HRT Cycling: Should You Do It?

It’s Q&A Day at 10almonds!

Have a question or a request? We love to hear from you!

In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!

So, no question/request too big or small 😎

❝I started HRT about 6 months ago, I take it every day, but now I’m reading there may be some benefits to skipping days like with birth control, to simulate a cycle. What does science say about this?❞

We will start by assuming that you began HRT at clinical menopause, that is to say, one year after your last period, or else that you began it after that point, not before. We realize this assumption may be incorrect, but it affects the answer, as we will explain, so it’s necessary to state this assumption up-front.

With that in mind…

The quickest and easiest answer is that if everything is fine as it is, there’s no need to fix what isn’t broken! That is to say, if you are not experiencing menopause symptoms, your serum hormone levels are equivalent to a normal premenopausal average, and you are not experiencing vaginal bleeding, then probably all is well.

With regard to “vaginal bleeding”, we do use those words and not “menstruation” in this case, because not all vaginal bleeding is menstruation.

Within the first 6 months or so postmenopause, it’s very common to have a brief, light, reprise of menstruation. There’s no egg involved, but your uterus (assuming you have one) will be cued to shed its lining as before. Obviously, this won’t happen if you’ve had a hysterectomy—but you may still get other period symptoms, including cramps in the uterus you don’t have.

You may be wondering how this latter happens: hormones are just messengers, and will deliver their message as best they can. In the case of having an important message to deliver to the uterus, and there being no uterus there to receive it, the message will be left with the nearest tissue resembling the uterus, which is the very similar (almost identical, in fact) smooth muscle of the gut. Which will then cramp, because it got instructions saying “cramp now”.

For more on that, see: HRT Side Effects & Troubleshooting

Later postmenopause, you should not be bleeding down there, at all, ever, and if you are, it’s cause for concern. Not cause for panic though; just, concern. The reason for such bleeding may be anything from fibroids to endometrial cancer, and it’s worth getting check out.

For more information about that, see: When A Period Is Very Late (Post-Menopause)

Non-bleeding period symptoms can (and often will) still occur in the case of taking menopausal HRT, even without cycling (i.e., skipping a few consecutive days each month; exact number of days may vary from prescriber to prescriber, but is invariably 3–7 days, with 5 days being common).

The reason for this is because even if you’re taking the hormones at the same amounts each day, your hypothalamus can and will influence the body’s use of those hormones (e.g. how much to metabolize). Premenopause, it is your hypothalamus, and not your uterus, your ovaries, or the phase of the moon, that regulates the monthly hormonal cycle. So, it can (and often will) do that in cases of treated menopause, just the same. Your hypothalamus neither knows nor cares whether your estrogen came from your ovaries or the pharmacy, and will treat it just the same.

That said, just because the hypothalamus regulates hormone metabolism doesn’t mean that you can just give it any amount because the hypothalamus will regulate it; it can still get overwhelmed if you do give it far too much to work with. See for example: What Happens If Your Estrogen Gets Too High? ← but this is much, much rarer than having too little

What if I began HRT pre-menopause?

Including: if pre-menopause you had hormonal birth control, and now have shifted your HRT up a gear into full menopausal HRT (the doses for this are typically orders of magnitude higher than the doses for birth control).

In this case, yes, regretfully (because it’s not fun), there is a case for hormone cycling, just as there was during birth control. The reason for this is less because it’s important to get the symptoms, and more because it’s best to not impede the body’s natural process of menstruation, as stopping it while it still has eggs to send forth can increase the risks of various things going wrong (including PCOS and endometriosis).

You can read more about that, here: Contraception meets HRT: seeking optimal management of the perimenopause

However, once you find you have stopped menstruation (i.e. even if other period symptoms persist, there is no more monthly bleeding), there should be no reason not to just take your HRT daily.

Last thing: good HRT management involves regular testing of your hormone levels. You should have a blood test done before any change to your HRT regime, and 1–3 months after the change to it, to check the difference. And if you’re not making any changes to your HRT regime (i.e. you have been taking the same dose with acceptable blood levels for many months and are just staying on this now), then you should still get a blood test every 6 months or so, just to be sure that nothing’s going off-piste and everything’s still working the same.

Want to learn more?

You might like this excellent book that we reviewed a while back:

The Menopause Manifesto – by Dr. Jen Gunter

Take care!