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[Mary G]

Kai_63, I was post menopause by the age of 45.  My very first symptoms were in 2004 and I was post menopause by 2007.  That said, my progesterone started tanking when I was in my mid 30s.

Why can't you continue taking the desogestrel progesterone pill (75mg?) and just add Oestrogel?

[CLKD]

I am wondering about this as the day goes on ............ 

The way to find out if you are into menopause proper is to stop all HRT .  But if you are on a regime that suits .......... I would be inclined to stick with, why rock the boat?  As for stopping The Pill, unless you stop replacements you won't know if you are through peri  - unless I'm really muddled.  [answers on a postcard]

[Kai_63]

Thank you both!

Honestly I don’t understand why I can’t just take the pill either. Totally agree, why the need to rock the boat. Just up the gel and Vagifem as needed.

I hadn’t realised how quickly someone can go from peri to post. It must have been such a whirlwind.

But basing the decision on a two year old blood test seems strange either way. 

[CLKD]

I wonder why you went to the private clinic, mayB think about which symptom/s you wanted to discuss there?  Has there been any answer to your original queries or is there more confusion?

[Dotty]

Hi before starting hrt, were you taking the mini pill ? X

[Hurdity]

Thank you. 2 years ago my periods were 8 months apart already.

The reason I went to see the specialist today is that the HRT wasn’t helping everything, still had bad VA and mood issues despite decent doses.

So I guess she’s taking all that information together and deciding I’m probably menopausal by now?

Hi Kai

I'm finding the information confusing.

Please can you give a summary timeline of what you were taking and when you had the blood tests, symptoms etc so we can try to work out. so (and looking at your past posts):

From your past posts I can see you were taking the combined contraceptive pill and this contains oestrogen so the question is were you taking this when you had the blood test done? Once you take any sort of HRT or pill even mini pill, then ALL blood tests are inaccurate in terms of your natural hormonal state so measurements cannot give you an indication of menopausal status. Even if you are not taking anything, FSH can go into the menopausal range during peri as it states on this website:

"If having a blood level measured, the blood sample should be taken on the 3rd to 5th day of a period. A normal level does not exclude early menopausal transition and a raised level does not exclude continuing ovarian function"

https://www.menopausematters.co.uk/diagnose.php

And it is not usual to go from peri to post that quickly. If you were taking the combi pill ( and this is the same for the mini pill and the Mirena coil)  and then went onto HRT then you won't know when you became peri and certainly not when you become post meno. If your periods were 8 months apart but they were not natural periods then this is also not a true picture of how far towards menopause you were...

If you were taking the combi pill then I am wondering what and how you experienced any peri-menopausal symptoms and what they were because the pill is often prescribed for the very reason to prevent menopausal symptoms because it suppresses the cycle while giving you replacement oestrogen.

My view is you're having a lot of progestogen that you probably don't need and I'm wondering why you didn;t stay on the combi pill if that;s what you were taking? Maybe due to your age if the oestrogen was synthetic?

If you still need contraception then a better option might be to take one of the newer contraceptive pills designed for peri- menopausal women that contain oestradiol, like oestrogel and oestrogen patches and pills - and then that woud be it - just one pill - until you're a bit older and more certain to have reached menopause.

One such pill is QLAIRA and this would suppress the cycle and give you oestrogen and (hopefully) a small withdrawal bleed. There is another one ZOELY. You wouldn't need a menopause specialist then - unless these didn't work?

Hurdity x

[Kai_63]

So sorry for the confusion.

So in 2021 I wasn’t on contraception. My natural period was every 8 months or so. They gave me a blood test to check FSH and it came back at 53.

Then I was put on the combined pill, which seemed to help my hot flushes and other symptoms.

In early 2023 I saw a gynaecologist as I had a lot of peri symptoms, who put me on Utrogestan (12 days), oestrogel (2 pumps) and Vagifem. She took me off the combined pill and put me on the progesterone only pill. I can’t remember the exact reason but she seemed to think this would be better given my peri state.

I was still having a lot of symptoms including VA so I decided to see a menopause specialist. She was the one who asked about my 2021 blood test (deciding I was likely menopausal by now) and recommended I go up to 4 pumps gel, daily Utrogestan, stick to Vagifem, add Blissell for external discomfort and come off the progesterone pill.

Hope this is clearer. Just feeling very confused at this point! Happy to try other contraception though.

[CLKD]

Morning.  Tnx Hurdity.

[Hurdity]

Hi Kai

Thanks for clarifying and no need to apologise - was just trying to work out what was going on.

The NICE Guidelines state that blood tests are unnecessary to determine peri-menopausal status if you are over 45 and experiencing cyclical changes and menopausal symptoms, but between 40 and 45 which you were at the time - is a bit of a grey area. However the fact that your natural periods were 8 months apart and you were experiencing symptoms means that you were likely to be late peri-menopausal (and therefore could be menopausal by now) though the younger one is, the more likely it is that sometimes periods do resume as the ovaries kick back into action - hence the recommendation to wait 2 years after natural menopause before stopping contraception if you are under 50 but only 1 year if over 50.

In terms of your situation - first - you say the pill helped with flushes and other symptoms, but what additional  peri symptoms were you experiencing that led you to see a gynaecologist - and I presume you were referred by your GP? (Apart from VA - which can be treated by local oestrogen in addition to systemic HRT (or the combined pill in your case).

