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[word_witch]

I started HRT just over two years ago and had no issues with it for the first 18 months. I use Lenzetto spray every day and Utrogestan from days 15-26. My period / withdrawal bleed has always come like clockwork at day 28 or 29 with a couple days of spotting in the lead up. I also have adenomyosis so my bleeds are often heavy and painful.

At the start of 2024 I started getting a lot of nighttime itching and my anxiety worsened so I was advised by my GP to increase my Lenzetto to 3 sprays per day. This made my next period very heavy and painful as adenomyosis is oestrogen sensitive so I started taking herbs in June through a qualified menopause herbalist to help with this. My June and July bleeds were virtually painless which hasn’t happened in years, and the itching and anxiety reduced greatly. I was very happy with the results of this.

Then in August when I stopped the Utrogestan I never had a proper bleed, only light spotting for 7 days. I was confused about when to start counting Day 1 again but a search online said I should consider Day 1 as the day after day 28 of the previous cycle, regardless of whether I bled or not. So I carried on as usual and started the Utrogestan on Day 15 but as soon as I started it I began bleeding very heavily and it carried on for 8 days. On Day 7 I called the GP as I wasn’t sure if I should stop the Utrogestan and she got me in for blood tests and swabs and has referred me for an urgent ultrasound to ensure it’s not uterine cancer since it’s unexpected bleeding.

I stopped the Utrogestan on day 26 as normal and am now on day 28. However, I am clearly ovulating which would make sense if I’m counting the recent heavy bleed as a delayed period rather than a mid-cycle bleed.

I am now really confused about whether I need to resync the HRT with my body’s natural cycle or if I carry on with the schedule regardless. My GP won’t discuss it with me until I’ve been for the scan and had the results but it’s really worrying me and I don’t know what to do for the best. Additionally, my anxiety has gone through the roof and my moods are all over the place. I am tempted to just stop the HRT altogether and see what my body does naturally. Is it ill advised to stop HRT ‘cold turkey’? Any tips or words of wisdom would be much appreciated.

[sheila99]

Medical advice is to carry on with the hrt cycle regardless of your own but I found it better to adjust the utrogestan to be in step with my own cycle. When your own periods are variable length it gets difficult but I found my own cycle was always stronger than the hrt one. This wouldn't normally have been classified as unexplained bleeding as in peri it's perfectly normal for your own cycle to vary.
 You can go cold turkey or reduce oestrogen slowly if you want to stop hrt but as your symptoms are creeping back in even with the additional oestrogen you're getting I think you might reasonably expect them to get worse. If I was in your shoes I'd want more oestrogen not less.
 A scan is often not helpful in peri. Ideally you want it to be immediately after a bleed when your lining is at it's thinest. If it's just before it could be 16mm and not be a concern (though they will then panic and send you for a hysteroscopy).
 I am assuming you're peri as you seem to have your own periods. If you're meno she's right to investigate.

[K45]

I had a similar experience and absolutely agree with Sheila that it's better to reset the hrt otherwise you end up bleeding at completely the wrong time. After 2 months of bleeding in the first week of taking utrogestan i decided this month to count day 1 as the first day of bleeding and restarted my utrogestan on day 15.  It seems irregular bleeding is very common during perimenopause so hopefully nothing to worry about.

[joziel]

I would not stop the HRT. It's a bit ridiculously over-cautious to refer you for a scan on the basis of that one incidence. I personally would have re-synced the progesterone and watched to see if weird bleeding patterns happen again. Only if they kept happening, would a scan be indicated really.

One thing to say is that you might want to increase your utrogestan if you have adenomyosis. It will help reduce the build up and should mean less painful cramps and periods. I know you think you fixed that with the herbs but if it happens again, I mean. I am on 300mg utrogestan continuously (except for 3-5 days to bleed) due to a history of endometriosis and this keeps me symptom-free.

This is especially the case if your estrogen has been increased, as your Lenzetto was. It's probable that this bleeding wouldn't have happened if your utrogestan was increased when your estrogen was.

