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[Lokilou]

Hi all,
I’m in a bit of a quandary about how I should take Hrt with the mini pill. I’ve been on everel 50 conti and utergestan 200mg for days 15-26 of my cycle for three months. I few loads better in myself so must have needed some hormone treatment! Although I’ve been experiencing some hair loss on the patch only weeks.
I’m wanting to take the mini pill to stop bleeds, the week of my period is awful, heavy and I feel so low, so in desperation I ordered the mini pill online. I’m just done with having periods and I know there is a way to prevent them. I know the mini pill  is safe to use alongside but I’m just not sure how to use with Hrt.  Do I switch to continuous uterogestan? Or still cycle it? Or give the Hrt up altogether? I’d really appreciate it if you could give me feedback on what regime you’re on if you’re in a similar situation to me! I’m 47 and still have a very strong cycle . Thanks in advance x

[CLKD]

   this is a query often posed, hopefully some1 will be along with advice.

[bombsh3ll]

If the mini pill you are referring to is desogestrel (cerelle/cerazette) you can take two of those a day ie 150mcg INSTEAD of micronised progesterone and in all probability will be completely bleed free after a few cycles, maybe sooner.

This is off label use but supported by the British menopause society as endometrial protection - see their website.

If you just took one desogestrel a day as is prescribed for contraception, you might get lucky and not bleed but this is not nearly as effective for menstrual suppression as 150mcg, and nor can this be relied on for endometrial protection so you would still need micronised progesterone.
 
This is a lose lose situation in my book.

If you did take one desogestrel in the hope of getting rid of your periods, it would also be counterproductive to take your micronised progesterone cyclically, as this is designed to induce withdrawal bleeding every time you stop it, so you would be better switching this to continuous.

[Lokilou]

That’s very interesting thanks! Yes I was thinking it might conflict with each other and my cycle. I’ve ordered cerazette so if I double them up I wouldn’t need uterogestan… Think I’ll have a chat with my Gp to see if they’ll prescribe them for me - probably say no if it’s off licence though x

[bombsh3ll]

I would have the relevant section of the BMS website about desogestrel for endometrial protection handy to show them when you go in.

If they say it is off licence, you can push back by pointing out that approximately 15% of prescriptions in primary care are off licence, for example acid reflux medication in children, and of course the ubiquitous antidepressants prescribed for menopause.

The chances are unless you are the first patient, they will already have prescribed something off label that day.

[GraceM]

Why are you on Evorel Conti as well as utrogestan?  Or is it just the Evorel oestrogen patches you use?
Would you consider the Mirena Coil?  It could work to cut back on bleeding and is suitable as the progestin part of your HRT.

[joziel]

I agree with Grace that the Mirena coil would be the best way to go. It completely stops all bleeding for almost all women (after a few months of it tailing off) and it will last 5 years - then can be replaced.

You don't need to take P as well with it, although you can if you want the health benefits of P.

The thing is this: You need to sort out a long-term solution. Because if you continue to take (enough) estrogen, your lining will build up. And (as Dr Gersh says) what builds up, must come out. You don't really want to stop or reduce the estrogen because you need it. But the mini pill isn't a long term solution, because you will be told to stop it at age 55 - plus it's a synthetic progestin so it's not great for you, especially as you get older. I mean, you're not going to be 65 and on desogestrel (when hopefully you will be 65 and on HRT).

So you need to find a progesterone solution for HRT which is viable long-term. The Mirena coil ticks all your boxes if you don't want to bleed.

[bombsh3ll]

I hadn't noticed that you were on a combined patch - you only need one form of progesterone (unless for example you are getting clinical benefits from micronised progesterone eg sleep but it is not controlling the endometrium).

If you were to use a progestin to provide bleed control plus endometrial protection eg desogestrel 150mcg or the IUS you would only need an estradiol patch, not a combined one.

The IUS can be a good option but I would always think about a non invasive treatment first, primarily because if it doesn't suit you can just stop it immediately and independently, however getting an IUS removed if it is causing problems or you just want it out for any reason can be really challenging especially with the current state of the NHS.

Also, whilst I personally wouldn't have any problems with taking a synthetic progestin at 65 (or 95) if it was the only thing I could tolerate in order to be on estrogen, this is not your situation as you clearly tolerate the utrogestan, it is simply not controlling your periods, which you won't be having anyway at 65.

