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[Liz]

Wonder if anyone can help?  Been on Oestrogel and Utrogestan regime for almost a year now.  Currently using 2 pumps Oestrogel and Utrogestan days 15-26 as I'm peri (age 47). Trouble is, I am getting bleeds approx every 2-3 weeks, this time it's on day 2 of Utrogestan, so effectively day 16 of my cycle.

I suspect it's to do with my own hormones, I assume the Oestrogel is not overriding my own cycle and it's breaking through.  I suspect I'd have to increase the Oestrogel dose to override my own cycle.  Bit of a pain as I'm effectively getting more periods than I did before HRT........

I'm thinking the only way to see what my own cycle is up to is to come off the HRT for a while....... Any thoughts?  Thanks!

[Dancinggirl]

Hi Liz - I am certainly no expert but if you are peri meno then your own hormones will still be going up and down and if you're using 2 pumps of Oestrogel daily then this could be too high a dose and may mean your womb lining is building up too much and could cause this erratic bleeding.  I believe one of the problems with using Utro is that it isn't as powerful as the more synthetic progesterones so won't control the bleeds so well.
Yes, possibly taking a break from the HRT for a month might help you to see where you are in your meno.  I would then start again and use just one pump per day and see how that goes.  I started my peri meno in my mid 3os and when I was in my early to mid 40s, and still probably peri, I used only one pump of Oestrogel daily and this was enough until I went post meno.
Dg x
 

[Hurdity]

As well as what the others have said - as Utrogestan tends to be more unstable because it is progesterone, and especially when taken orally, then if you can tolerate it, taking it for more than 12 days in the cycle may be the answer, especially if your own cycle is breaking through and you have plenty of oestrogen one cycle. While you are peri-menopausal you may still get erratic bleeding but perhaps not as much?

Some women take it orally (100 mg) for Days 1-25 of their cycle which can also help - as reported by women on here.

Hurdity x

[Liz]

Thank you!  I think what's concerning me is if my own cycle is strong enough to break through, then is the HRT doing anything at all, if you see what I mean?  What I mean is....... is it working and do I really need it?  Hope that makes sense.  I've just ordered another prescription so will need to collect that, but I am wondering about a break to see what's going on?  Do you think that would be a good idea?

An alternative is to reduce the gel to 1 pump per day, as DancingGirl suggested?

I know you can't advise me exactly what to do, but I'd appreciate your views.

If I do decide to take a break, would I need to finish this course of Utro, if I've started a bleed already on day 2 of it?

[Hurdity]

You should always definitely finish the course of Utrogestan - in the absence of professional medical advice telling you that you should not.

The cycle breaking through doesn't mean that HRT is not needed - but if it is a true period, it shows that ovulation has taken place and the drop in progesterone as the coprus luteum decays, provides the bleed. As I understand even though you are still ovulating oestrogen production declines during peri-menopause.

Also some bleeding at this time is caused by oestrogen breakthrough bleeding - when the lining thickens in the absence of ovulation (and therefore progesterone) and spontaneously comes away. I imagine this is less likely in your case because you are taking Utrogestan? As I said earlier when taken orally it can be unstable and subject to the vagaries of your digestion etc so this could also be a factor.

This probably isn't much help!

The article on peri-menopause explains the whole process better than I can (not in relation to HRT though).
http://www.menopausematters.co.uk/article-perils-of-the-perimenopause.php

Hurdity x

[Liz]

Thanks Hurdity - very kind of you to reply and much appreciated.  I think I may try as Dancing Girl suggested and drop to 1 pump of gel, as I'm a bit concerned that I'm taking on board too much Oestrogen (causing my lining to build up more combined with my own Oestrogen).  I may consider a break in the HRT, perhaps after Christmas, just to see where I'm at and see how I feel and how my own cycle is going.  I will have no hesitation in starting again if I feed I require it.

[TheDuchess]

I have used the same as you for 7 years but I was pretty much post meno when I started.

If you are bleeding on day 2 then I doubt it has much if anything to do with the Utrogestan. After just 200mgs ( you use 200mgs a day?) then it's not very likely that within 48 hours your body has absorbed enough then it's left your system also, to promote a withdrawal bleed.

I sometimes start to bleed slightly on day 9 of my 10 days on Utrogestan, but the bleed proper - in full flow- is not until around 3 days after the last tablet.

