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[bombsh3ll]

That's a good point about testosterone and dry skin.

I had oily skin and acne when I was younger, and was 32 when I did IVF and used the patches.

When I told my consultant they weren't sticking he said that was a common experience in his patients, and joked that they were designed for much older women who aren't very active and don't wash that often!

Fortunately the surgical dressings that I was then advised to stick over the top sorted this, but I do think the skin's natural oils that are stimulated by androgens also play a big role.

As I never plan to go without androgen replacement, it's unlikely I'll ever be able to use patches without having to buy additional products to stick over the top.

[Holsy]

Thanks Bombsh3ll, I'll have a look at the Prof John Stevenson research reports. I've not actually heard of him before. I admit the gel is a faff, that's why I loved the patches....hey ho!, need to let them go. Although I do like the ability to change & control the dose easily with the gel. 

[Wrensong]

That must have been frustrating with the patches bombsh3ll.

As for your consultant

he said that was a common experience in his patients, and joked that they were designed for much older women who aren't very active and don't wash that often!

What an insulting, sweeping statement!  I hope I never have to deal with him    .  At the advanced age of 60-something, I'm pleased to report I'm still pretty active & enjoy a lovely shower twice a day.  Perhaps not helping my dry skin, but it's never dislodged my patches & my skinny carcase needs the warmth  !
Wx

[Wrensong]

Holsy, glad you are having a T test & that you don't have probs with dry skin.  T can be v beneficial in more ways than it's most renowned for, for those of us who need it.  I'm not au fait with how much the androgenic progestogens may influence our T levels, so be interesting to see what your test shows.  Another thought is if you've lost weight & now have little/less fat in the area where you routinely applied the patches, that's another factor that can influence how well they work for us.

I'm so with you on the need for good education on the many changes of menopause & the possible consequences of loss of our various gynae organs.  Having lost ovaries & then some years later both uterus & cervix, I have found each op has had cons as well as pros.  No time to research the consequences of BSO at the time as the op was advised as urgent with an assurance of "no adverse long term effects" given I was already postmenopause, but I did read v extensively before going ahead with the total hysterectomy, so knew what I could be in for there.

Good luck with the gel.  If Oestrogel, don't forget there's also Sandrena which is more concentrated so needs a smaller application area which can be useful if several doses are needed & body parts in short supply!
Wx

[Holsy]

Totally agree with you Wrensong about Bomsh3ll's consultant. It's a shame but very common in my experience not with just male consultants either. Age is just a number anyway isn't it, it's how you feel and how active you are etc.

I don't know much about T levels at all, so I'm glad the GP has requested a blood test to check it out. If anything I have put on a little weight over Christmas but the patches stopped working around September, so can't blame it on that either. I'm wondering if my levels got that low due to not being on a high enough dose that it's just going to take a long while to get them back up to where they were again. So I may be able to try patches again at some point.

I'm so sorry that you've had so many organs removed, as you say, it's pros and cons. Just having an operation is invasive enough without then considering the consequences and not being told what to look out for. I was told that my ovary had been saved, but the consultant lied as I discovered a few years later following a scan that it couldn't be found. So maybe I should have had hrt or testosterone then as I was never myself after that. I just put it down to having 2 young kids.

Thanks re: the gel, I've decided to apply another dose tonight before bed, as it seems that it can also help with sleep, so that will be 3 pumps that I'm taking. I will ask about Sandrena at my next review with the GP in a few weeks time.

Have a good evening. Thanks so much for your replies. Means a lot. xx

[Holsy]

Hi ladies, here's an update as promised:

After reading a lot about magnesium on here I requested that it be added to my blood test.

Blood magnesium level 0.86 mmol/L [0.66 - 1.07]

Serum oestradiol level 105 pmol/L;

Serum testosterone level 0.7 nmol/L [0.101 - 1.42]
Serum sex hormone binding globulin level 40.5 nmol/L [27.1 - 128.0]
Free androgen index 1.7 [0.187 - 3.63]

Also reading about iron levels on here, I do think that my iron levels have been overlooked, as my Serum ferritin level is 27 ng/ml [13 - 150], which reading on here should be over 100. GP has classed that as normal as it's within the range.
Haemoglobin A1c level - IFCC standardised (XaPbt) 36 mmol/mol, non-diabetic normal range 25-41 mmol. I also read on here that this should be over 100 too. Not sure if this is the correct Hb as the range is 25-41.