Putting you on the POP in addition to HRT as I said would be giving you a lot of extra progestogen and as far as I understand it Desogestrel suppresses the cycle and inhibits oestrogen production (though not sure how it reacts with HRT) hence the need for replacement - but you needed it for contraception.

Although you may well be menopausal because of what your cycle was doing 2 years ago - because I think you are still only in your 40's, this cannot be assumed, as I saids above. I would have thought you would still need some form of contraception. What did the menopause specialist say about this? Was this person a specialist doctor or nurse? On NHS?

So if you are to use contraception, then the alternatives are the pills that I suggested, or you could have the Mirena coil which releases most of the progestogen directly to the uterus - and this can be used both for contraception and the progestogen part of HRT. Then you would be able to add oestrogen at whatever dose you need to control symptoms, as well as local oestrogen for VA.

Obviously you have been given other advice by your menopause specialist and it's up to you whether you follow it or not, or whether to get a second opinion, but I would be a bit worried about not using contraception ( depending on your age now?). Also to reemphasise, the docs should not be using the standard blood tests (FSH etc) to determine your menopausal status (in terms of whether or not to use contraception) because these are inaccurate, though there is the AMH test here but dont' think it is widely used:

Recently, measurement of Anti Mullerian Hormone (AMH) is being recommended in women who are commencing fertility treatment. AMH is produced from the egg cells in the ovaries and the more egg cells that are remaining, the higher the level will be. This can be helpful in assessing the likelihood of success of fertility treatment, and in helping choose the dose of drug to be used to stimulate the ovaries. It is not routinely used to diagnose menopause, when the level will be very low, but can be helpful if the diagnosis is unclear.

https://www.menopausematters.co.uk/diagnose.php

As Dotty (I think) said - if you were happy on your current regime of mini pill and oestrogel and utrogestan generally, you can increase the oestrogel and also increase the local oestrogen eg use Blissell in addition to Vagifem.

Re Mary G suggestion - the mini pill on its own is not licensed for HRT although off licence some docs prescribe double dose.

Hope this helps and all the best

Hurdity x


 

[CLKD]

 

[Kai_63]

Thank you so much, this is really helpful.

I’m about to turn 46, the blood test was done when I was around 43.

The symptoms initially VA (and associated things such as thrush, UTIs etc) and the hot flushes but they calmed down with the contraceptive pill. More recently, and the reason I wanted to see a specialist, was that the VA was only marginally better, I’ve lost drive, motivation and confidence, have low mood, skin issues, brain fog, migraines, anxiety on and off! Some of this might of course be HRT side effects.

The person I saw is a GP but she describes herself on the clinic (one of the well known private ones) website as a menopause specialist.

I’m not keen on mirena coil but was concerned about coming off contraception when I’m this young. I’m waiting for the follow up letter which might have more details on the rationale she had for contraception.

There was a lot of information during the session so I want to make sure I understood it all correctly and can relay it here.

[joziel]

If you can come off desogestrel, it would be a good idea to. It is a synthetic progestin and they do carry slightly higher risks of a few things. (I was on desogestrel for about 10 years and it nuked my sex drive but that's another story.)

So if you don't need it then you should stop really. You can for sure try a continuous utrogestan regime and see how that goes, at the same time as stopping the desogestrel. If you were only having a period every 8 months before it's incredibly unlikely you'll get pregnant/need contraception. Are you not ok just using condoms for a few years until you feel more confident? Sometimes it's a psychological thing, we've spent so much of our lives trying not to get pregnant when we don't want to be, it can feel crazy to just drop it all...

From what you say there it sounds like you need more estrogen Kai_63 (more than your 4 pumps) and also testosterone

[Kai_63]

Thanks. That’s interesting about the desogestrel.

I don’t mind using condoms, although it’s not a great combination with the VA at the moment. i might look at other contraception options mentioned above though.

I also wondered if I should be on testosterone. The specialist suggested I could look at adding that once the other meds settle down.

I don’t really understand the pros and cons of daily vs 12 days a month Utrogestan. I seem to be fine on 12 days so don’t see the point in changing to be honest.

[joziel]

It's because you will likely get unpredictable break-through bleeding if you stop desogestrel and just take utrogestan sequentially. The reason you're not at the moment is probably the desogestrel (which is a powerful progestin) is stopping it. The utrogestan - being natural and body identical - isn't going to be enough.

There is also research showing it is slightly more risky to be on sequential for ages/long-term than continuous. For eg: Research shows there is NO increased risk for 5 years of sequential HRT. After that, there is a slight increased risk if you stay on sequential over switching to continuous. (Risk = endometrial build up, leading to cancer.) So women are started on sequential but when they are ready, moved to continuous.

You will hopefully find some testosterone might help with your VA as well. It really helps with sex drive... (as does getting the estrogen level high enough).

[Kai_63]

Thank you, that’s really helpful. Perhaps I’ll stay sequential for a little while and see what happens. It’s not even been a year of taking it and it seems to be one of the few meds that isn’t causing issues/is actually working! But I don’t have a major problem with moving to continuous.

If I add testosterone (which I really think will help general motivation as well as sex drive as you say), is it best to let other things settle down first e.g increased Oestrogel and no contraceptive pill for the time being?