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[MegnB]

I'm currently on .5 Divigel and 100 Utrogestan continuous, but went in for an appointment bc of bleeding after 1 year of no bleeds.
These are my lab numbers.
I was hoping for a better understanding of my situation before I go to my next appointment.

FSH 48.1 U/l
Progesterone 1.63 nmol/l
Oestradiol (E2) 44.1 pmol/l

My last appt a year ago they were
Progesterone .159
Oestradiol  182.2

Thank you for helping me!

[laszla]

Hi Megn,
your estradiol is very low indeed - even a year ago it was low for someone on hrt, now even more so - it should be at least around 300 pmol.
I don't know Divigel so not sure how your dose compares with oestrogel but it looks as if you need to increase the dose or try a different type of estrogen - some women have absorption problems (myself included).

[joziel]

Your FSH indicates you are post-menopausal (it is high - normal for menopause).

I have no idea about progesterone, as it's not usually done for HRT bloods.

Your estrogen is really really low. As Laszla says, it was low at 182 and at 44, it is almost non-existent. Ideally you want 300nmol+ for bone protection but if you need more than that for symptom control, then you can go much higher....

It's not surprising that it is so low, because 0.5 Divigel is a really really low dose of estrogen... You likely need much more. Assuming it is the same as Sandrena, that is.

None of this explains your bleeding after a year of no bleeds though - with estrogen that low, you should be less likely to bleed, not more. I wouldn't worry but you do probably need an ultrasound scan to check your lining and just make sure it isn't too thick, causing the bleeding. And to check you don't have a fibroid. Some women need additional progesterone.

[Hurdity]

Hi MegnB

I'm not sure why you had blood tests done for bleeding - this would not be done in UK but for any bleeding as joziel suggests you would be sent for a scan  to check your lining.

Also depends on your age - if you had only been 12 months without a bleed it could just be a late ovulation, and the younger you are the more likely this could be to happen.

If it was a bit of spotting not a proper bleed then occasionally the uterus lining can overthing due to insufficient oestrogen and too much progesterone - and a scan will determine this.

Also polyps (and fibroids as suggested) can cause abnormal bleeding.

The progesterone value is irrelevant and not necessary except for fertility diagnosis.

Also a one-off oestrogen reading is not necessarily very accurate though that is a low reading - I don't think 300 pmiol/l is necessary (though again depends how old you are) but probably around 200 would be good to aim for I would suggest, if bone-protection, depending on your age ( younger women who go through menopause early should have higher levels of oestrogen).

Good luck with your appt and let us know

Hurdity x

[MegnB]

Hi Megn,
your estradiol is very low indeed - even a year ago it was low for someone on hrt, now even more so - it should be at least around 300 pmol.
I don't know Divigel so not sure how your dose compares with oestrogel but it looks as if you need to increase the dose or try a different type of estrogen - some women have absorption problems (myself included).

Yes! I was shocked at how low it was! Sigh. The .5 mg of Divigel and 100 Utrogestan was obviously not doing the job. By absorption problem do you mean my thick rhinoceros skin doesn't absorb anything anymore? How do people work through that?

Thank you for responding!

[MegnB]

None of this explains your bleeding after a year of no bleeds though - with estrogen that low, you should be less likely to bleed, not more. I wouldn't worry but you do probably need an ultrasound scan to check your lining and just make sure it isn't too thick, causing the bleeding. And to check you don't have a fibroid. Some women need additional progesterone.

I had an ultrasound the same day they drew the labs which is why I was confused. The ultrasound showed a thickened lining (10mm) and one ovary slightly enlarged. I couldn't mentally pair the low estrogen/progesterone with the lining issue.

She said they don't like to jump to a scope or d & c because they are invasive and rarely reveal any issues. Her plan is to double my progesterone for 10 days to prompt a bleed and double my estrogen. She also considered giving me synthetic progesterone which will absolutely produce a bleed. I have a follow up in 6 weeks for a rescan. She did say that they probably won't redo the bloods bc they're just a "snapshot."

None of this makes sense to me. Thank you for taking the time to reply!

[MegnB]

Hi MegnB

Also depends on your age - if you had only been 12 months without a bleed it could just be a late ovulation, and the younger you are the more likely this could be to happen.

If it was a bit of spotting not a proper bleed then occasionally the uterus lining can overthing due to insufficient oestrogen and too much progesterone - and a scan will determine this.

Also polyps (and fibroids as suggested) can cause abnormal bleeding.

The progesterone value is irrelevant and not necessary except for fertility diagnosis.

Good luck with your appt and let us know

Hurdity x

Thank you so much, Hurdity! The scan showed thickening (10mm), and ovary that was thinking about ovulating (how is this possible with such a low estrogen level). 

I had two bleeds, the first was just like a regular period. I was very annoyed. Then I had another a week later, lighter, but no less annoying.
I have a known fibroid, which was a bit larger, but marginally. I didn't know progesterone wasn't all that important!

I responded to joziel that my appointment yesterday was because I couldn't understand why my estrogen was so low yet I had a thickened lining, etc. She offered synthetic progesterone at a high dose to prompt a bleed, or just to double my current dose to 200 and increase my estrogen and see her in 6 weeks for another scan.

The journey continues.

[joziel]

It is a little weird to have a thickened lining like that on such a low dose of estrogen and with adequate progesterone. The ovary which is thinking about ovulating probably means they saw a follicle getting ready...

Which country are you in MegnB? In the UK you'd probably be getting a hysteroscopy at this point...

I don't get the reasoning for increasing the progesterone and the estrogen. I mean, I'm not sure how that is going to help you bleed.

[MegnB]

I’m in Switzerland.
Her solutions didn’t make any sense to me either, so I’ve stopped the estrogen (which is obv useless) and will finish out the 12 days of 200 utrogestan and stop. Hopefully that will trigger a bleed.

I did ask about further tests and she said she would rather wait as they used to routinely do a procedure and d& c and 99% of the time all was well. I just don’t want to be the 1%. My insurance is happy to pay for a second opinion, but finding a doc taking new patients is impossible.

I’ll wait to start anything again until the scan in August.