I started on the gel on 31st December, initially 2 pumps, but I didn't feel any better, so after a week I went up to 3 pumps, still not sleeping well and feeling anxious and irritable, feeling very overwhelmed and low. So after another 2 weeks I went up to 4 pumps, 2 in the morning and 2 in the evening. So I've only been on 4 pumps for a week before the blood test. On the back of the blood test coming back higher than the previous test of 82 pmol/L back in mid December, but only slightly the GP sent me a text saying to go up to 3 pumps!! I'm already on 4 now, so have an appointment with her next week to discuss.

I'm hoping that only being on 4 pumps for a week before the test has not been long enough to gauge whether the gel is going to work for me or not. Or should I know by now after being on 2 then 3 pumps for a month? I will stay on 4 pumps for the foreseeable and see if things improve, I do think that my sleep has slightly improved over the last couple of days. I will request another oestradiol test in another 4-5 weeks. How quickly should I see improvements with being on 4 pumps?

I am presuming that the magnesium and testosterone results are ok with them being in the range! I will discuss this with the gp next week. If you think not, then please say, so that I can raise that with the Gp if she thinks they're ok.

Thanks so much as always.

[Wrensong]

Hi Holsy, thanks for the update.  Your oestradiol is again low isn't it  .  I think it's documented that on Oestrogel serum levels are expected to have reached a steady state after 3 days*, so unless I've misunderstood, this is probably a good indication that you are still not absorbing at all well even from 4 pumps, though test results can vary markedly at different times on the same transdermal oestradiol dose.  As an example mine on 50 mcg patches have been all over the place from 480+ to <120 in past 2 years.  The 3 months guideline we are often given to test a dose is to allow the body as a whole time to settle & give us reliable feedback as to adequacy.  If I remember rightly your levels have been low over several consecutive tests & most importantly your symptoms & instincts as an experienced HRT user seem to confirm you need more, having felt much better with the higher levels you had for some years.   I'd see what your v helpful sounding GP thinks about the situation next week, but if you want to persevere with transdermal methods it looks as though you may need to combine a higher dose patch with some gel or perhaps use more than one patch to achieve your formerly asymptomatic state.  I think you said you tried both Evorel & Estradot & different patch application sites.  If you retry patches, there was a study I came across some years ago in which significantly higher levels were achieved when applied to the buttocks compared with the tummy.  A fatty site is said to work best - my v good gynae even suggested I apply gel to my butt rather than thigh.

I've never had SHBG tested but I think BMS advice these days is to look at total testosterone  - someone correct me if I'm wrong please - & at 0.7 yours is mid-range without supplementing, so if you & your GP are happy with this I think I'd want to concentrate on optimising your oestrogen replacement for now.  You are using an androgenic progestogen in Mirena (albeit effects are said to be mostly localised to the uterus) & if you have no obvious signs of androgen deficiency I wouldn't worry about T at this stage.

Agreed your ferritin seems quite low @ 27.  Mine was 20 at one point a little while back (range 15-300), so like yours my GP signed this off as no action needed as per NHS guidelines.  She was amenable to my supplementing with iron though & even with low dose OTC supplements I managed to get ferritin up to 60+ when last tested.  I needed something with minimal gastrointestinal effects & cautiously tried v low dose iron citrate first but made little progress until I changed to a higher dose of ferrous bisglycinate which quite quickly worked far better.  If you do feel you'd like to supplement I'd mention it to your GP & monitor with repeat testing to assess response & be sure you don't inadvertently go too high.  The brand I used with most success was Holland & Barrett's cheapie marketed as Gentle Iron 20mg.

