Starting Menopause Hormone Therapy (MHT)—also called Hormone Replacement Therapy (HRT)—can be life-changing. Many women experience relief from hot flashes, brain fog, joint pain, insomnia, and even mood shifts. But what happens when you start estrogen therapy and suddenly experience spotting or bleeding?
For many women, especially those well past menopause, this can be a terrifying symptom. You’re not alone—and at Antigravity Wellness, we want you to feel informed, supported, and safe.
Why Bleeding Can Happen After Starting Estrogen
Let’s break down the physiology.
In postmenopause, estrogen levels have been low for a while—often years. The uterus has been dormant. When estrogen is reintroduced, it can cause the uterine lining to “wake up,” especially if there was any residual endometrial tissue or if the estrogen dose is too high for your body’s needs. This is why unopposed estrogen (estrogen without progesterone) in women with a uterus is not only inappropriate—it’s dangerous.
Progesterone is essential to balance the effects of estrogen on the endometrium (uterine lining). It helps prevent endometrial hyperplasia—abnormal overgrowth of tissue that can lead to cancer. The North American Menopause Society (NAMS) and other guidelines are clear: every woman with a uterus who is on estrogen must also be on progesterone.
What Happens If You Start Bleeding?
First, don’t panic. A little spotting within the first few months of MHT can be common as your body adjusts.
However, it should never be ignored. Here’s how we approach this at Antigravity Wellness:
Step 1: Confirm Your Protocol
- Are you taking progesterone consistently?
- Are you using it in the correct dose and form (oral micronized progesterone is typically preferred)?
- Are you applying or ingesting your estrogen properly (transdermal, oral, vaginal)?
Step 2: Evaluate the Timing
- Bleeding that occurs in the first 3-6 months of starting MHT is often related to the body’s adjustment.
- Irregular bleeding after 6 months on a stable dose warrants further investigation.
Step 3: Troubleshooting & Monitoring
A hormone specialist will:
- Review your symptoms and history
- Assess the form and dose of hormones
- Order follow-up labs (e.g. estradiol, progesterone, sometimes FSH)
- Consider a pelvic ultrasound to assess the endometrial thickness
In some cases, especially if bleeding is persistent, heavy, or occurs after an initial adjustment period, we may refer for an endometrial biopsy to rule out pathology.
Red Flags That Need Further Evaluation:
- Bleeding after 6+ months on a stable MHT dose
- Bleeding that is heavy (soaking a pad or tampon every hour for several hours)
- Bleeding that occurs after sex
- Pelvic pain or pressure
- Personal or family history of uterine or breast cancer
What About Women Without a Uterus?
Even if you’ve had a hysterectomy, we often still recommend bioidentical progesterone as part of your hormone therapy plan. Why?
Because progesterone supports:
- Brain health (neurosteroid effects and sleep regulation)
- Heart health (anti-inflammatory and lipid-modulating effects)
- Mood and anxiety regulation
- Bone health when combined with estrogen
What the Research Says
- A 2022 meta-analysis in Menopause journal confirms that combined estrogen and progesterone therapy (vs estrogen alone) reduces the risk of endometrial hyperplasia in women with a uterus (NAMS Guidelines).
- The Kronos Early Estrogen Prevention Study (KEEPS) and Women’s Health Initiative (WHI) have demonstrated that when appropriately used, MHT is safe and effective for symptom relief and long-term health, particularly when started near menopause onset.
- Bioidentical oral micronized progesterone has been shown to have a protective effect on the endometrium and is associated with fewer side effects than synthetic progestins (The PEPI Trial).
A Message to Providers
If you’re a healthcare provider starting a woman on estrogen therapy postmenopause, please remember:
- Estrogen must be paired with progesterone in women with a uterus.
- Spotting may occur during the adjustment period and does not always indicate pathology.
- Reassure your patients and monitor closely before jumping straight to invasive procedures.
- Collaborate with hormone-literate specialists when needed to avoid over-treatment or under-diagnosis.
At Antigravity Wellness
We specialize in guiding women safely through menopause using bioidentical MHT when appropriate. Our approach includes:
- Thorough consults and history review
- Customized protocols with both estrogen and progesterone
- Regular follow-up and labs
- Gentle guidance through unexpected symptoms like spotting or mood shifts
- Prompt escalation when something truly needs more evaluation
If you’re experiencing spotting on hormone therapy—or want to know if MHT is right for you—book your initial consult call today. Dr. Nicole Smith will walk you through your options and ensure you feel heard, respected, and well cared for.
You deserve a provider who listens, explains, and personalizes your care.
Let’s work together to help you feel your best—safely and confidently.
