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[Ljp]

Hi again

I have been thinking about things a lot, and am very confused as to what's going on with me, and what the best treatment should be.

My last period was August 2014, leading up to that, several years of scanty periods, sometimes up to six months apart.
Night sweats and flushes horrible, brain fog and anxiety and paranoia horrible, but most troublesome symptom is overactive bladder and urgency.

Urgency so troublesome I went to GP, initially two years ago, vesicare prescribed, didn't use as side effects (dry yes etc) too worrisome, especially as I have dry eyes (another meno problem)

Went to GP in May again re urgency and frequency, had bloods taken, eventually had estriol cream prescribed, which has helped.
In August I had a full abdominal and intravaginal ultrasound done plus bloods again, as I had a chronic discomfort in my right side, which turned out to be soft tissue ( I teach dance fitness) the intravaginal scan showed thin lining, 4mm

End Oct, sudden bleed, not heavy, no clots, light bleed (brownish in colour) lasted three days. I called GP on first day, she said she would refer me to gynae at hospital for hysteroscopy.

Appointment was 7th Dec, those of you following my story will know, I has hysteroscopy done, gynae said she couldn't get much sample/biopsy as lining thin, also had to open my cervix as it was closed, she said I was 'too young for this' (I'm just 51) but she was  happy that all looked normal inside.
Here's where it gets confusing, all looked normal, thin lining etc, YET recommended mirena to protect my uterus from effects of estriol cream, which she felt could be causing bleed, so I had coil fitted, also estring to help bladder.
She did mention patches, but said no rush and to discuss with GP.

I came home thinking the coil was there to oppose any effects from the estring/estriol cream, but on posting on here was scared to read advice that it's unnecessary to oppose with progesterone, and that mirena could cause endo atrophy!… so I contacted my GP and have since started using oestrogel one pump, still have estring in place too.

This is my second week, on day 7 of having mirena in, I started spotting, and I've spotted every day since.

I am confused as to why I was advised to have the mirena if my uterus lining is thin? And if the bleed was due to using vaginal estriol, then opposing it with mirena should be sufficient without adding oestrogel?

I know I need something to help my frequency, bladder issue, but I am so confused as to the thought process behind what's happened, and now I'm on oestrogel too as I was concerned by the suggestion of endo atrophy.

The fact that I'm spotting is worrying me too as both my ultra sound and hysteroscopy/biopsy said thin lining, I don't want atrophy of lining, anymore than I want a build up.

All I want is control over bladder frequency predominantly, the night sweats are improving with the oestrogel, and my moods and mental clarity have improved, although been feeling a bit crap since the spotting started, and thinking and reading all sorts to try and make sense of what's actually happened, and questioning what treatment I'm now on and if it's right and necessary?

If the mirena was only advised to oppose the effects the gynae considered were from the estriol or estring, then is oestrogel really necessary too?

If oestrogel IS necessary to stop endo atrophy from coil, then is coil necessary? Or would it be best removed and either a) see if post meno bleed happens again? Or b) use utrogestan instead?

I so wish there were more sensible guidelines and help available from our GPs at this confusing and scary time of life, it's unnecessary stress and anxiety, at a time when we feel stressed and anxious enough from our hormonal changes as it is!

[dahliagirl]

Maybe you don't need the mirena for the previous bleeding. Maybe you need more oestrogen in your system from the oestrogel to help with the bladder problems, and the mirena will help with this.  Otherwise you would need tablet hrt like I have which includes progestogen.  Some gynaes prefer the mirena/oestrogen method, and maybe this is why she has given you a mirena, rather than to thin lining.

Do you have a letter from your consultant to your GP?  If you go privately, you usually get a copy.  If not, your GP might oblige and give you a copy/explain it.

I hope your bleeding settles.  It should once you have settled into your routine, and there are no more changes.  It takes a few months sometimes.

[Ljp]

Hi dahlia girl,
Yes letter arrived today, doesn't say a lot really, just endometrium, appeared normal, no intracavity pathology was seen.
Biopsies taken: location pipeline biopsy from endometrial cavity. Minimal cur retinas obtained. IUCD/IUS Insertion, attempted successfully. Type mirena intrauterine system.
Complications non.
Diagnosis based on hysteroscopy: normal cavity.
Estring inserted, advice to have it changed in 3 months
Coil check with GP six weeks
Change mirena in 4 years
Follow up: write with histology results.

Nothing even mentioned re patches or use of any further oestrogen

[dahliagirl]

I can see the sense in having it fitted if you are having frequent periods like what I was having or a lot of build-up, and having it fitted as the progestogen part of hrt, but you are right - it does not make a whole lot of sense in this case, unless she thinks you are particularly sensitive to the oestrogen in the estring.

