Continuous vs Sequential HRT: Which Type Is Right for You?
Continuous and sequential HRT differ in how and when progesterone is taken. Learn which regimen suits your stage of perimenopause and your symptoms.
Understanding the Two Main HRT Regimens
Hormone replacement therapy for women with a uterus always involves both estrogen and a progestogen, because estrogen taken alone without adequate progestogen protection can cause the uterine lining to thicken and increase the risk of endometrial cancer. The two main ways of delivering progestogen within an HRT regimen are sequential (also called cyclical) and continuous combined. The right regimen depends primarily on where you are in your hormonal transition, whether you still have regular periods, and what your individual symptom pattern looks like. Neither is universally better. Each has specific indications and advantages.
What Sequential HRT Involves
In sequential or cyclical HRT, estrogen is taken continuously every day, but progestogen is added for only part of the cycle, typically 10 to 14 days each month. This mimics the natural rhythm of the menstrual cycle, where progesterone rises in the second half. The result in most cases is a monthly withdrawal bleed when the progestogen stops. Sequential HRT is generally recommended for women who are still having periods or whose periods have stopped within the last 12 months. It is considered the more appropriate starting point during perimenopause when the body's own hormonal output is still variable, because it works with the existing hormonal pattern rather than against it.
What Continuous Combined HRT Involves
In continuous combined HRT, both estrogen and progestogen are taken every day without a break. This suppresses the monthly withdrawal bleed entirely, which is one of its main practical advantages for many women. Continuous combined HRT is recommended for women who are postmenopausal, meaning they have not had a natural period for at least 12 months. Starting continuous combined HRT before that point is likely to cause irregular, unpredictable spotting and breakthrough bleeding because the body's own hormonal fluctuations interfere with the steady regimen. For fully postmenopausal women, continuous combined HRT eliminates the inconvenience of a monthly bleed and provides consistent, stable hormone levels throughout the month.
Which Is Better for Perimenopause Symptoms
Both regimens deliver estrogen continuously, so the direct symptom relief from estrogen, including reduction of hot flashes, night sweats, and vaginal dryness, is broadly comparable between the two types. Where they differ is in the pattern of progestogen exposure. Some women find that the 10 to 14 days of monthly progestogen in sequential HRT causes PMS-like side effects including mood changes, bloating, and breast tenderness during the progestogen phase. Micronised progesterone, the body-identical form, tends to cause fewer side effects than synthetic progestogens in this phase, and some women find it has a mild calming effect. If you switch from sequential to continuous combined HRT at the appropriate time, you may find that spreading the progestogen evenly across the month reduces those cyclic side effects.
The Role of Timing in Choosing Between Them
The most important practical guideline is straightforward: sequential HRT for women who are still having periods or whose last period was less than 12 months ago, and continuous combined HRT for women who are fully postmenopausal. Using continuous combined HRT too early in the perimenopausal transition causes breakthrough bleeding that is difficult to manage and can mask abnormal bleeding that needs investigation. Getting the timing right avoids this problem. Most women who start sequential HRT during perimenopause transition to continuous combined HRT after they have been period-free for a year. Your prescriber should review your regimen at least annually and discuss whether a switch is appropriate.
Progestogen Choices Within Each Regimen
Whether you are on sequential or continuous combined HRT, you have choices about which progestogen to use. Micronised progesterone (sold under the brand name Utrogestan in the UK) is a body-identical hormone that is chemically identical to the progesterone your ovaries produce. It is available as an oral capsule or, when used off-label as a pessary, and is associated with fewer mood-related side effects than synthetic progestogens. Synthetic progestogens such as norethisterone and medroxyprogesterone acetate are also commonly used and are effective for uterine protection, but some women find them more likely to cause bloating, mood changes, and breast tenderness. Discussing your response to progestogens honestly with your prescriber allows you to find the form that suits you best.
Monitoring Your Response and Adjusting Over Time
HRT is not a one-size-fits-all prescription. Most women need at least two to three months of adjustment to fully assess how well a regimen is working, and it is common to adjust the dose or delivery method more than once before finding the right fit. Keeping a symptom log makes this process much more efficient. If you can tell your prescriber exactly when in the month your symptoms are worst, whether your breakthrough bleeding is heavy or light, and how your mood changes across the cycle, they have far more to work with than if you rely on memory alone. PeriPlan lets you log symptoms and track patterns over time, which can turn a vague sense that something is not right into a clear and useful record for your next appointment.
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