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[joziel]

I thought I understood this but I just want to check...because I've heard a few conflicting opinions 

The thing is: I'm not bleeding even when I stop my utrogestan. I am taking 300mg orally and continuously (due to a history of endometriosis), but when I stop for 3-5 days to 'schedule' a bleed, nothing happens. So I re-start it... That has happened the last few months. I don't bleed at other times either, although occasionally I get a tiny amount of spotting after I've had a wee. (I did today.) This makes me think there is something that needs to be shed....??

I DID bleed until I increased my estrogen to about 8 pumps, which seemed to override my own cycle: I'm on a very high dose of estrogen (12 pumps of Oestrogel/day) due to 1) not absorbing it well and 2) needing a high-ish serum level to counter my symptoms (debilitating insomnia). I'm due to get bloods done next week via Medichecks, just to see how much I am absorbing of this dose. The last time I tested was on 6 pumps when I was at 350pmol.

I have no other high estrogen symptoms, no sore boobs, although occasionally I do get egg white cervical mucous for a few days. I also have no endo symptoms, which is usually what happens if my estrogen is high and unopposed. (I tried sequential HRT at a much lower estrogen dose and I got endo symptoms back, which is why I went continuous - which leaves me symptom-free.)

I guess my worry is that I'm not shedding my lining and I worry that it is building up, with this high estrogen dose. I know the thinking is that, if your estrogen is too high, you will bleed too much. And I'm not. So I shouldn't worry if I'm NOT bleeding. But there is this very occasional literally one blob of blood I get...

I am up to date on my smear - had that just a few months ago.

I don't know if I should try not only stopping my utrogestan for a few nights but also hugely reducing my estrogen - as would happen when we cycle, to induce a bleed?

I have tried increasing my utrogestan to 400mg for a few nights and then stopping that - to see if the bigger drop will cause a bleed, but that didn't work either. Should I try cutting estrogen to induce a bleed?
 

[Wrensong]

I guess my worry is that I'm not shedding my lining and I worry that it is building up, with this high estrogen dose.

Would ultrasound clear this up for you?  Not sure whether endometriosis compromises US imaging - you'd know better than me?  I didn't bleed on sequential for the first 10 months after resuming HRT following a long break, but my oestradiol wasn't high dose & scan showed lining was thin.

[sheila99]

You could wait until you have the results before deciding. A huge dose is going on your skin but it might be that you're only absorbing what another person would get from 4 pumps. And you're on a high utro dose which may be enough to stop any build up. In late peri I bled about 1 in 3 when my own cycle wasn't involved and it wasn't a problem though of course everyone is different. I'm inclined to think it's probably OK  but in your shoes I would have a scan just be sure. The occasional blood doesn't really sit with the no build up theory unless there could be another explanation for it such as va. Let us know how you get on.
 

[joziel]

Thanks folks. The occasional blood was slightly more than that yesterday so last night I didn’t take utrogestan to see if I can allow a bleed.

My hunch is it’s not going to happen because of the higher estrogen levels.

I also don’t know if I feel any better on 12 pumps of gel than I did on 8. There was a huge improvement with sleep around 8 but increasing further after that didn’t help sleep more.

So I’m going to test on Monday on these 12 pumps and see if it’s very high or not. I think also my body is doing something under all this because a week ago I had egg white cervical mucus as well. Which I don’t have usually even on 12 pumps. So clearly I made some more estrogen alongside. Hopefully if I’m now bleeding my body isn’t making tons of it’s own estrogen and I get some kind of reflection of what I’m getting from gel…

Yes I might need an ultrasound but I’d rather force a bleed so doctors don’t worry with scheduled bleeds. Depending on the result of these tests I might try reducing down to 8 pumps and seeing how I feel. I would hopefully cycle again then and bleed… At least I was until March this year having regular 23 day cycles. Then I went over 8 pumps…

[aj1971]

I understand why you are wondering what is going on Joziel. All a bit disconcerting!

It could be that the 300mg utrogestan per night has settled and is being very effective. In  which case, you might get a bleed every few months rather than monthly because the utro is keeping the lining 'trimmed'.

You are aware, by knowing your own body, that oestrogen does not feel high.

Your own production of oestrogen could be reducing because you are further into perimenopause, or it could be that your own body is reducing its production of oestrogen in response to the increase in oestrogel pumps. (There is not a lot out there, as far as I am aware, on how the body's own feedback system to the pituitary operates when hormones are added via HRT. For example, will it decrease production if it senses too much oestrogen being added? Don't know.)

It would be more concerning if you had heavy bleeding or if you had a lot of recognisable endometriosis pain, which you have said you don't.

As you have done, see what the Medichecks test says. Are you having progesterone measured too, or perhaps you already know what level you are achieving? The two figures for oestrogen and progesterone, taken together, will perhaps give you an idea of how likely it is that the progesterone is controlling the bleeding.

And then, as has been said, a scan would let you know definitively how the lining is doing.

[bombsh3ll]

It's 2024. Nobody needs to bleed unless they choose to.

If you have stopped getting withdrawal bleeds you could just take continuous progesterone.

