Print

Please login or register.
1 Hour 1 Day 1 Week 1 Month Forever
Login with username, password and session length

[Sarah2]

The quick answer is you won't know if your natural periods have stopped while you take HRT unless you have cycles which may override the HRT and give you irregular bleeding.

I don't understand why you didn't have a bleed on your previous brand of HRT because it's sequential and designed to give a bleed. Did you ever follow this up with your dr then?

[Spangles]

Yes I did Sarah and she said it was probably because my periods had naturally stopped, hence the long cycle which she put me on. The idea was that if I still didn't have a bleed she would then switch me to a conti regime. Like I say I'm finding it all confusing.
xXx

[Sarah2]

I think it's your dr who is confused!

She doesn't seem to understand what she is prescribing.

Long cycle HRT is usually for women who are having irregular but 'natural' periods during peri. Having said that, some consultants ( mine) prefer it for even older women ( post meno) for various reasons (and i do too.)

But the usual regime is monthly or longer sequential cycles in peri meno for women who are having periods, and then continuous regime ( with no bleeding) for women whose periods have stopped for at least a year or who are over 54 years old.


I really do think your dr is confused.
One of the first questions my consultant asks me at each appt is whether I have a scheduled bleed as expected. If I wasn't, then he would want to know why and adjust the HRT in some way.

If you are not post meno ( and you won't be if it's only 4 months since your last natural period OR you are under 54) then you can only have sequential HRT- this means you can either have a monthly bleed, or long cycle like the one you have just had. If the pain was really bad then it might be worth going back to a monthly or even a 6 week or 8 week regime which may give less bleeding and less pain.

[lubylou]

Hi Sara2 (and anyone else who can help with this)

When you say that some consultants ( mine) prefer it for even older women ( post meno) for various reasons (and i do too.) , can you say what these reasons are? I am asking because I am going back to my GP because the higher dose Premique isn't working for me and so I want to go back onto Tridestra (bleed every three months) which did work for me and I was one before I stopped HRT (I was on Tiboline for a while but I had breakthrough bleeding so previous and now retired GP put me back on Tridesra. The only reason I stopped was to see if my endometruim lining shrunk down from 7mm (it shrunk to 2mm in just over 6 months off HRT). I have already posted about my HRT chronology!   

So any information I can give my GP about a post meno woman being on a long cycle HRT would be really helpful. I am getting more and more frustrated because with my life being on “hold due” to the constant furnace and sleep deprivation every night which means I cannot function well in the day. I want to go back on something that I know has worked effectively. Premique has never got rid of symptoms just made them more bearable and I had hoped that I would be able to reduce and get off and be symptom free. That has not happened in fact my symtoms are much worse now If the Tridestra (or even another trial of Tibolone) does not work them I don't know what to do. I was able to take these two HRTs and be symptom free and they didn't interact in any way with my other essential daily medications. I hope that makes sense.

I am not sure if I could face a trial of another HRT which I haven't used successfully before.   

Thanking you in anticipation
Lubylou

[Sarah2]

Hi Lubylou

I think it is always hard for a patient to tell a dr what another dr is doing because it is one professional opinion over another- though of course one would assume that a GP might credit a consultant who has menopause as a special interest with greater knowledge.

I can only tell you what my experience is. It may not be the same as other people's!

 I was put on Oestrogel because my consultant likes it- for ease of altering the dose and because it is bioidentical unlike oestrogen made with mares' urine (CEE.) You can use a tiny amount of less than 1 pump, or up to 4 pumps daily- whatever controls your symptoms. I was told to experiment with about a quarter of a pump and increase it gradually until I had symptom control.

The other reason for a long cycle is that there is research appears to show that high amounts of synthetic progestogens ( anything except natural micronised progesterone) are associated with more cases of breast cancer. It has been known for a long time ( since the MW and WHI studies) that women on combined HRT- ie oestrogen and progestogen- have more breast cancer than women who use oestrogen only.
There are now some studies which show that taking continuous HRT with a synthetic progestogen gives the highest risk of any combination.

For this reason my consultant prefers to use sequential HRT not continuous, because the amount of progestogens are kept low. This gives a slightly higher risk of endometrial cancer but the upside is that breast cancer risk is probably lower.

It also depends on what women want. some women do not want a period/bleed at any cost and will prefer to have continuous HRT and not care about any increased risks.

I don't know if this helps and many GPs may be reluctant to move away from standard practise - which says women over 54 or post meno should be on continuous combined HRT. Obviously consultants who are not working in the NHS have greater flexibility.

[Hurdity]

Hi Shellb

Just to clarify re your confusion over why you got a bleed

You are on long cycle HRT ie oestrogen only for 10 weeks

Oestrogen builds up the lining of the uterus in a dose-dependent way ie the more oestrogen you have the thicker the lining will get.

