Print

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

[Quandry]

I started HRT on (sequential/cyclical) Elleste Duet (tablets) a few years ago.
On this I was taking
Estradiol 1mg  for 16 days
Then Estradiol 1mg + Norethisterone 1mg for 12 days

So the progestogen element was at the same level as the estrogen for the second half of the cycle.

Earlier this year I moved to a continuous regime. After trying the Estradot/ Utrogestan combination and hating it I've ended up on Everol Conti patches.
The balance of hormones in this is:
Transdermal estradiol 50mcg & transdermal norethisterone 170 mcg for 28 days

So the progestogen element is over 3 times that of the estrogen!

I'm not feeling great on the Everol Conti. I think the continuous progestogen is causing bad back and neck ache, also I think I'm losing more hair and my skin is spotty.

The GP said I could go back to tablets and try
KLIOVANCE*   1mg estradiol & 0.5 mgs norethisterone daily
This might be an option? Here the progestogen element is just half that of the estrogen?

So can anyone explain what's with all the different ratios of Estrogen/Progestogen between pills and patches?
Is progestogen  not so well absorbed via patch, so do we need more?

[Kate]

This is something I'm very keen to know too. Hopefully somebody in the know will be along soon

[Hurdity]

With tablets much of the dose is lost through digestion so the amount in the tablet has been set to take account of that and the amount absorbed systemically which is needed to protect the womb from particular doses of oestrogen.

Transdermal  - ie patches is absorbed straight into the system so can be much lower - for the same progestogen. The amount given for daily use ( ie continuous combined) may be less than that for cyclical use. However in practice it seems that manufacturers of patches save money but using the conti patches ( eg Evorel conti) for the combi part of Evorel sequi - so they don't have to manufacture another type of patch!

It doesn't matter that the amount of oestrogen is the same as the progestogen in the actual tablet. What matters is how this translates into systemic levels and crucially that the amount of progestogen is sufficient to protect the womb with the particular delivery method and progestogen. I agree if you compare it as you have - it does seem odd!

Not sure if any of the above makes sense! You would need to examine the pharmacodynamics (and/or pharmacokinetics - can't remember which (what happens to the product in the body over time from a given dose given through a specific route) of each product with the different methods - so quite technical!

Hurdity x

[Kate]

Thanks Hurdity. Are you saying that the sequential patches have more progestogen than necessary or have I misunderstood? It's disappointing that separate progestogen patches are not available so that people who struggle with that part of the regime have more options to try

[Quandry]

Kate - I agree re separate progestogen patches, but I suspect the risk is that for those of us who seem to suffer bad side effects from this part we'd be skipping doses/ cutting patches and risking our uterus lining thickening!
What we really need is a quick and easy way to have our linings checked regularly.

When I was switching from tablet to patch I was given NHS guidance which said that, broadly speaking, 
2mg oral oestradiol=50mg patch
But no equivalent figures for the progestogen part.

I do wonder whether there is a 'progestogen dominance' in the lower dose HRT which causes unnecessary problems?

[Dancinggirl]

Ladies - it's using progesterone all the time that is the problem - not necessarily the amount used.  Many women have more side effects with conti HRTs for this reason and this is why so many women, even into post meno, stick with a sequential HRT.

You can use Oestrogen as gel or patches and then take progesterone separately as either Provera (MPA) or Utrogestan (micronised progesterone) - either of these can be used sequentially or continuously and they are both kinder progesterones.  However, if you struggle with progesterone in any way, it's best to stick with a sequi HRT regime and put up with a monthly bleed.

The only other alternative - which can suit many women well - is the Mirena with separate oestrogen alongside. After the initial hit of progesterone in the first few weeks,  you will usually have 4 years of no bleeding and the option of using as little or as much oestrogen as you need.  DG x

[Quandry]

Hi Dancinggirl
.
"You can use Oestrogen as gel or patches and then take progesterone separately as either Provera (MPA) or Utrogestan (micronised progesterone) - either of these can be used sequentially or continuously and they are both kinder progesterones."

I started off with Estradot/Utrogestan but had to give up after a few weeks as I felt so terrible with the Utrogestan. I know there are lots of supporters for Utro on here, but I think you need to be careful calling it 'kinder' - it certainly wasn't for me. In fact, I seemed to tolerate the Norethisterone  in Elleste Duet better, but once I started taking it continuously, at what appears to be a much higher level, it started causing problems.

That's interesting what Hurdity pointed out about Evorel Sequi/Conti - the fact that the Sequi regime just uses Conti patches for the last two weeks. So if the progestogen element in the last two weeks is presumably sufficient to counteract the estrogen for the whole month why does someone on the Conti regime have to take twice as much?
Obviously I'm not a pharmacist, but could it not be a lower amount spread continuously?

Wouldn't it be great if we had some expert sessions on here to answer all our pharmacokinetics questions!