Were you desperate for contraception? (straw clutching here  )

Ideally, it would be preferable to see the consultant, take their advice, think about it, go back and then have mirena put in.  Whether it is the right thing or not.

It is handy to have in if you need to up your oestrogen though, so it may be better in the long run as it will give you more flexibility and less hassle than changing preparations.  I know Dancing girl was happy with hers.

[Dancinggirl]

Oh dear lisajp - you are over thinking things.  Sadly I think on the NHS they simply don't have the time to explain the 'whys and wherefores' when offering treatment so we often come away from a doctors visit feeling confused and frustrated.
Firstly, the spotting you are getting now shows that the Mirena is doing it's job  - the spotting should stop completely within a few weeks - it may be a bit inconvenient but it is nothing to worry about. You tell us that you are already getting some benefits from the Oestrogel and once the spotting stops imagine how great you are going to feel.
I do agree that the gynae you saw may have acted too quickly by putting in the Mirena when she knew you were only using local oestrogen and the thin lining would indicate that there is no build up as a result of this local oestrogen treatment - why you got this spotting is a bit of a mystery but I believe this can happen with local oestrogen use but is seldom of concern.
I would personally be very worried about having a Mirena in place without sufficient oestrogen to counter the progesterone going into that area, as I would expect there to be some consequences e.g. nasty cramps, endo atrophy.
When you ask about 'guidelines' - well there are guidelines but of course we are all different so treatments need to vary.
I do believe you are trying something that could be very helpful to you. Systemic oestrogen is generally far more effective for the bladder and many women who suffer badly with urinary problems and VA do need both local and systemic oestrogen.
You have nothing to loose and possibly a lot to gain by keeping with this HRT regime - it is certainly not a permanent option but as you already have things in place now it would be pointless to 'jump ship' and try something different at this stage until you have given the current situation at least 3 months trial. You have mentioned that you get some flushes and other meno symptoms, not just the bladder urgency, so the systemic oestrogen may help many things and help get your life really on track. If after 3-6 months you don't feel better then you can have the Mirena removed, stop the Oestrogel and go back to just using the local oestrogen.

Re Utrogestan: I am using this and though it is heralded as the 'best thing going' I must caution you that it also has it's down sides.  I have found it is not strong at the lower dose to stop breakthrough spotting and on the higher dose it makes me feel quite sedated and I get period cramps - it doesn't suit everyone.  The Mirena is the preferred option of most specialist gynaes as it does suit many women extremely well, is particularly good at controlling any bleeds and gives fewer problems generally.

If you are really worried about staying with the Mirena and Oestrogel then remove it all and stick with the Estring or try Vagifem maybe 3 times a week.  If you then get some spotting the GP could possibly give you some Utrogeston to take for a few days, a couple of times a year, to just ensure your lining stays thin but I suspect the spotting was just a random thing.
I hope this is all helpful.   Dg x

[Ljp]

No frequent periods, no bleeds for over a year.

Contraception not necessary hubby had vasectomy over 20 years ago.

All she said was, mirena would protect uterus from effects of cream, could have estring (which I did) as a bit stronger and less messy.

Could have a patch, but think about it, simple prescription.

That was all, hence my confusion, nothing said re needing a patch only that I could have a patch, but when I posted on here about what was done etc, a rep,y stated no need for opposing local oestrogen, and could cause atrophy if lining is thin, hence me contacting my GP and getting oestrogel, but feel very confused and questioning what's needed and what's not and what's best and what's not. Going crazy 😟

[Ljp]

Thanks again DG I'm sorry if I'm driving you to distraction X

I am frustrated to think I acted too quickly on the mirena choice, and in hind sight could have continued with cream to see if any further bleeds occurred. But I guess I'm here now, with this thing inside me, and maybe should go with it for a while and see what happens.

I do have co troll issues and hate anything I don't fully understand, and just the fact of knowing that progestogen and oestrogen combination HRT can increase chances of breast cancer, really scares me, and makes me feel I've done the wrong thing x

[dahliagirl]

I think this is the least progesterone option, without a hysterectomy.  It is concentrated in the uterus where it reduces cancer risk and is not circulating round as much to areas where the opposite might be true (but not proven).

I think that using vagifem probably increased my periods, but it is hard to say for sure, even though I charted my 'cycles' for quite a while.  Maybe I should have been referred to a gynae like you.  I started taking hrt tablets and it has been fine.

