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[karab]

I have been on HRT since 45, when I started having terrible insomnia.  After some frustrating conversation with my OBGYN, I found a doctor who specializes in menopause who was able to explain that the hormonal changes in perimenopause were causing the problems and started me on HRT. 

After starting micronized progesterone and the estradiol patch, not only did my sleep improve (more and more as my dose increased), many other symptoms I didn't even realize I had were improving.  My energy level was better, I was happier, I stopped getting migraines, I was better able to build muscle than I had been in years, my skin was healthier -- there were even more things that changed -- I felt so grateful.   

My doctor told me that even high doses of HRT were safer than the pill, and encouraged me to gradually increase my dose until I could return to the great sleep I got most of my life.  She informed me many people in perimenopause need higher doses to control symptoms.  Eventually I was taking .125 estradiol patch, and 200 mg micronized progesterone nightly, which worked well for a while.  Eventually though, I began to have breakthrough bleeding in the middle of the month, a considerable volume comparable to a period, so I was bleeding 2x a month for 5 days.  We tried lowering my estradiol dose and sleep deteriorated while the extra period continued.

I'm just starting to take 300 mg micronized progesterone nightly (while going back to .125 estradiol) to see if it controls the bleeding.  At first I was afraid to have so much progesterone, but after a week bloating is already better and my mood seems good.  I found journal articles endorsing the 300 mg dose of micronized progesterone for women with sleep problems.  I'm curious to hear the experience of others on higher doses of HRT for perimenopause.  What has worked for you dose wise, and do you take higher doses of progesterone successfully?

If you haven't found a doctor who is willing to work with you, persist -- it was life changing for me to get away from my original OBGYN, who was making me feel like the severity of symptoms was my fault, although my lifestyle is very healthy.  Thank you for this forum!

Kara

[CLKD]

      

[sheila99]

Am I right that you're peri but taking utro daily? If you use a sequi regime (as would be normal in peri) perhaps you wouldn't have the unscheduled bleeds? My insomnia was due to oestrogen deficiency.

[joziel]

I'm on 9 pumps of gel at the moment and due to increase to a record TEN PUMPS of gel in 2 weeks time. I think I'm around 430pmol, although I last tested at 6 pumps so it's a bit of an estimate. I know I'm not really high... I'll test again when I need to do T bloods.

I'm also on 300mg of utrogestan from days 16-26 and 200mcg from days 3-16. I have a break for 3 days to allow a bleed (although sometimes it doesn't come, I guess because not enough has built up). I'm very tolerant of utrogestan and can take any amount of it and taking this amount seems to shut up anyone who's worried about high estrogen levels.

If you need to take high doses of estrogen but get break through bleeds with the utrogestan, I'd think that trying a Mirena coil might be a good answer. You can always have utrogestan as well for sleep benefits but that would fix bleeding. Or you can schedule a bleed by stopping for 3 days, like I do. That way you don't have random sporadic bleeding and everyone is relieved because it's expected...

[karab]

Thanks Joziel.  I am in the U.S., and I haven't heard of any practitioners around me telling people to stop their dose to schedule a bleed, although I see mention of this from people in the U.K.  Do you completely stop your doses, or just reduce them?  This practice is mentioned in medical journal articles, so it's odd to me that no one here talks about it.  Also helpful to hear you can stop for 3 days and that's enough to induce a bleed.

I have heard about the Mirena, and I guess that will be the next thing I try if upping my micronized progesterone doesn't work out.  Helpful to hear someone else is doing 300 mg.

[karab]

Thanks Sheila99.  Yes, I have wondering about doing sequential instead of continuous combined.  My practitioner says many people feel better on the continuous combined, and I get migraines, which apparently can be caused by the sequential dosing of progesterone.  My practitioner says she doesn't usually suggest sequential, but it sounds like that might be another option if this keeps being problematic.    I have also read that is appropriate for perimenopause, with combined for later.

I like the idea of scheduling bleeds like Joziel suggests if that would actually work, so I could just take the same dose all of the rest of the time.

Am I right that you're peri but taking utro daily? If you use a sequi regime (as would be normal in peri) perhaps you wouldn't have the unscheduled bleeds? My insomnia was due to oestrogen deficiency.

