What is the difference between continuous combined and sequential combined HRT?

The main difference between continuous combined and sequential combined hormone replacement therapy (HRT) lies in how and when the progestogen hormone is taken and whether you have regular monthly bleeding. Both regimens contain oestrogen (to manage menopause symptoms like hot flushes and night sweats) and progestogen (to protect the lining of the womb against the cell-overgrowth risks of oestrogen alone).¹²

1. Sequential Combined HRT (Cyclical HRT)

• How it is taken: You take oestrogen every day, and you add progestogen for 10 to 14 days (out of a 28-day cycle).¹
• Bleeding pattern: At the end of each progestogen phase, the drop in hormones triggers a predictable monthly withdrawal bleed (similar to a period).¹²
• Who it is for: Generally recommended for perimenopausal women who are still having regular or irregular periods, or whose last natural period was less than 12 months ago. Starting continuous HRT too early while still having natural ovarian activity can cause erratic or frequent bleeding.¹²³⁴
• Learn more via the NHS Sequential Combined HRT Guide.¹

2. Continuous Combined HRT

• How it is taken: You take both oestrogen and progestogen every day continuously without a break.¹²
• Bleeding pattern: It is designed to result in no regular monthly bleeding (amenorrhoea). Some light spotting or irregular bleeding can happen during the first 3 to 6 months while your body adjusts, after which bleeding typically stops.¹²³
• Who it is for: Generally recommended for postmenopausal women who have not had a natural period for 1 year or more, or who have been transitioned from sequential HRT.¹²
• Learn more via the NHS Types of HRT Guide and Dr Louise Newson's HRT Comparison.¹²

Key Comparison Summary

If you'd like to share:

• How long it has been since your last natural period
• What symptoms you are hoping to manage
• Whether you have any specific concerns about bleeding or side effects

I can help you explore what to discuss with your doctor or menopause specialist.

The main difference between sequential combined HRT (often called cyclical HRT) and continuous combined HRT comes down to how and when you take progesterone (or progestogen) alongside oestrogen, and whether you have a monthly withdrawal bleed.¹

If you still have a womb (uterus), you need progesterone to protect the womb lining from thickening too much due to oestrogen.¹

Sequential Combined HRT (Cyclical)

• How it works: You take oestrogen every day without a break, and you add progesterone for 12 to 14 days out of every month (or 28-day cycle).¹
• The bleed: When you stop or lower the progesterone phase, your hormone levels drop, triggering a predictable monthly withdrawal bleed (similar to a light period).¹
• Who it is for: Designed for women who are perimenopausal (still having regular or irregular natural periods) or who have only recently stopped having periods.¹
• Why: If you gave continuous progesterone during perimenopause, it often leads to erratic, heavy, or prolonged bleeding.¹

Continuous Combined HRT

• How it works: You take both oestrogen and progesterone every single day of the month, without any breaks or changes.
• The bleed: No monthly bleed. Your womb lining is kept thin all the time, so you should not have periods or withdrawal bleeds (though some light spotting or irregular bleeding can happen in the first 3 to 6 months of starting it).
• Who it is for: Designed for women who are postmenopausal —typically defined as having had no natural period for 1 year or more (or women who have been on sequential HRT for 6–12 months and transitioned over).
• Why: Using daily progesterone is safe and comfortable once the natural menstrual cycle has properly stopped.¹

At-a-Glance Comparison

You can read more detailed guidance via the Newson Health Menopause Society or check treatment options on the NHS Hormone Replacement Therapy page.

Are you currently experiencing perimenopause or postmenopause, and are you trying to decide which regimen is right for you, or experiencing unexpected bleeding?

The main difference between continuous combined HRT and sequential (cyclical) combined HRT is how the oestrogen and progesterone (progestogen) are taken, and whether you have a monthly bleed.

Both types are used for women who have a uterus, because the progestogen protects the lining of the womb (endometrium) from the effects of oestrogen.

1. Continuous combined HRT

(No planned monthly bleed)

• You take oestrogen and progestogen every day.
• Both hormones are taken continuously, without a break.
• The aim is to prevent monthly bleeding.
• Some spotting or irregular bleeding can happen initially, but this usually settles.

Usually recommended for:

• Women who are postmenopausal.
• Generally, women who have not had a period for at least 12 months.

2. Sequential combined HRT

(Monthly withdrawal bleed expected)

• You take oestrogen every day.
• You take progestogen for approximately 12–14 days of each 28-day cycle.
• During the remaining days, you take oestrogen alone.
• When you stop the progestogen, a withdrawal bleed usually occurs.

Usually recommended for:

• Women who are perimenopausal.
• Women who are still having periods or whose last natural period was less than 12 months ago.

Comparison at a glance

Examples of HRT preparations

Continuous combined

Evorel Conti – combined oestrogen and progestogen patches used continuously.

Sequential combined

Evorel Sequi – provides oestrogen patches and combined oestrogen/progestogen patches in a cyclical pattern.

Why does the distinction matter?

The timing of starting continuous combined HRT is important. Starting it too early in perimenopause can cause irregular or unpredictable bleeding.

Sequential HRT is generally preferred until a woman has been without a natural period for 12 months (if not using hormonal contraception that affects bleeding patterns).

One important point: If you have a womb, you need adequate progestogen alongside systemic oestrogen to protect against endometrial thickening and endometrial cancer.

If you'd like, I can also explain how to choose between the two types of HRT, including the advantages and disadvantages of each and how they affect bleeding, mood and menopause symptoms.