Two pumps of gel is 1.5mgs of oestrogen which is a low-ish dose (based on most pills being 1mgs or 2 mgs.)

I'd suggest that it's nothing to do with the HRT and that it's your own cycle breaking through, which may happen on any kind of HRT during peri.
The important thing is to use the gel to control your symptoms, so if you are finding you can manage ok on 1 pump then do that.  If you are having a full bleed- at whatever point- then that's what counts. The danger is if you don't bleed at all and your lining proliferates to a level that may cause hyperplasia,  but TBH this happening during peri is not very likely because you are having bleeds.

[Mary G]

Liz, I agree with all the other comments but would suggest you try using the Utrogestan vaginally.  I don't get on with any progesterone and that includes Utrogestan and I take it under sufferance but I have found that taken vaginally it is much, much more effective for several reasons. 

Firstly, no breast pain whatsoever which must be a positive - I always had painful breasts when I took it orally.  Secondly, it hits the spot and I never get any breakthrough bleeding while I am taking the Utrogestan.  Thirdly, no digestive problems which I used to get when taking it orally i.e. indigestion at night and last, but not least, I have heard that when taken orally, only about 25% (this could vary for different women and I doubt it is an exact science) of it reaches the womb whereas taken vaginally, practically all of it does.  That was the opinion of one doctor and I stand to be corrected.

Hope that helps.

[TheDuchess]

The only thing to be aware of is that 'legally' it's not licensed for vaginal use within the NHS unless your GP gives you the okay- but then you needn't tell them anyway.
The other issue is that some women find it irritates their bladders if used vaginally. I have a chronic bladder condition and would not use it vaginally for that reason. I have discussed both options with my dr and he's not mentioned anything about lower absorption through the oral route, but we know that all women digest and absorb differently. Not sure about only 25  per cent being absorbed- may be true, but if so, why is the dose not increased to compensate for this? or is 200mg prescribed to allow for this? My dr has never raised this as a problem.
 My personal opinion is that if you use it for 14 days or so as a 28 day cycle, you are probably getting enough. So far- fingers crossed - my scans have shown no increase in my lining compared with Norethisterone which is much more powerful.

[Hurdity]

There is definitely lower absorption via the oral route!!! There are studies that show this - haven't time to look them out at the moment. The point is vaginal use avoids the liver "first pass effect" and instead you get the "uterine first pass effect" ie much of it goes straight to the uterus where it is needed.

In terms of the amount absorbed - yes the HRT dose is designed for oral use only and because there have been insufficient studies to license vaginal use in this country, many gynaes will prescribe the same amount. However somewhere a few years ago I remember reading in a paper that as a rule of thumb only half the dose is needed for vaginal vs oral use - but no-one should go doing that without doc approval!  Some private gynaes will probably prescribe on this basis too.

This paper I quoted on another thread http://www.mialundin.se/wp-content/uploads/2012/02/Micronized-progesterone-and-endometrial-cancer.pdf says that a study showed that 50-60% of the amount ingested (orally) is absorbed (measured by exrcetion of one of the metabolites in urine), and of this once this has been through the liver, a study showed that the absolute bio-availability was 6-8% - and comparable to estradiol in this respect. I have probably over-simplified it as I said I haven't read in detail but the gist will be correct hopefully!

The absurd thing is that utrogestan is licensed and sold for vaginal use for fertility but not as HRT! Exactly the same product!!! Another example where more studies are needed...

Hurdity x

[TheDuchess]

Just to edit the above. yes, I know that the oral route gives a reduced absorption rate compared to vaginal and so does my dr. What I meant was that I'd not been advised it was an issue (concern) or that the vaginal route was always preferable for all women, because for some women like me it's not an option as ALL progestogens and progesterone irritate my bladder to an extent, including the post-ovulation time when I had natural cycles pre-menopause.
Surely the amount we are advised to take as HRT is prescribed on the basis of a quantified low-absorption rate and the quantity allows for this?

[Liz]

Thanks ladies.  I think what I'm trying to do is to try and avoid the two/three weekly periods and bleeding on the Utro phase.  Do you think vaginal use would help with this problem then?

[Mary G]

Liz, I certainly think it is worth a try.  Using the Utrogestan vaginally will certainly put more of it into your womb so it should stop the bleeding while you are taking it.  You have nothing to lose by trying!