[Hurdity]

Hi karab

 

You said how old you were when you started HRT but not how old you are now nor how long you've been taking HRT? Also whereabouts in menopause you were when you started? ie what your periods and cycle were doing in the months leading up to sarting HRT. You are on an unusual regime but as already said - if you are very early peri then the bleeding will be your natural cycle breaking through, and utrogestan is not really designed to work like this with soneone who is peri.

If you are still ovulating fairly regularly (though with high dose oestrogen maybe you are not?) then you will be producing your own progesterone so the key is to tie your HRT in with your natural cycle when it occurs ie take it cyclically. This doesn't work so well in mid to late peri - but progesterone can still be taken cyclically, or a trial of continuous prog.

By the way the advice to stop the for 3 days to cause a bleed is only stopping the progesterone - not the oestrogen. I can see there might be an issue with migraines but the other solution is to taper off the prog gradually depending on the capsule doses you are taking - easier with the 100 mg doses....

I realise you weren't asking for advice but as you are in US it is interesting to see what other specialists are prescribing so just passing on views from the UK standpoint!

Hurdity x

[karab]

Thanks Hurdity,

I'm interested in advice if you have it, especially if something seems off!  I did wonder since I rarely heard of anyone on a similar regime, but my doctor said there is a lot of variation in what works for people.  Since the bleeding, I have wondered about a different regime.  I started HRT in late 2022, when I was 45, I'm now 46 and have been on it about 1.5 years.  They raised my progesterone early because of the lack of sleep so I've been on 200 mg daily most of the last year and a half.  I have been on a higher dose of estriol (.1-.125) for about 5-6 months at this point, with 3-4 months of having two bleeds a month, which I hate!

Around the time I started HRT, cycles were getting shorter, 27, 26 days, occasionally 24.  Sleep was terrible for the first time in my life, and my hair was falling out.  How would I know if I was too early in peri for this regime?  I read that progesterone is what we lose first in peri.  I thought estrogen dominance was often the problem in peri.  Maybe the wrong regime is the cause of the extra bleeds and not progesterone being too low? 

I might try consulting with a second doctor and see what they have to say if things seem too strange, but open to any further thoughts you have.

[joziel]

karab, I think I'm not quite understanding your questions but I'll give some answers a go....

I personally wouldn't worry about where you are in peri or post meno etc. I'm 46 and peri. When your estrogen gets over a certain amount (varies from woman to woman how much) it overrides your ovaries anyway and you stop having a normal cycle. (You stop ovulating.) That is why birth control pills use much higher doses of hormones by the way, they have to override your own. Anyway - if you override your own cycle you have no 'normal' cycle to be fitting in with.

Second, even if you do have a cycle still going because you haven't hit that level of estrogen yet, you can fit the progesterone around it. For eg, if you start to bleed, you can just stop the P for a few days to allow a proper bleed (continue the E of course) and then re-start the P. So - don't fight your body, go with it.

The reason I'm on continuous P during peri is because I have a history of endo and the P controls that. But there are many reasons women might want to do this and it would work well for any number of situations.

And yes I just totally stop all P for 3 days. This is actually an 'old' version of continuous HRT. Before continuous really was 'continuous' the advice used to be to take P for '25 days out of 28' and then stop for 3 days. So it's a perfectly safe and well-researched thing to do. I may or may not have a bleed though - if I stop and 3 days go by and I don't bleed, I just restart again and assume I haven't built up enough lining to have a bleed that month. (And then, as above - if I bleed unexpectedly I stop for 3 days to allow that.)

Any time you increase E or change products you might also get some spotting erratically. Which is why in the UK they say not to worry about spotting within 3 months of starting HRT, increasing E or swapping products.

[sheila99]

If you still have a cycle of your own stopping bleeds completely is hard except with a mirena and obviously the more oestrogen you're on the greater the build up so the more likely you are to bleed. That's why we normally use a sequi regime in peri, it fits in with your own cycle (at least in theory!). Although you get huge oestrogen spikes in peri the symptoms you get are usually from oestrogen deficiency as for much of the rime it's too low. My insomnia was caused by lack of oestrogen so you may find now your levels are higher you don't needca huge dose of utro to help you sleep. You might also want to familiarise yourself with the symptoms of too much oestrogen as they can be very similar to too little. If you do still have a cycle you're on quite a lot of oestrogen, you'd normally start on 50mcg in peri here and increase only if this doesn't control your symptoms. The 25/28 utro regime is particularly useful in late peri as it allows a bleed if there's been a build up but it works best if you can sync it with your own cycle.

