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[Shannonplussed]

Last week, I had a pelvic ultrasound after I found out that my aunt has ovarian cancer. As my sister-in-law tragically died of ovarian cancer in her 30s, I'm aware of the vague non-specific symptoms that often go missed. For background, my family dr sent me for the scan, as I've been bloated and had a 40lb weight gain over 5 months after going off birth control. Eventually, two high FSH tests resulted in a (surprise) diagnosis of early menopause at age 42. I've been on estrogel and Prometrium (which is micronized progesterone equivalent to your Utrogestan) 100mg continuous since May, so about 5 months.

I'm going to post the findings of the scan while I wait for follow up. Of course I will follow up with a professional; I assume my family dr will refer me to an OB-GYN and that will take some time. I'm not asking for medical advice, but if anyone has had a similar report and can share what their next steps were, I'd appreciate it!

Highlights of the report:

FINDINGS:
The uterus is retroverted and measures 7.2 x 5.5 x 4.3 cm with endometrial thickness of 6.4mm. There are two tiny subendometrial/submucosal cystic lesions identified measuring up to 7 x 5 x 7 mm.
Both ovaries are unremarkable. There is a trace of free fluid in the posterior cul de sac. Bladder is morphologically unremarkable with no wall thickening, masses or calculi present.

IMPRESSIONS:
The endometrial lining is slightly thickened for a postmenopausal female. Given that the patient is on hormone replacement, this could still be within normal limits. There are two tiny cystic areas at the subendometrial region which can sometimes be seen in the setting of hyperplasia and hence clinical correlation is advised.
The bladder is grossly unremarkable. No ovarian or adnexal lesions are detected.

Soooo...Dr. Google seems to suggest hyperplasia, which can be fixed with progesterone (which I already take continuously). So a possible hysteroscopy and/or D&C? If it's in fact hyperplasia, would that be a result of too high a dosage of estrogel? I'm currently taking 2 pumps daily, although I started on one and slowly slowly ramped up to 3 pumps daily. When I found I was crying a lot, I reduced to 2 pumps and that seems to be nice for me. I (unwillingly) stored loads of extra fat leading up to my diagnosis--I thought because my body was trying to retain as much estrogen as possible going into menopause. I assumed some weight would release once I started bHRT, in getting exogenous estrogen my body wouldn't need to hold on to fatty stores, but that didn't happen. I wonder if I should stop all estrogen at this point, until I have more answers? (I would be happy for my breasts to stop growing, already!). I dropped to one pump instead of two last night.

As I've been sensitive to hormone fluctuations as well as being post-menopausal, I opted for continuous regime. I'm still within till the first 6 months when bleeding is said to be unpredictable. I've had occasional brown spotting, nothing in the last 4 weeks. The only actual bleed I've had was approx 35 days ago. It was light but lasted 4-5 days and was thin red blood (no tissue or clots; different from previous periods). I light of this being somewhat recent, I suppose I'm concerned with the report of my lining being slightly thickened.

Sorry to go on and on. I'm happy to pick your brains and if you have stories to relate, even better. Or questions that I should ask at follow up!

Thanks in advance

[Hurdity]

Hi Shannonplussed

As you say the best person to interpet and advise on this is your doctor and then referral to a gynaecologist.

However just a few observations.

Firstly, if you started HRT only 5 months after stopping the pill then you don't know if you are menopause yet. This is defined as 12 months without a natural period (ie not on HRT, mini pill, COP, or Mirena coil). You only went5 months before starting HRT? Given your age then you may still be peri-menopausal (FSH tests cannot predict whether you are post-menopausal as they can go into post-menopausal range even in peri-menopause.)

"A normal [FSH] level does not exclude early menopausal transition and a raised level does not exclude continuing ovarian function." https://www.menopausematters.co.uk/diagnose.php

That being the case then you might expect some thickening of the uterus lining and even bleeding (beyond the 6 months settling in time) if ovulation takes place.

Secondly, as I understand it, a slight thickening of the uterus lining per se is not necessarily a cause for concern especially when taking HRT. You bleeding could have been an actual period - but not as heavy as you would expect because you are taking progesterone continuously.

Hyperplasia doesn't develop from too much oestrogen per se - but the ration of oestrogen to progesterone is too high. You can take as much oestrogen as you feel you need to feel well, provided that the amount of progesterone is sufficient to keep the lining thin.

Obviously the lesions will need checking but in the absence of bleeding are far less of a worry I would say. When I had unusual structure identified on a scan I had a hysteroscopy and biopsy - because I was well post-meno and had had some abnormal spotting or bleeding - which should always be investigated.

As you say - if it is thickened there could be all sorts of reasons eg if you are still fertile but it can be thinned as you say with a higher dose of progesterone if it continues to remain thick - or as advised by your doc.

I don't follow your argument about the body needing to hold onto fat stores in order to make oestrogen? I don't think it works like that. Storage of fat is under metabolic control and dependent on your diet and exercise amongst other things. If you have excess fat then the fat cells can make estrone from androgens which can then be converted to estradiol elsewhere in the body, so I understand, irrespective of exogenous oestrogens. In order to reduce the "fatty stores" you need to increase exercise and change your diet - (unless you have a thyroid problem) - and sometimes that doesn't even work we find!

Just a few random observations - hope you get on Ok at your appointment and all is well!

Hurdity x

[Shannonplussed]

Thank you so much, Hurdity! Lots to chew on. So I may have been misdiagnosed, too early at least.

I was on Mirena and definitely dealing with perimenopausal symptoms by year 4 (which was 2 years ago). I didn't have any periods on it (which I know is not unusual) up until the 4 year mark, when the OBGYN suggested maybe my natural cycle was coming through. I wanted off that roller coaster (painful breasts and dry, painful sex) so I opted for oral contraceptive pill, to keep a steady dosage of hormones. OBYGN said to take back-to-back as a period wasn't necessary. After about a year on that, my husband got a vasectomy and I went off the pill. My period never returned, so in one sense I have gone two years without a period...but your comment that it has to be a year without any intervention is key. (aside: How do people on cyclic regimes know when to switch to continuous?) I shudder at the thought of going a full year on the rollercoaster.

As for the high FSH, your link is interesting because I had come off birth control (albeit 5 months earlier...not sure what constitutes "recent".) As well, as I am on an SSRI (and I'm currently decreasing my dosage because I seem to be one of the lucky ladies quite stable on progesterone). Putting the investigation of the lesions aside, which will certainly be done, I'm about ready to go off everything and see what happens; start from scratch. No SSRI, no estrogel, no progesterone, no birth control. Pray for my family