You are already on a fairly high dose of almost continuous progesterone anyway so you may well have an atrophic lining by now

Blood tests can be helpful to check estrogen absorption particularly if an individual requires a higher dose for symptom control.

However they will not tell you anything about if/when you might bleed.

Nor will a scan - it would rule out an overly thick lining but that usually presents with excessive/unexpected bleeding and personally I would save my money.

Blood levels of progesterone have no clinical utility in this situation.

[joziel]

Thanks folks... Well, I didn't take utrogestan last night and I'm bleeding more today than I have since March. It's still hardly anything, only need a pantyliner, and it's brown and not red, but it's not just the 'is this really blood?' dot on toilet paper I've been getting every few weeks before.

I'm not getting progesterone measured as well, because I got very confused about that. I'm in a FB group which is US based and apparently there are different types of progesterone test and the one many doctors use is irrelevant and not reflective of true levels, for some reason I didn't figure out - and I couldn't work out if the Medichecks test was the version they advised or the waste of time misleading version... plus I do well with utrogestan so can happily take more of it than I need. (I'm confident it's not causing my night time symptoms as they continue whether I take none of it or a lot.)

bombshell, I was taking continuous progesterone but occasionally I get this tiny dots of blood. It's like when you get ovulation bleeding, if you know what I mean. It's mixed in with cervical mucus. So I didn't know if my body needs/wants a shed. I'd rather schedule this so all worry about bleeding can go away, than need investigations. But it doesn't happen when I try to schedule it.... not just by stopping the utrogestan.

And since this all began when I raised my estrogen over 8 pumps, I'm wondering if I need to reduce it to enable the shed to happen. I could do that temporarily to allow a bleed or I could try decreasing - I'll see what these blood results are and take it from there.

[bombsh3ll]

If you are having the breaks in progesterone to try and induce withdrawal bleeds so you don't have to worry about unpredictable bleeding, yet this is not what is happening and you are still tying yourself in knots over whether/when you might bleed, I would conclude that to keep chopping and changing is probably not serving you.

If I were you would find the dose that you feel well on and just stick to it. If you are on a relatively high dose of estrogen it might be worth just ONE blood test once settled on your ideal dose, more to exclude very high levels than anything else as blood levels are extremely unstable with gel, and maybe just get one pelvic scan for reassurance about your lining on continuous progesterone.

After that I would just leave both your doses, Medichecks and Facebook alone 😉

[joziel]

That's all well and good except for the " find the dose that you feel well on and just stick to it. "

Since I have debilitating and life-changing symptoms at night going on for 2.5 years now and the reason I'm on 12 pumps is an effort to address those. They have improved but are not resolved by any means. So the bloods are to see if I really am getting levels up into a high enough therapeutic dose, or if I'm just not absorbing this...

It will be far from my last blood test though, because I will likely need to switch products and then check absorption and levels on those...

[bombsh3ll]

The thing with gel though is that unless you are applying it every hour throughout the day, you get a spike in blood estradiol level soon after applying, then it can quickly drop off and go quite low (however many women feel fine with this as their various tissues can still have enough even after the plasma level has plummeted).

There is also significant variation between individuals, so it's not necessarily easy to know when your peak and trough are occurring in order to time your blood test.

So you could get a dramatically different blood level at two different times on the same day, one leading you to reduce your dose, but the other having you feel your dose is too low.

You have to think about how the result will change management.

[joziel]

I always test the same time every day (first thing in the morning). I don't apply gel the morning of the appointment, only the night before. I keep everything consistent. Whilst the levels will fluctuate, it will reflect the increased dosage. I also always test during my period and fortunately I happen to be bleeding now...

As for how it will change treatment, if my levels are very high (1000pmol +) and I still feel like this, then I don't think more estrogen is going to help and I will reduce back down to 8 pumps. (Assuming I haven't contaminated my inner arm somehow.)

If the levels are reasonably high but could be higher (under 600pmol) then I will need to find a way to increase dosage further, which means switching products.

If the levels haven't improved much since last test at 6 pumps (350pmol) then I will definitely need to switch products.

[bombsh3ll]

That sounds like a good plan and I hope you manage to attain a level in your desired range.

I am on 1.5mg oral estradiol with a blood level of around 400pmol/L.

I am happy with this both clinically and biochemically, but some of this will still be my own production as I have relatively high ovarian reserve and the pill doesn't shut you down to zero.

[joziel]

I do wonder if this is all about serum blood levels of estradiol though, or whether neurological symptoms like I have are not really about brain uptake of estradiol.

I'm just thinking about ferritin/iron, which is something I've investigated and treated: You can have normal serum ferritin levels (say, 100) but low brain ferritin levels (single digit) - they found this in research where they measured serum ferritin and compared it to ferritin in a spinal tap which is essentially brain levels of ferritin. They found the two can differ hugely. And that serum ferritin has to be pretty high to get the brain to uptake it and be able to use that iron.

So what with all Lisa Mosconi's research into brains and estrogen and neurological symptoms being brain-related, it just makes me wonder. I'm so pissed off that it is 2024 and the current state of knowledge is fck all when it comes to women's bodies and minds.