Why do you think you are ovulating now? Is it due to egg white mucous? Our bodies on estrogen can do weird things. Usually we would not have high estrogen during a period. But on HRT, we can indeed have both our period (well, a bleed) and also high estrogen. The high estrogen causes egg white cervical mucous which we are used to getting when we ovulate. But it doesn't necessarily mean we are, now.

Even light spotting I would count as Day 1, since our bleeds can get quite light. Stop the utrogestan when that happens. Since you are now further along in peri, why don't you use utrogestan continuously except for when you start to bleed? This takes all the guesswork out of where you are. When you bleed, stop taking it for 5 days to allow the bleed to happen. Then start again. It will keep the lining thin better than sequentially and you don't have to worry about where you are in the cycle, plus it will help with the adenomyosis. It's what I do, in peri, and it works great.

I think this 'third way' of taking utrogestan should be more widely known. It is the 'old' continuous regime when you'd just stop for 3 days once a month.

[Hurdity]

Hi wordwitch

 

Sounds like maybe your natural cycle was regular when you started HRT and may now becoming more irregular as you get further into peri-menopause?  What your natural cycle was doing in the months and years leading up to your starting HRT will also be a guide. The fact that you didn't have a proper withdrawal bleed when you stopped the utrogestan but then started bleeding heavily 2 weeks later, to me is a very strong indication that it is due to your natural cycle kicking in. 2 sprays of lenzetto is hardly any oestrogen. If you ovulated just before you stopped the Utrogestan course, then your own progesterone would be produced over the next 2 weeks so the lining would not have been shed - unitl your own progesterone level fell -  even though you then started progesterone again.

Just also to make the point that "syncing" with your own cycle is almost impossible once you reach peri-menopause as you won't know when you're going to ovulate - you don't have a cycle as such,  or when you do, and if it is infrequently you still need to take the progesterone regularly to ensure protection of the endometrium.

Unless you do start ovulating regularly then it should all even out after a couple of cycles and the withdrawal bleeds will be due only to oestrogen from your HRT

Hurdity x

[word_witch]

Thank you all for your feedback and comments. Joziel, I have asked my GP about increasing my progesterone to help with the adenomyosis but they always fob me off and just tell me to increase the oestrogen. They clearly think that oestrogen solves everything and the progesterone is there only as a protective factor. Sigh. I’m going to be much more forceful next time we speak about upping the progesterone and/or taking it continuously. I think that might really help. None of the GPs or gynaecologists I’ve seen have even mentioned continuous HRT as an option, does anyone know why they might be hesitant to try that? If it makes any difference I’m 45.

[bombsh3ll]

There's no medical reason why you shouldn't take the progesterone continuously if this works better for you.

GPs who know little about menopause often stick rigidly to dogmatic and non patient-centred guidelines which say that perimenopausal women should get cyclical and only go onto continuous once presumed to be postmenopausal.

This is based on the Idea that cyclical produces a regular bleed pattern, which as we all know isn't everyone's experience, particularly if your underlying cycle is becoming erratic.

Ironically cyclical HRT is much better at inducing regular bleeds in postmenopausal women who no longer have competing ovarian activity.

The only reason continuous is not recommended is because you might get some irregular bleeding on it! Seriously that's it, not because of risk of any disease or important complications.

And women with conditions that fare best with stable hormone levels such as migraines, PMDD, endometriosis etc are often given continuous from day 1 if they have a knowledgeable doctor.

The progesterone dose for continuous is usually half that of cyclical, in order to provide the same amount of protection overall.

This means you generally don't need anyone's permission to take it continuously as you should already have enough.

If you wanted a 3 day break every month or so as others have suggested, that's also an option, again no medical need but down to personal choice. Withdrawal bleeding is more likely if you interrupt the progesterone however some like to time this with their own bleed if having one anyway.

[joziel]

As bomb says, the only reason they don't recommend continuous is because you are still peri and therefore will get random breakthrough bleeds.

However you can prevent that if you take a 5 day break every month (as I do) to allow the bleed to happen then. Then it is all scheduled and no one need to worry about unscheduled bleeding, but you get all the benefits of continuous progesterone.