Continuous vs. Cyclical HRT: Which Regimen Is Right for Your Stage of Perimenopause?

Two Regimens, One Goal

If you are considering hormone replacement therapy for perimenopause, your doctor may mention two different approaches to how it is taken: continuous combined therapy or cyclical (also called sequential) therapy. Both involve estrogen and a progestogen, but they differ in timing and who they are designed for.

Understanding which regimen makes sense for your situation can help you have a more informed conversation with your provider and set more realistic expectations for how your body might respond.

What They Both Do

Both continuous and cyclical HRT aim to manage the symptoms of perimenopause and menopause by supplementing declining hormone levels. Both typically involve estrogen, taken daily, combined with a progestogen to protect the uterine lining.

If you have had a hysterectomy, you only need estrogen, and the continuous versus cyclical distinction applies to your progestogen use specifically. The estrogen component is generally the same in both approaches. The difference lies in how and when the progestogen is added.

What Cyclical HRT Involves

Cyclical HRT, sometimes called sequential HRT, is typically recommended for women who are still having periods or who are in early perimenopause with regular or only slightly irregular cycles. In this approach, you take estrogen continuously throughout the month and add a progestogen for 10 to 14 days each cycle, usually in the second half.

This pattern typically produces a regular, predictable withdrawal bleed at the end of the progestogen phase, similar to a period. For women who are still menstruating, this feels more aligned with their body's current rhythm. Cyclical HRT is generally not recommended for women who have been period-free for 12 months or more, as the risk profile and appropriateness change.

What Continuous Combined HRT Involves

Continuous combined HRT involves taking both estrogen and progestogen every day without a break. There is no deliberate hormone-free period, and the goal is to avoid withdrawal bleeds entirely. This approach is typically recommended for women who are postmenopausal, meaning they have not had a period for at least 12 months.

In the first few months of continuous combined HRT, some irregular spotting or light bleeding is common as the uterine lining adjusts. This usually settles within 3 to 6 months. If bleeding continues beyond that or is heavy, your provider should evaluate it. When it settles, most women on continuous combined HRT have no regular bleeding, which many find preferable.

Key Differences at a Glance

The clearest difference comes down to where you are in your hormonal transition. Cyclical HRT is generally for women still in perimenopause who are having periods, even if those periods are irregular. Continuous combined HRT is for women who are fully postmenopausal or very close to it.

Using continuous combined HRT while you are still in active perimenopause with your own hormone fluctuations can cause unpredictable bleeding, which makes it harder to manage and monitor. Getting the timing right, with guidance from your provider, makes a significant difference in how well the regimen works and how you feel on it.

Can Your Regimen Change Over Time?

Yes, and this is actually common and expected. Many women start on cyclical HRT during perimenopause and then transition to continuous combined HRT once they reach postmenopause. This is a normal part of managing hormone therapy across the full transition.

Your doctor will reassess your regimen over time based on how your cycle has changed and how you are responding. If you have been on cyclical HRT for a year or more and your periods have stopped, it may be time to discuss switching. These decisions are individual and depend on factors like your age, symptom pattern, and bleeding history.

Track Your Cycle and Symptoms

Whether you are on cyclical or continuous HRT, or still deciding, tracking your cycle and symptoms over time gives you and your provider valuable information. PeriPlan lets you log symptoms and track patterns, including how bleeding changes and how symptoms shift month to month.

If you are on cyclical HRT and your withdrawal bleeds become heavier, lighter, or stop entirely, documenting that pattern helps your provider know when it might be time to reassess your regimen. If you are transitioning to continuous combined, tracking any irregular bleeding helps establish a baseline timeline for when spotting should resolve.

When to Seek Medical Attention

Contact your doctor if you experience heavy or prolonged bleeding at any point on HRT. Report any breakthrough bleeding that occurs after the first 6 months of continuous combined therapy, as this should be investigated. Any bleeding after a period of complete amenorrhea on continuous combined therapy also warrants evaluation.

Never ignore unexpected changes in your bleeding pattern on HRT. While most causes are benign, your doctor needs to rule out other causes before attributing them to the regimen itself.

Getting the Regimen Right

Continuous and cyclical HRT are not better or worse than each other in any absolute sense. They serve different stages of the hormonal transition. Getting matched to the right regimen at the right time makes hormone therapy more comfortable and more effective.

If you are unsure which approach is right for you, ask your provider to explain the reasoning behind their recommendation given your current menstrual pattern. You deserve a clear, tailored explanation, not a one-size-fits-all prescription.

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