[Dancinggirl]

Quandry
When I tried Utrogestan, I too had more side effects than I had experienced with any other progesterone - it doesnt suit everyone. When I say ‘kinder' I was basing this on the findings from many women who post on this site who find it really good - also Utrogestan is deemed the least risky regarding cancer risk.
Perhaps try Provera- some women, who struggled with Utrogestan, do better on this.
Provera can be used at a lower dose when used continuously.
I believe dosage of any particular progesterone depends on the effectiveness to protect the womb lining but, I agree, there does seem to be some strange dose levels in some HRTs. DG x

[Kate]

I didn't get on with utrogestan either. In fact I was dreadful on both that and provera. I've found norethisterone the least worst option so far which seems contrary to most other ladies.

I have wondered if the reason for sequi patches having to be used for 14 days is simply to fit in with the pattern of changing patches either weekly or bi weekly. I would be thrilled to cut it down to 12 days in line with elleste tablets. 2 days less with progestogen would make it a little more bareable.

I had an ablation a couple of years ago but my worry about cutting back on the dreaded progestogen is not being certain I would get the bleeding symptoms tobflag up any sinister changes

[Quandry]

I'm very reluctant to try the Mirena as I hate the idea of anything so permanent being implanted. I also have some historic cervical issues (had an ablation in my 20s). Also, one of my annoying menopause symptoms was irritable bladder and I've seen a few people on here reporting that the Mirena has made them wee more. I'm not keen to go back to that.

I don't know anything about Provera - I need to investigate further.

In the meantime, I decided I couldn't cope with the terrible neck and shoulder pain so I saw my GP and I've gone back to Elleste Duet for the moment. I wanted to go 'back to base' to see if the neck pain disappears once I stopped the continuous progestogen. Guess what? After two days back on Elleste my neck pain has subsided significantly already. I can't believe it's a coincidence. It's scary how powerful these hormones are!

[Dancinggirl]

Quandry - I get this neck and shoulder pain that was certainly better when on HRT, however, I think this is an inflammation thing with joints in them neck.  HRT does help joints, so this would explain the relief from pain.
Now off HRT (I'm 61 and got fed up with HRT side effects), I have to take great care with posture and do regular stretching and strengthening exercise to reduce the discomfort in all my joints. Getting older is a pain in every way. 

BTW - I have bladder and urogenital atrophy problems, so still use local oestrogen regularly, however, when I had the Mirena this caused the fewest problems for me while I had it, as part of an HRT regime with separate oestrogen.   It's not permanent, it can be removed very easily if need be - so maybe worth considering in the future if all ease fails.
Dg x

[Quandry]

Thanks DG. I know what you mean about joint pain as we get older, but I'm only 51 and it seemed too much of a coincidence that it started within days of me starting the continuous regime. It felt as if someone had injected superglue into my left shoulder blade!
Nothing has really helped over the last two months (painkillers, physio, exercise etc) and yet within 48 hours of coming off Evorel Conti my shoulder has become noticeably more relaxed again.

That's interesting what you say about the Mirena, perhaps I should consider it. I'm such a wuss about surgical things though!

Can I ask what the local oestrogen you use is please? My intention is to try to come off the HRT at some point in the next few years, but I think I will need something for the irritable bladder. Does local oestrogen not need any accompanying progestogen then? (why is that?)

[Hurdity]

Thanks Hurdity. Are you saying that the sequential patches have more progestogen than necessary or have I misunderstood? It's disappointing that separate progestogen patches are not available so that people who struggle with that part of the regime have more options to try

What I meant was the other way round now I think about it. The naming is misleading because the conti patches (called Evorel conti) are the same ones as used in the combi patches for Evorel sequi. In many cases the progestogen for cyclical HRT is double that for continuous and used for half the time or a bit less ( ie 12-14 days) and therefore this has to be enough to protect the lining. Therefore those who are using Evorel conti may be having too much - but it does also depend on the individual woman, her uterus, how it responds to oestrogen, whether any fibroids etc. Interestingly the Femseven patches are different  Femseven conti patches deliver 7 mcg levonorgestrel per day but the sequi patches ( used for 14 days per 28) deliver 10 mcg per day!

Quandry - if you are interested in the pharmacokinetics of HRT then there is a fantastic (but pretty technical) paper (my "go to" for all of this stuff) by Kuhl written in 2005 - might be a bit out of date or rather there will be more info available now - but I am sure the general principles are still the same: "Pharmacology of estrogens and progestogens: influence of different routes of administration". You should be able to Google it - I downloaded the pdf to my computer.

Hurdity x

[Dancinggirl]

Quandry. I use Vagifem local oestrogen 2-3 times a week. There are several types of local oestrogen but Vagifem is easy to use. It's just a small pessary that comes with an applicator to push up the vagina. I will hopefully be using this for the rest of my life as it helps to keep that area healthy. I also use vaginal moisturiser daily. DG x

[Quandry]

Quandry - if you are interested in the pharmacokinetics of HRT then there is a fantastic (but pretty technical) paper (my "go to" for all of this stuff) by Kuhl written in 2005 - might be a bit out of date or rather there will be more info available now - but I am sure the general principles are still the same: "Pharmacology of estrogens and progestogens: influence of different routes of administration". You should be able to Google it - I downloaded the pdf to my computer.

Hurdity x

Thanks! That sounds completely my sort of thing! I worked with the pharma industry for a short time, so I like to know the DETAIL about things! All my friends tease me about it 

DancingGirl - thanks for that. I'll store it in my bank for future reference!