[Hurdity]

Thanks Hurdity,

I'm interested in advice if you have it, especially if something seems off!  I did wonder since I rarely heard of anyone on a similar regime, but my doctor said there is a lot of variation in what works for people.  Since the bleeding, I have wondered about a different regime.  I started HRT in late 2022, when I was 45, I'm now 46 and have been on it about 1.5 years.  They raised my progesterone early because of the lack of sleep so I've been on 200 mg daily most of the last year and a half.  I have been on a higher dose of estriol (.1-.125) for about 5-6 months at this point, with 3-4 months of having two bleeds a month, which I hate!

Around the time I started HRT, cycles were getting shorter, 27, 26 days, occasionally 24.  Sleep was terrible for the first time in my life, and my hair was falling out.  How would I know if I was too early in peri for this regime?  I read that progesterone is what we lose first in peri.  I thought estrogen dominance was often the problem in peri.  Maybe the wrong regime is the cause of the extra bleeds and not progesterone being too low? 

I might try consulting with a second doctor and see what they have to say if things seem too strange, but open to any further thoughts you have.

Hi karab - thanks for clarifying.

So in relation to this: "How would I know if I was too early in peri for this regime? ", your answer tells me that you were not strictly peri-menopausal according to the medical definition ( at least that we go by in UK).
Although it is not cut and dried - women don't just go from normal menstrual cycle to being peri-menopausal overnight, early peri-menopause is defined by a variation in cycle length from month to month of at least 7 days.

The last stage before this is termed the Late Reproductive Phase ( or maybe Stage) and this is characterised by shortening cycles exactly as you describe. Now during this time hormones do begin to go awry giving rise to symptoms which is what makes it so difficult. Our medical guidelines recommend HRT from early peri-menopause but then what about all the women who are like you - shortening cycles and still ovulating regularly, and then all the women up to those whose cycles are varying by 7 days between cycles. Of course doctors do not interpret things quite as strictly but what works for some in true peri may not work for someone like you and in your case I am now even more puzzled by your HRT regime.

I doubt doctors in UK would prescribe either such a high dose of oestrogen nor high dose of continuous progesterone to someone who hasn't even started missing periods.

In terms of your symptoms poor sleep, and hair falling out - these aren't the classic early menopause symptoms. Poor sleep is usually as a result of hot flushes and night sweats though you haven't mentioned these, and sometimes palpitations. Hair falling out could be due to other factors which I hope the doc has measured eg thyroid function, vitamin and mineral deficiencies etc....however if your symptoms improved after starting HRT then it must have been doing something!

Oestrogen dominance is an unhelpful and misunderstood concept invented by somone sone years ago who wanted to sell a product to cure it! Yes progesterone declines but as I understand once you start skipping periods, ie there is no ovulation. It is likely your progesterone is fine if you are still having regular periods. Progesterone is sometimes given to regulate heavy bleeding from the oestrogen spikes of peri-menopause, and lack of ovulation, so can be given on its own during the second part of the cycle. This regulates the cycle and should reduce bleeding, but once periods are skipped then oestrogen falls hence HRT replaces it.

It may well be that you are peri-menopausal now?

I would be tempted to reduce patch to 100 mcg but take progesterone x 200 mg for 12 days per month (which is the licensed prog regime in the UK) for a few months and see how you get on re bleeding and symptoms?

I hope that's not too garbled and it probably doesn't help your situation

Hurdity x

[karab]

Thanks Hurdity,

Yes, I actually was having hot flashes well before starting HRT, at least a year, as well as some other symptoms.  The sleep problems were just the most severe.   I did also have heart palpitations, and my thyroid was checked, as were other potential causes of hair loss like vitamins and iron.

I haven’t had a break in progesterone since I started, and was on 200 mg nightly fairly quickly because of the sleep.

Hearing from all of you is actually really helpful, and it sounds like I might benefit from a regime change. I made an appointment with a practitioner to discuss whether or not I should actually be on sequential, or maybe lowering my dose and having the three day break from the progesterone. I’ll hold your dose suggestion in mind.  I don’t think I got that much benefit from going up beyond the .1 estradiol patch.  I will write again if I figure out the solution, in case others end up in a similar situation.  Thank you so much for taking the time to reply! 

