“The HRT’s made me bleed again”

Unscheduled bleeding on HRT is not automatically "just the HRT". Bleeding in the first 6 months of continuous combined HRT (or within 3 months of a dose or preparation change) is common and usually settles (NICE NG23, updated April 2026); but bleeding that PERSISTS beyond that window, or is NEW/heavier after settling, requires assessment — examination, endometrial assessment (TVUSS), and referral per the 2024 joint guideline on unscheduled bleeding on HRT (the NICE NG12 endometrial criteria cover postmenopausal bleeding that cannot be attributed to HRT, so NG12 is not the route for bleeding on HRT; the joint guideline decides who needs a suspected cancer referral). The classic error is simply stopping the HRT and considering the problem solved — which both abandons the investigation the bleeding demands and returns the patient to severe symptoms. The examinable hidden agenda is that "stop the HRT" is driven by a friend’s breast-cancer diagnosis and an unspoken fear that HRT (and the bleeding) means cancer. Surface it, give honest proportionate breast-cancer risk information weighed against her severe symptoms, separate the two problems (the bleeding is assessed regardless; the HRT decision is made calmly with real numbers), and keep her symptom control safe.