The HbA1c is a test to see how your body handles sugar over time.  I think the recommendation you mention having seen on the forum that haemoglobin should be 100+ probably relates to haemoglobin assessed as part of a full blood count i.e. with suspicion of anaemia?  The range my lab uses is 115-165.

Hope you make some headway soon.
Wx

* Later edit.  Oestrogel SmPC extract: "Daily application of 2.5 g or 5 g Oestrogel over a surface area of 400-750 cm2 results in a gradual increase in oestrogen blood levels to steady state after approximately 3-5 days".

[Holsy]

Hi Wrensong
Thanks for the very detailed reply, most helpful as always.

I was dreading you agreeing with me that I'm not absorbing the gel either.  I don't think I can go back to patches either, which is preferable as I did apply them to my buttocks, before discovering that I wasn't absorbing them, so was told to try my tummy, but no luck there either. It's really frustrating as to why they stopped working. How quickly does it take to go from 82 to a steady state though, should I have a lot more than 105 after 7 days? Or do I need to be patient? Which I'm not good at. I'm obviously not producing any of my own oestrogen now, hence it being rock bottom. I will ask the GP about applying the gel to my buttocks too. Should every change of type of hrt only take about a week to feel the difference too? I know when I first started on hrt it did take about 4-5 weeks to start noticing little improvements.

At the moment the GP thinks that my levels have increased from only 2 pumps, so I suspect she will try to push the tablet form next, which I'm really not keen on but desperate to get back to how I was on the patches. Wondering whether to try Lenzetto again, as that seemed to take the edge off when I was on Evorel 50 patch before I knew I wasn't absorbing. But that was only one spray. I think you can only have 3 sprays of that too.

I have been taking an iron supplement but don't feel any different, so I will try the ferrous bisglycinate after talking to the GP thanks. They'll be fed up of me having regular blood tests!

My haemoglobin assessed as part of a full blood count was 151 in October, so that's obviously ok.

Thanks again, I'll keep you posted after the GP appointment next week. xx

[Bungo]

Hi Holsy, thanks for the update.  Your oestradiol is again low isn't it  .  I think it's documented that on Oestrogel serum levels are expected to have reached a steady state after 3 days*, so unless I've misunderstood, this is probably a good indication that you are still not absorbing at all well even from 4 pumps, though test results can vary markedly at different times on the same transdermal oestradiol dose.  As an example mine on 50 mcg patches have been all over the place from 480+ to <120 in past 2 years.  The 3 months guideline we are often given to test a dose is to allow the body as a whole time to settle & give us reliable feedback as to adequacy.  If I remember rightly your levels have been low over several consecutive tests & most importantly your symptoms & instincts as an experienced HRT user seem to confirm you need more, having felt much better with the higher levels you had for some years.   I'd see what your v helpful sounding GP thinks about the situation next week, but if you want to persevere with transdermal methods it looks as though you may need to combine a higher dose patch with some gel or perhaps use more than one patch to achieve your formerly asymptomatic state.  I think you said you tried both Evorel & Estradot & different patch application sites.  If you retry patches, there was a study I came across some years ago in which significantly higher levels were achieved when applied to the buttocks compared with the tummy.  A fatty site is said to work best - my v good gynae even suggested I apply gel to my butt rather than thigh.

I've never had SHBG tested but I think BMS advice these days is to look at total testosterone  - someone correct me if I'm wrong please - & at 0.7 yours is mid-range without supplementing, so if you & your GP are happy with this I think I'd want to concentrate on optimising your oestrogen replacement for now.  You are using an androgenic progestogen in Mirena (albeit effects are said to be mostly localised to the uterus) & if you have no obvious signs of androgen deficiency I wouldn't worry about T at this stage.

Agreed your ferritin seems quite low @ 27.  Mine was 20 at one point a little while back (range 15-300), so like yours my GP signed this off as no action needed as per NHS guidelines.  She was amenable to my supplementing with iron though & even with low dose OTC supplements I managed to get ferritin up to 60+ when last tested.  I needed something with minimal gastrointestinal effects & cautiously tried v low dose iron citrate first but made little progress until I changed to a higher dose of ferrous bisglycinate which quite quickly worked far better.  If you do feel you'd like to supplement I'd mention it to your GP & monitor with repeat testing to assess response & be sure you don't inadvertently go too high.  The brand I used with most success was Holland & Barrett's cheapie marketed as Gentle Iron 20mg.