Therefore the pill is only needed until you drop your last egg, and after that you can just take continuous micronised progesterone without needing anything else.

[joziel]

It may not be true that periods will stop at 65.... It depends on how much E is used. There are those who (like Dr Felice Gersh) believe that we should take enough E to cause a bleed every month - because this is a sign that we have enough E to be triggering growth factors. If we have sufficient E for that, it is more likely we have enough for all our other bodily organs rather than the micro dose of E which just treats hot flushes and the worst symptoms but isn't optimal.

For eg, I fully intend (if no problems arise) to be taking a high enough dose of E that I will need to stop and allow a bleed every month or I will get unpredictable breakthrough bleeding. And some women prefer to remain sequential - there is some thinking that we need to allow enough time without P for the E receptors to work properly.

However, these won't be proper 'periods' they will just be allowing build up to come out. And they probably won't be painful - and shouldn't be heavy if enough P is being used. They will be like pill bleeds on BC pills. So the OP might not mind them.

I agree it is weird to be on the combined patch plus micronised progesterone PLUS desogestrel, that is a waayyy too much.....

[Lokilou]

Thanks for the replies all,
Apologies for the confusion (it’s all new to me!) I’m on oestrogen patch only plus uterogestan days 15-26 Silly me got the name wrong.
I am unfortunately not able to tolerate a mirena, tried a few year ago and ended up in shock, they had to remove it immediately, so understandably I really don’t want to go down that route again. It could only happen to me,  emergency buzzer pressed while I’m naked from the waist down 
I’m just so sick of the heavy bleeds, I’m looking at what options I have. Thanks again!

[joziel]

You might be able to have an ablation.

By the way, have you checked your ferritin? Because I know the common belief is that ferritin is low because of the heavy bleeds - but actually the opposite has been found to be true - that heavy bleeds happen BECAUSE of low ferritin. Meaning, if you get your iron up (ferritin to 100) the bleeds will be less heavy. That's exactly what happened to me and lots of other women in the Facebook group called The Iron Protocol (which I highly recommend).

[Lokilou]

My ferritin was 17 at last bloods! No action needed according to dr!

[joziel]

Lokilou, that is really awful and negligent really. The NHS is soooooooo useless, I've lost all faith after what I've experienced the last few years.

Your ferritin should be over 100, preferably over 150 if you've been deficient for a while. To get it up there, you need pretty high doses of iron 3x/day (the dose is calculated by your weight and the type of iron).

Whilst iron can cause gastro upsets when people take it (usually constipation) there is a heme iron which is made in the US by Three Arrows called Simply Heme, which is absorbed through a totally different pathway to other non-heme iron and doesn't usually cause any gastro issues even at high doses. I've imported it many times and highly recommend - they ship to the UK.

Meanwhile, go onto Facebook and join the group there called The Iron Protocol. (Not the UK one, but the 'main' group. The UK mini group is rubbish and doesn't have the guides and help which the main group has.)

I used to have very heavy periods, where every time I had a wee I was basically weeing out massive clots. This has been the case all my life and I have a history of iron deficiency my entire life too, since I was turned away from giving blood when I was 18 due to being anemic. It was only when I got to peri-menopause and had problems sleeping that a sleep specialist told me I should get my ferritin over 100-150. I needed an infusion to do that (which I had to get privately in London at the London Iron Clinic because the NHS disagreed that I needed one). Almost immediately my periods were way way way lighter, less painful and more like everyone else's 'normal' periods. I then read this is very common.....

So I would really look into this...

[CrispyChick]

My ferritin was reading at 20 and I got it up quite nicely using spatone (nice tasting) then better you iron spray.

I didn't use heavy duty iron that upsets your stomach and it happily went up. Spatone is meant to be excellent for adoption.

I also take a decent dose of vit c every day and take them together as that aids the absorption of iron.

[Lokilou]

Okay thanks for the info! I’m definitely going to address the ferritin levels, I have joined the fb group. Sometimes feel like dr’s are a bit useless. I’ve got thyroid issues too that they keep brushing me off with!
I’m wondering now if I should try it a day 1-25 cycle with the uterogestan… and see if that helps? And leave the mini pill for now, so give a chance for a bleed but maybe controlling it better? I know that’s more for post menopause but is there any problems doing this in peri?