You didnt get a bleed on the Femseven because presumably the lining did not build up sufficiently during the two weeks of oestrogen only, and then the progestogen in the second patch was sufficient to "thin" the lining already there.

In every woman the uterus lining will grow in the 10 weeks of the loing cycle and must be shed. I am very surprised if your GP did not explain this, so don't worry! It will also likely be heavier, again because of the increased build up - so if it is too heavy (for comfort or otherwise) the cycle would need to be shortened.

Lubylou - consultants do not prefer long cycles (ie 3 months) - well maybe one or two, in fact many actively dislike them due to the risk of endometrial hyperplasia. Maybe a prviate consultant might allow this - but that's because women are paying and can pay for the extra scans that might be necessary. On the NHS it is not usually recommended except under exceptional circumstances. Many women have problems on long cycles due to over stimulation with oestrogen causing breakthrough bleeding.

However many women and some consultants, prefer to continue to have cyclical HRT even after psot-menopause, either because of progesterone intolerance, or to keep progestogens to a minimum because of the research linking this with breast cancer (I think in the WHI study the incidence of BC was higher in the oestrogen/progestogen group than with oestrogen only). That's it really!

I was on an 2 month cycle but got a bit worried due to spotting (even though it was from an ectropion) and because I am getting older so I reduced it to 6 weeks and now to 7 because 6 weeks seemed too short - especially with vaginal progesterone for 12 days! My female doc seemed happy about this.

Dr Currie on this site recommends conti HRT in the first instance because of the risk of endometrial hyperplasia

I hope this helps x

Hurdity x

[lubylou]

Blimey Sara2 and Hurdity that was quick!
Thank you, I will read your replies properly, but just wanted to pop up and say you are amazing to get back so quickly. Thanks ever so much.
Luby 

[Hurdity]

Hi lubylou
No problem - actually I've been working all day and only just come on here - I just go through the list of unread topics I am interested in, in the order in which they appear - so I answer the latest ones first if you see what I mean!
Hurdity x 

[Sarah2]

When HRT was first used in the 1960s it was oestrogen-only. There is a lot of evidence now about the effect progestins have on breast cancer- ie more cases with combined HRT than oestrogen-only. There is still a debate about whether it's dose-dependent or if the type of progestin is a factor too. There is some research which shows that progesterone is less of a risk than synthetic progestins. I've included something here from one paper which incidentally raises the comparison between the risks of endometrial cancer and breast cancer.

Here we are...

an extract from the paper on the effects of different progestogens


Progestins and progesterone in hormone replacement therapy and the risk of breast cancer
Carlo Campagnoli,1,* Françoise Clavel-Chapelon,2 Rudolf Kaaks,3 Clementina Peris,1 and Franco Berrino4
Author information ► Copyright and License information ►

In accord with trial results, almost all observational studies published over the last 5 years have also reported an increase in BC risk associated with progestin use in HRT [11,13–20,38,39,43,44,139]. The reported increase in risk was 2–4 times greater than that associated with the use of unopposed estrogen (Tables 4 and ​and5).5). Furthermore, although there were exceptions [11,16,18,19], most studies providing information on the two regimens of progestin addition [14,15,17,38,39,139] found that the risk was greater with continuous-combined than sequential regimen (Table 6).


Estrogen plus progestin therapy and breast cancer: consequences of the sequential regimen (sEPT) and the continuous-combined regimen (ccEPT) (observational studies)
These findings, which are consistent with the ‘estrogen augmented by progesterone' hypothesis [23–25] prompted suggestions that alternative ways of protecting the endometrium – that have no or reduced effects on breast tissue – should be tried, e.g. the use of an intra-uterine device with a progestin or the intravaginal administration of progesterone [23]. The elimination of progestins from HRT preparations was even suggested, since the increased risk of endometrial cancer with unopposed estrogens would be more than counterbalanced by the reduced risk of BC [18].

[Hurdity]

Thanks Sarah - yes I've seen this paper. The most important point re breast cancer risk though is in the conclusion:

The balance of the in vivo evidence is that progesterone does not have a cancer-promoting effect on breast tissue. This provides a biological rationale for the finding that oral micronized progesterone added to estrogens in sequential or cyclic-combined regimens does not increase the risk of BC [26]. The greater BC risk persistently related to the use of HRT preparations containing estrogen and synthetic progestins seems in all likelihood due to the regimen and/or to the kind of progestin used. The “non-physiological” continuous-combined regimen, could increase the risk because it does not allow sloughing of lobular duct epithelium (such as occurs when progesterone declines at the end of the normal menstrual cycle). More importantly, many of the progestins used have several non-progesterone like actions that potentiate the proliferative effect of estrogens on breast tissue and estrogensensitive cancer cells. We therefore suggest that when HRT is indicated, preparations containing progesterone and not a synthetic progestin should be used, according to a sequential or cyclic-combined regimen. In this way the risk of endometrial cancer is minimized without increasing the risk of BC.