The HbA1c is a test to see how your body handles sugar over time.  I think the recommendation you mention having seen on the forum that haemoglobin should be 100+ probably relates to haemoglobin assessed as part of a full blood count i.e. with suspicion of anaemia?  The range my lab uses is 115-165.

Hope you make some headway soon.
Wx

* Later edit.  Oestrogel SmPC extract: "Daily application of 2.5 g or 5 g Oestrogel over a surface area of 400-750 cm2 results in a gradual increase in oestrogen blood levels to steady state after approximately 3-5 days".

Hi Wrensong,  interested when you say your levels varied from 120 to 480, are you post menopausal? Amazed they can vary this much ,,if you're on the patch wonder was the 480 level on day one of the patch and 120 on the last day or is there any pattern you can  see? I'm fixating on blood serum levels for bone density but also on joint pain- if levels can vary that much even post menopausal,the would explain why my pain levels can vary so much from day to day

[Wrensong]

Oh Holsy, I'm sorry.

I was dreading you agreeing with me that I'm not absorbing the gel either.

It is a heartsink situation for you, I know, but perhaps better for tests to validate the way you're feeling than be told you're imagining it?

should I have a lot more than 105 after 7 days?

The Oestrogel Summary of Product Characteristics (SmPC) refers to a steady state/plateau in blood levels from day 3-5.  It also cites a study that showed an average of approx 280pmol/l on just 2 pumps (50mcg patch equiv). Their results are given in pg/ml so I used an oestradiol conversion calculator to get the equivalent in pmol/l (280). 

Doing a v quick trawl I can't find any indication of what level is expected on 4 pumps, i.e. whether roughly double that from 2 pumps, or if it doesn't increase proportionately the more you use.  But either way your 105 is pretty low compared to what I remember as the level you felt well on prior to symptoms returning. 

I was once told to expect at least 250 pmol/l from a 50mcg patch so in line with their average 280 on 2 pumps of gel. 

But bear in mind that even if we absorb well from the initial days onwards & manage to hit on what turns out over the longer term to be the optimum level for us, symptoms may still take several months to resolve once the various tissues become replete with oestrogen & the body begins to function better as a whole.  That's why the 3 month guideline, so technically it's still early days for you.  You can hang on in there for as long as you feel sensible to see whether you feel better on 4 pumps in time - you don't have to make any changes yet.  It's just that your recent tests have repeatedly shown much lower levels from a higher dose than you previously felt well on.  I was told to aim for 300+ (I'm well postmenopause) for symptom relief & osteopenia, but the level we feel well on differs greatly among individuals.

I can't see your original post as I type this, but I think you mentioned 75mcg as highest patch dose you've tried, so if you've not yet tried a 100mcg patch you could perhaps discuss that with your GP.  If you only used 1 spray of Lenzetto it's known to give comparatively low levels of oestradiol, so there's leeway to go higher to supplement a patch if your GP is happy for you to combine the two methods, or supplement patch with gel if need be.  And you might have more success with Sandrena than Oestrogel.  So please don't lose heart - there are still several options left to try if you prefer to keep oral as a last resort.

W x

[Wrensong]

Hi Bungo, yes postmenopause 12+years, no ovaries, on HRT 8-9 yrs total with long break in between.  Symptoms have got worse over last 2 years in my early 60s, coinciding with much less stable levels over that time.
 
The 480+ was approx 12 hrs after patch change & the <120 at end day 3, deliberately tested that way to try to find out if our suspicion I was getting v erratic levels might account for relentlessly poor symptom relief, especially vasomotor.  It's known that levels vary somewhat over the life of each patch & I'd been advised many years ago to change every 3 days to try to minimise the tailing off, but this was no longer working at all well for me.  I'd been testing on day 3 roughly every 3 months for consistency, but even that showed levels all over the place.  I'm unintentionally underweight & we think the absorption probs might be due to insufficient subcutaneous fat for the depot effect that helps maintain stability with transdermal methods.

