Hormone Therapy and Blood in Urine (Hematuria)

Blood in the urine (hematuria) can have many causes, and while it is not a common direct side effect of standard hormone therapy, there are situations where hormones may be linked indirectly to urinary bleeding. It’s important to treat any visible blood in urine as something that merits medical evaluation, regardless of hormone use. ^[1]

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What hematuria means

• Hematuria simply means red blood cells in urine; it can be visible (red/pink urine or clots) or microscopic (found on a urine test). Both forms can be associated with issues in the kidneys, ureters, bladder, or urethra. ^[1]
• Typical causes include urinary infections, kidney stones, glomerular diseases, and cancers of the urinary tract, among others. Because the list is broad, clinicians evaluate hematuria with history, exam, urinalysis, imaging, and sometimes cystoscopy (a camera exam of the bladder). ^{[1] [2]}

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Can hormone therapy cause hematuria?

Estrogens and progestins

• Routine estrogen or estrogen‑progestin therapy is not known to directly cause hematuria as a common adverse effect. However, high or prolonged estrogen exposure can stimulate endometriosis, and rare urinary‑tract endometriosis (bladder or ureter) can present with gross hematuria. [PM19]
• There are case reports of postmenopausal women on estrogen therapy developing ureteral endometriosis with hematuria, especially at excessively high doses. This suggests a possible indirect link when ectopic endometrial tissue involves the urinary tract. [PM18]
• Malignant transformation of endometriosis in the ureter has been described in the context of hyperestrogenism, also presenting with painless hematuria. This is exceptionally rare but highlights that estrogen exposure can influence endometrial tissue behavior outside the uterus. [PM20]

Androgens (testosterone or other anabolic/androgenic agents)

• In specific settings where androgens are used chronically (for example, older protocols in hereditary angioedema), hematuria has been reported among long‑term adverse effects. This appears uncommon but documented in long‑term androgen use cohorts. [PM13]

Combination estrogen–testosterone products

• Consumer and professional labeling for esterified estrogens with methyltestosterone lists many genitourinary adverse reactions, but routine urinary bleeding is not highlighted. Abnormal uterine bleeding is common in labeling; urinary bleeding is not a listed typical effect. ^{[3] [4]}

Bottom line: Hematuria is not a typical, expected side effect of standard hormone therapy, but hormones can be indirectly associated in rare scenarios (urinary‑tract endometriosis with estrogen exposure, and hematuria reported with long‑term androgen use). Because most hematuria comes from non‑hormonal urinary causes, a proper medical work‑up is important. ^{[1] [2]}

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When to seek urgent care

• Go to urgent care or the emergency department if you have heavy bleeding with clots, severe pain, fever, difficulty urinating, dizziness, or if you are on blood thinners. These features may indicate infection, stones, or significant bleeding that needs prompt treatment. ^[2]
• Smoking, certain chemical exposures, prior pelvic radiation, and age increase the concern for urinary tract cancers; with these risk factors, visible hematuria warrants prompt specialist evaluation. ^[2]

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How clinicians evaluate hematuria

• History: onset, visible vs microscopic, pain, recent exercise, menstrual history, hormone dosing, smoking, occupational exposures, prior radiation. These details guide which tests are needed. ^[2]
• Tests: urinalysis and urine culture; blood tests for kidney function; imaging (ultrasound or CT) to look for stones or masses; cystoscopy to inspect the bladder. This stepwise approach identifies common and serious causes. ^[2]
• Specialist referral: Urology and nephrology teams evaluate hematuria depending on suspected source (lower vs upper urinary tract vs glomerular). ^{[5] [6] [7] [8]}

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Practical coping steps while you arrange care

• Hydration: Drink water regularly unless your clinician has given fluid restrictions; this may reduce irritation from small stones or infections. ^[1]
• Avoid intense exercise temporarily: Strenuous workouts can cause transient hematuria; pausing helps distinguish exercise‑related bleeding from other causes. ^[1]
• Track episodes: Note timing, color, clots, pain, relation to your hormone doses or menstrual cycle; bring this log to your appointment. ^[2]
• Review medications: If you take blood thinners or NSAIDs, ask whether they could worsen bleeding risk while you’re evaluated. ^[2]
• Do not delay testing: Even if bleeding stops, a single episode of visible hematuria generally deserves evaluation to rule out important causes. ^{[1] [2]}

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If you are on hormone therapy

• Discuss dose and formulation: If hematuria appears shortly after dose changes, your prescriber may consider adjusting or temporarily holding therapy while evaluating. ^[2]
• Consider endometriosis evaluation if symptoms suggest it: Cyclical urinary pain or hematuria around menses can point toward bladder or ureteral endometriosis; gynecology and urology can co‑manage. [PM19] [PM18]
• For androgen therapy: If you use androgens long‑term and develop hematuria, report it promptly and ask about monitoring or alternative treatments. [PM13]

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Red flags and risk factors to share with your clinician

• Visible blood, clots, pain pattern, urinary frequency/urgency, fevers. These suggest infection, stones, or bladder inflammation. ^[1]
• Smoking history or chemical exposure at work. These increase the need to rule out cancers. ^[2]
• Prior pelvic radiation therapy. This can predispose to urinary bleeding and strictures. ^[2]

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Summary table: Hormones and hematuria

Scenario	Likelihood of direct hematuria side effect	Key notes
Standard estrogen/progestin therapy	Low	Rare indirect links via urinary‑tract endometriosis presenting with hematuria, more likely with high/excess estrogen exposure. [PM19] [PM18]
Long‑term androgen therapy (e.g., older HAE regimens)	Uncommon but reported	Hematuria listed among long‑term adverse effects in cohort reports. [PM13]
Combination estrogen–methyltestosterone	Not typically listed	Labeling emphasizes uterine bleeding; urinary hematuria not typical. [3] [4]
General hematuria causes (non‑hormonal)	Common	Infection, stones, glomerular diseases, and malignancies are frequent etiologies. [1]

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Takeaway

Most hematuria is unrelated to hormone therapy, but hormones can occasionally play an indirect role, especially with estrogen‑related endometriosis involving the urinary tract or with long‑term androgen exposure. Any new or visible blood in urine should be evaluated by a clinician to pinpoint the cause and guide safe continuation or adjustment of hormone therapy. ^{[1] [2]} [PM19] [PM18] [PM13] [PM20]