In other words - it is suggested that to minimise breast cancer risk, then natural progesterone should be used rather than synthetic progestogens - but either on a continuous combined or a cyclical regime.

The starting point for this is the biology and mechanism of action (of progesterone on breast tissue) rather than the statistics, from which it is always difficult to disentangle cause and effect from simple correlation.

Interesting that they refer to continuous combined HRT as non-physiological, when that is what happens during pregnancy  - ie continuous high levels of progesterone for 40 weeks for substantial parts of our life (well that's what we would be doing in the absence of contraception!).

To minimise the risk of endometrial cancer then theoretically the ideal regime is continuous combined (I have been told).

As always the most important point is that there is increasing evidence from so many different sources that bio-identical, transdermal HRT is the safest form to be taking long term - as I am always saying!!!!

Hurdity x

[Sarah2]

The effects of high progesterone during 40 weeks of pregnancy several times over a lifetime could be offset by positive changes to the breasts with breast feeding ( which is what women would do if they had lots of children in the past.)

Would you agree that endometrial cancer caught early has a better outcome for most women than breast cancer? not that any of us want either!

[lubylou]

Sara2 and Hurdity
I have read and reread your responses to my post and done some searching around on the internet.

Hurdity when you say you were on a 2 month cycle and then reduced it to 6 weeks and now to 7 because 6 weeks seemed too short do you mean that you had a bleed evry 2 month and then reduced to a bleed every e 7 and 6 weeks ? If I have understood that right, which types of HRT give this flexibility? I cannot see what HRT tablet  preparations on the menu would give that flexibility. So am I right this is a combination of  a patch /gel regime (I have to say I am still trying to get my head around the Oestrogel and Utrogestan.

Sara2, I would never say to my GP that another Dr had said xyz, my profession was all about confidentiality and respecting my clients ( and a no name no pack drill approach). Nor would I disrespect my GP's expertises by implying  I know more than she. I am tending to the view that I should not be on Premique. The gynaecologist I saw was not a menopause specialist and old school. I wasn't given any reason as to why I was prescribed Premique.  Mind you I didn't ask either! The more I have read and looked back over the last two years on the Premique low dose, the more I think this is not right for me. I am vegan and have big issue with the ethics of producing a foal to make the CEE (I don't drink milk because I am not keen on calves being taken from their mums and the rest...............)
Anyway I guess you might be expecting this question. I have not been able to find the studies you refer to which show that taking continuous HRT with a synthetic progestogen gives the highest risk of any HRT combination. I would like to read those and add them to the other information I have found about why the CEE/MPA is perhaps not a great combination.

To everyone,
I cannot thank you all enough, just a few weeks ago I was struggling with all the different terminology, let alone making sense if it all but I think I am getting their now so I can have a productive conversation with my GP. Did anyone here the item on BBC radio 4 Woman's Hour about the research at Manchester University regarding high breast density and breast cancer? You can download it as a podcast. I think it was transmitted on the 12 March
LubyLou

[lubylou]

Ok you two (Sara" and Hurdity) you have lost me again in your last two posts. But I assume the report you are discussing is the one I found earlier this evening at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1974841/

I don't think I will ever get to the point I fully understand all the details and complexities.

To be honest i just want to be prescribed something which will give me a quality of life back so I can spend good quality time with my husband and friends! But in order to get to that place I need to understand my options.

Lubylou

[Sarah2]

Hi Lubylou
Yes that is the right paper. If you just read the beginning and the conclusion and maybe look at the graphs it gives you some facts.

The combination of gel and Utrogestan ( or another progestin such as norethisterone- which is synthetic) allow you to tailor the bleed in terms of cycles. Patches would do the same though I've never used those.

[Hurdity]

Hi lubylou

To answer your question, yes by cycle length I mean a bleed every X weeks. so a normal 4 week cycle is a bleed every 4 weeks. I now have a bleed/cycle every 6-7 weeks depending on when I time the progesterone (sometimes it depends what I'm doing and when I'm going away).

There is no licensed method that gives this flexibility - I am choosing to do this off license from what I've learnt over the years, reading papers and discussing with women on this forum and what their consultants have been prescribed. I first went to a longer cycle in 2011 when I started using Utrogestan.

However I did say that my GP was happy when I told her I was hasving a two monthly cycle - although this isn't written on my prescription which says "Use as directed" !!

Really it is advisable to alter the regimes only under medical supervision.

As I think I said below I use Estradot patches (for 7 years) and Utrogestan but as Sarah says you can also use gel. You can also take estrogen only tablets with Utrogestan separately. I think it's already been pointed out the Tridestra is the only licensed long cycle HRT which is why you can't see the otheres listed!

Hurdity x