If you haven't seen the attached link to the Menopause Socy Journal originally posted by bombsh3ll it's worth a read.  Testing is generally considered not to be a very reliable indicator, but for postmenopausal women with persistent unexplained symptoms I think it can still be a useful tool.
Wx

[Wrensong]

Holsy, a few more thoughts, though this doesn't solve the problem of how to get your levels up now, as bombsh3ll suggested earlier, if you were still premenopausal in 2019 & postmeno now @ 55, perhaps the much higher test result you had then was mostly due to endogenous oestrogen, with your patches only contributing similarly low levels then to those found in your more recent tests on transdermal methods since last year.

The 280pmol/l figure I mentioned earlier from the Oestrogel SmPC on 2 pumps (76.8 pg/ml in the units given for their tests) was an average calculated over a 24 hr period.  It gives the max as 117pg/ml (approx 430pmol/l), but doesn't state the min.  I'm not sure how this fits with the "steady state" they mention, but quite wide variation in levels found on testing is the reason we are advised that symptoms are a more reliable guide to assessing dose suitability. 

If your consistently low results since 2023 have been from tests carried out under the same conditions each time i.e. time interval between patch/gel application & blood draw, maybe the figures represent the lower end of whatever range you are getting from each method as an individual.  We can't know anything for sure.  A week is a very short time to assess response to the latest dose change & you might just feel a lot better at the end of 3 months on 4 pumps when your body has had time to settle.  I'd see what your GP thinks about whether it's worth persevering without making further changes just yet.

The following extract from Wicki on pharmacokinetics of oestradiol relates to what I mentioned earlier about differences in absorption according to application site.

"The site of application of transdermal estradiol can influence its bioavailability.[96] A study found comparable absorption of transdermal estradiol patches (within ±25% of reference) for a number of skin sites including the abdomen, upper arm, upper thigh, lower back, and side.[195][196] However, absorption was 15% lower for the upper thigh compared to the abdomen and the difference was significant.[197][196] Another study found that transdermal estradiol patches had 20 to 25% higher bioavailability when applied to the buttocks than when applied to the abdomen"

Wx

[Wrensong]

Bungo - this extract from Wicki on the pharmacokinetics of oestradiol mentions the depot effect in subcutaneous fat I mentioned earlier that we think might be a factor for me.

"There is a depot effect in the skin with transdermal estradiol, which results in continuous delivery of transdermal estradiol into the circulation.[17][194] This is because the skin functions as a semipermeable membrane and there is a concentration gradient between the application site of transdermal estradiol and capillary blood, with the rate of diffusion of estradiol across the stratum corneum being the specific rate-limiting factor in absorption.[10][194] As a result, peaks and troughs in circulating estradiol levels are limited, and the skin and subcutaneous fat act as a reservoir of estradiol that maintains circulating estradiol levels between doses.[17] For these reasons, transdermal estradiol can provide near-constant circulating levels of estradiol"
Wx

[flo69]

In my experience Oestrogen helps get rid of the symptoms unless the progesterone is too high, then the Oestrogen will not work.

If you google about the mirena you'll find that every year it's in situ, it gets weaker.

A brand new mirena gives out 21mcg per day. After one year a mirena gives out 19mcg and the rate of output continues to fall steadily year after year. So after five years it will be noticeably different from new.

That decline in mirena output means your progesterone dose was low and now is much higher with a new one in place.

I see this is a different direction than other posts took with this query which concentrate on the oestrogen, but it is about achieving balance.

I stopped with the OE&P type of HRT for exactly this reason.

I'd be fine with my oestrogen, I've had oral pills, transdermal patches and gel. I'd start any of the oestrogens and feel good. Then the progesterone days would begin and my menopause symptoms came back with a vengence. The good effects of oestrogen are wiped out for me once my body is swamped with progesterone and I feel far worse than menopause ever made me feel. (That's why I'm on tibolone now, it's so easy and just works with no fuss!)

