the days after progestogen is stopped. Some people experience mood changes, bloating, or other symptoms tied to the progestogen phase.

Continuous HRT tends to produce more stable hormone levels day to day, which many people find easier to tolerate once the initial adjustment period passes.

Both regimens use the same types of estrogen and can be delivered via patches, gels, sprays, or tablets. The difference lies in the progestogen schedule, not the estrogen delivery.

Benefits and Limitations of Each Approach

Cyclical HRT benefits include suitability during active perimenopause when periods are still present, a more familiar cycling rhythm, and flexibility if you want to stop and have a period on a predictable schedule. Limitations include the ongoing monthly bleed, the potential for mood variability across the progestogen phase, and the need to track your supplement schedule.

Continuous combined HRT benefits include no monthly bleed once established, stable daily hormone levels, and simplicity in dosing. Limitations include that it is not suitable for those still regularly menstruating, that unpredictable spotting is common in the first three to six months, and that any unexpected bleeding beyond the first year warrants prompt medical evaluation.

Neither regimen is inherently superior. The right choice depends on where you are in your perimenopausal transition and what your priorities are.

Who Is Best Suited to Each Regimen

Cyclical HRT suits people who are still having periods, even if they are irregular. If you have had a period in the last 12 months, cyclical is generally the recommended starting point. It also suits people who prefer a bleeding pattern, whether for reassurance that the endometrium is being shed regularly or for personal comfort.

Continuous HRT suits people who are postmenopausal (no period for 12 months or more), people who found the progestogen phase of cyclical HRT difficult to tolerate, and people who prefer not to have a monthly bleed going forward.

For those in the later stages of perimenopause, where periods are becoming very infrequent, the transition from cyclical to continuous HRT often makes sense and can be discussed with your provider.

Monitoring and Follow-Up

Whichever regimen you use, regular follow-up with your healthcare provider is important. Any unusual bleeding, particularly bleeding that occurs outside of the expected withdrawal phase in cyclical HRT, or any bleeding beyond the first six months of continuous HRT, should be evaluated.

Symptom tracking across the cycle can help you and your provider identify whether your progestogen phase is causing mood or physical side effects, which can influence decisions about the type or timing of progestogen.

PeriPlan lets you log symptoms daily so you can see patterns across your cycle and compare symptom severity across different phases of your HRT schedule. That kind of dated record is useful in clinical conversations.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.