Side Effects and Contraindications. Common adverse effects for HRT include vaginal spotting and bleeding; breast tenderness and breast enlargement, especially in older women; and pedal edema. Compliance with ERT/HRT is an important issue to address. The two most common reasons women discontinue usage are vaginal bleeding and breast tenderness. Women need to be educated about vaginal bleeding and its expected onset, frequency, and duration. Dosage manipulations may be required to control and eliminate vaginal bleeding. If continuous therapy is used and amenorrhea does not develop after 6-12 months, following a workup to rule out abnormal causes of bleeding is suggested; predictable bleeding patterns with cyclic therapy may be preferred for these women. Breast tenderness may decrease with time. Other management options are described. The benefits versus risks, including adverse reactions, must be continually assessed.

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