You might get used to the higher dose of a new mirena or you might need a corresponding increase in oestrogen to get back the balance you felt before.

PS I found the gel many times stronger than patches at the same estimated dose, I'm talking about half a pump of oestrogel on my arms feeling stronger than two Evorel 50s no matter where they were stuck.

[Holsy]

Hi Wrensong

Thank you so much for all of the information, I am also hoping that the 1 week on 4 pumps is too early to measure it's affect, but I also think that it's wishful thinking.

I'm sorry to hear that you're still not absorbing properly and the weight loss as you say is quite possibly the cause. It's good that your GP is supporting regular blood tests. Have you tried higher dose patches or the gel? Or is that still the same problem? If so, what is next for you? Tablet too, or are you not keen either?

You're right, back in Oct 24 my levels were 45 on Evorel 50, so tried Estradot 50 for 1 month, but my levels only went up to 71, so was then was moved to Estradot 75. After another month my levels were 82. So 31st Dec I started on the gel.

31Dec - 7 Jan - 2 pumps
8 - 20 Jan -  3 pumps
21 - 27 Jan - 4 pumps.
27th Jan blood test showed levels to be 105, so I had been on the gel for a month but at varying doses.

Flo69 - You are also correct in that the issue did start after having the mirena coil replaced in March 24, so I knew I would be receiving more progesterone initially, hence having Lenzetto as a top up. I wish I had had a blood test before the coil was replaced to see what my levels were then. As you say Wrensong back in April 2019 when my levels were higher at 413, it was most probably due to endogenous oestrogen, so with not having any other oestradiol tests since then up until Oct 24 it's impossible to know what my levels were when I was feeling back to being me again.

I need the coil for fibroids, so can't change that at the moment. I am dreading going through this again in another 4 years when having the coil replaced again. I could request an x-ray to see if the fibroids have shrunk any and remove the coil, but I have a friend struggling to get her progesterone levels correct on tablets and has given up, only to have the coil fitted.

I'm hoping that I can go down to 2 pumps at some point, once the progesterone calms down, but as you say it does take a while to reduce it's output. I wish there was an equivalent progesterone to oestrogen ratio that works. i.e 19mcg progesterone = ? oestrogen, but I know it's not as simple as that.

I have basically gone back to having no oestrogen and high levels of progesterone in comparison haven't I. So I'm having to build my oestrogen back up again, which based on what you have kindly found out for me Wrensong, is that it should really be higher than 105. In your opinion and experience do you think going up to a 100 patch and trying on my buttocks again might work? I will stick with the gel for a while and see what the GP says next week, but even though she is good I think she is baffled why the patches have stopped working.

Sorry to hear that you've also had problems with progesterone Flo69, it's an absolute nightmare. I don't know anything about tibolone but I'll look into that thank you. I'm pleased that you have found something that works for you. It's an absolute minefield and takes time going through trying anything and everything just to feel normal again.

I'll keep you posted. Let me know how you're getting on Wrensong. The site of application is very interesting and amazing how the body can absorb so differently from varying parts. Which also takes time to know which area works best for you unless you can test every 2 weeks or so. I might request a blood test in another 2 weeks, so that I will have been on 4 pumps for almost 4 weeks by then.

Just thinking of other things, did I actually stop absorbing from the patches or was it just not a strong enough dose because of the progesterone and the Lenzetto was only masking it a little? Although based on the info of absorption that should occur over 24hrs to 3 days my levels should still be higher shouldn't they?

Serum progesterone level on 14th Oct 24 - the doctor said that this test isn't very helpful. It was classed as satisfactory. I don't know what to make of it.
Serum progesterone level < 0.6 nmol/L; Normally menstruating females: Follicular phase <0.616 nmol/L, Ovulation phase 0.175-13.2 nmol/L,
Luteal phase 13.1-46.3 nmol/L, Post-menopausal
(without HRT) <0.401 nmol/L 


Thanks ladies. xx