[Hollyboll]

I relate to what you say karab - when I finally started HRT (after years of a very ignorant GP missing what in retrospect was clearly a very rocky peri, and drugging all sorts of things inappropriately and separately) not only did I sleep through for the first time in years but I began slowly to realise just how many other symptoms were related - and they improved!

I'm also on 200mg utrog every night, after my oestrogen doses were then later pushed up WAY too high.  It's not clear to me why I was put on continuous at the start of HRT, since I'd not had 12 months without a bleed - but I trusted the private GP meno 'specialist' who started me on HRT (after my own GP told me it was incredibly risky and spouted all the rubbish that's so out of date, but I didn't know that then) and have been on continuous ever since - by continuous I mean every single night! 

Unfortunately, that private GP meno 'specialist' then pushed up my oestrogen way too high (way above 125, don't worry!), as well as too fast, which caused all sorts of other problems - and eventually I ended up with a leading meno consultant who has helped hugely - one of the things I've learned from his (very different to previous) approach is that it's fluctuations at least as much as levels that cause symptoms.  So if you do decide to reduce the patch, I'd recommend doing it slowly (here that's 12.5 mcg at a time for 6-12 weeks each).

All of which is to say I recently asked him about why I'd been put on conti to start with (he has no idea!) and whether I might try cyclical/sequi now.  I've had some irregular bleeds, but nothing prolonged or heavy enough to be alarming.  His answer was that a progesterone break is just more fluctuations/changes to levels within each month, so no.  In fairness, I've suffered extraordinary fluctuations thanks to very high oestr exacerbating a very unusual uptake pattern, so he might be particularly cautious about that with me, but if the bleeding isn't really causing you a big problem I'm not clear why you'd risk fluctuations by taking progesterone breaks. 

I have asked him repeatedly whether my symptoms could be caused by continuous 200mg utrog, which is higher than many - especially after reading the many many people here who struggle with utrogestan at even lesser dose.  He is adamant it's highly unlikely. 

As others (and my consultant) have said, it's academic and irrelevant whether you are in peri or post, as well as completely impossible to tell once you're on HRT.  Also these phases are broad guidelines and a bit of a nonsense really.  Eg there's a big issue with the term 'postmenopause' ... it suggests as in the old-school view that meno is a point in time (12 months without a bleed) and once you are passed/through it, that's it, all fine / out the other side.  Which is obviously nonsense - it's not like hormone levels come back!!! 

That's just me of course and everyone is different but I hope it helps!

xx

[karab]

Thanks Hollyboll!

Interesting to hear you were put on even higher doses, what dose oestrogen ended up working for you with the 200 mg progesterone?

I did meet with a different practitioner at my same practice last week, who like your practitioner and my previous practitioner, was supportive of continuous dosing from the very beginning.  She also said most women do better on continuous even in peri, but said I could try the progesterone break for a few days when I thought my bleed was due and see how I felt.  I did try that this month, and so far I feel better.  I'm staying on .1125 oestrogen for now and continuing with 200 mg progesterone at night with food.  I may try to reduce my oestrogen dose again in a couple months to do .1 and just have one patch.

I talked to a couple others in perimenopause in my area, and others were also put on continuous, and I didn't talk to anyone who was started on sequential/cyclical, so it's definitely not just the practice I'm working with doing this.  The new practitioner I met with last week agreed with your practitioner, less fluctuations=better.  She also felt that the dosing alone shouldn't be causing me to have two periods, she said that is sometimes a phase of perimenopause for some women.  She is sending me for scans and blood levels just in case.

Both my practitioners were also very supportive of the progesterone dosing being continuous, they believed that most women had progesterone issues related to changing the dose, and that was part of why they were recommending against sequential.  They thought cyclical pauses in progesterone might be okay for just that 3 days, and were worth a try.  They thought I might not feel good, but I think I've felt better since the pause.

I did want to try to stop the bleeding, because I've already been struggling with anemia, and the fluctuations around the second period also cause more trouble with sleep, same as my real period.  It's not just breakthrough bleeding, it's two full, heavy periods, really too much for my body.  Since the two periods began, I have also generally been feeling less hormonally stable.

Thanks also for the advice to decrease the patch slowly.  I wish more practitioners would support this; I figured that out the hard way!!!  And thanks for taking the time to write; hope this is helpful to others.