[Dancinggirl]

lisajp - I do understand - it all happened so quickly and you should have been given time to think over your options. Do try to go with the flow - I personally think that gynae has done you a favour.  Don't worry about the very, very small risk of breast cancer.  The risks don't actually kick in till you are over 60 and you are using such a low dose the benefits will certainly out weigh any risks.  Do remember that by using HRT for 5 years in your 50s you reduce your chance of developing osteoporosis and heart disease - you will even be reducing your risk of bowel cancer.  It will also help with bladder and VA problems - I even read somewhere that statics now show that HRT use in our 50s will lengthen our lives by a year or more - we may even see a time when HRT is recommended as a preventative against long term health problems!!!! So the benefits long term of using HRT in our 50s can definitely outweigh the risks.  Hope that makes you feel less frightened.  Dg x

[Mary G]

Lisajp, the Mirena coil is not the same as oral progestins and does not carry the same risks, albeit very low risks.  It is concentrated in the womb and unless you are unlucky enough to be severely intolerant to synthetic progestins like me, it is a good way of protecting the womb from lining build up. 

Cramps and spotting are normal when you first have a Mirena fitted.  You will reap endless benefits from the Oestrogel, it is fantastic stuff and, in my opinion and from my own personal experience, nothing else even comes close to it.  As others have said, your bladder and other problems should soon disappear and you should not need the Estring once the effect of the gel kicks in.  Vagifem alone is not going to cut it long term.

There are far too many scare stories around for my liking so it is not your fault that you worry.  The menopause and HRT are a very specialised part of medicine and many GPs are not well versed with it.  The risks of HRT have been hugely exaggerated and not helped by a couple of dangerously bad studies which have since been discredited but it will take years for the HRT = breast cancer hysteria to finally be consigned to the history books.  Listen to the real experts, like Professor Studd, who have made hormones their life's work and really know what they are talking about on the back of their own extensive research. 

Please try to persevere with it.  Too many women have been scared off HRT only to find themselves on about 5 or more different types of medication to combat endless health problems in later life when they could have solved it by a simple dose of oestrogen. 

If all else fails after a fair trial, you can have the Mirena removed and then try the Utrogestan. 

[Hurdity]

Just to say I agree with everything that's been said - and so sorry to know that all your worries would not have occurred if the doc had not suggested you needed a Mirena to oppose the endometrium from the tiny dose of Estriol, when your lining was thin. I don't think you are confused - but it is the docs that have confused you!!

Do go with the positive words of encouragement you have had from Mary G, Dancinggirl and dahliagirl and concentrate on the fact that you are feeing better . Yes the spotting is a nuisance but hopefully it will settle and as the others have said - you can always get it taken out after a few months if it doesn't stop.

Hurdity x

[Ljp]

Thank you  I really can't express my gratitude to you all for your patience and reassurance, today I am feeling positive, I have decided to stick with it, as I have generally felt a lot better since I started using oestrogel, the spotting has got me down and worrying this week, but even that isn't that bad, it's only a bit when I wipe. The cramps have now settled.

I am considering using two pumps of oestrogel though as it is the recommended starting dose, and my night sweats, although less sweaty are still very hot, also if I want to manage bladder without estring or vagifem, I think I might benefit from two pumps of oestrogel to load my poor oestrogen deficient body?  And then after a few months if all is continuing to go well, maybe try dropping to one?

Thank you all again, I will keep you posted, and hopefully won't have too many more anxiety attacks re my decision, as my mind is also feeling clearer  xx

[Dancinggirl]

I really wouldn't increase your dose just yet - it might trigger more bleeding at this initial stage.  As your oestrogen levels were probably low in the first place it will take time for the levels to build up and I was told to use one pump per day for at least 4 weeks before increasing, if I felt I needed to - Oestrogel absorbs so well and works very efficiently and I find one pump is keeping my bladder etc. ticking over much better. Many women think that a higher dose will work quicker or offer more improvements but I think a gradual approach will bring fewer side effects (e.g. tender breasts etc.) and one wants to find the lowest dose that controls symptoms anyway.   BE patient - I'm so pleased to hear you are feeling better already - better sleep works wonders on everything.  DG x

[Ljp]

Thanks DG will take your advice and keep with one pump until at least 4 weeks have past, it's the nights that still need improvement to be honest, I am still waking several times hot and restless, just not drenched in sweat as I was before x

[Dancinggirl]

The nights have been unusually hot lately!!! Last night was about 15 degrees which is frankly hotter than summer, so I woke feeling really hot last night. There is a difference between the night sweats and just being too warm due to unseasonably warm weather, so I wouldn't blame a lack of oestrogen at this stage.
I would give the one pump per day at least 2 months to work it's magic - I think you will be surprised how effective it is.  DG x