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[Tulip256]

I have been using hrt for around 3 years. When I first started I took utrogestan 200mg for 12 days 15 days after my period. Lately though my cycle has been been getting shorter moving from 28 days to 21 to 23 days ish. Should I instead take the utrogestan every 28 days and not worry about syncing with my cycle?

[bombsh3ll]

Trying to synchronise micronised progesterone with a natural menstrual cycle, particularly during perimenopause when this is becoming irregular, is rather like trying to time the stock market.

This frequently results in chaotic bleeding, and more days spent bleeding overall than without treatment.

So firstly I just wanted to make sure you know that there are multiple bleed free options that can make for a much better quality of life until you are postmenopausal, after which micronised progesterone makes more sense.

However if you don't mind all the bleeding and are really keen to cycle micronised progesterone, then instead of counting days from the beginning of your cycle, you take the progesterone for the 12 days leading up to when you expect to get your next period.

This *should* have any withdrawal bleeding occur at the same time as menstruation.

[Tulip256]

Thanks for your reply. I thought bleed free options were higher risk though in terms of endometrial and breast cancer and cyclical options are also meant to be better in relation to both bone and brain health in order age?

[bombsh3ll]

Bleed free options which generally involve a progestin either oral or IUS have a significantly LOWER risk of endometrial cancer.

Those that suppress ovulation also reduce risk of ovarian cancer however this is duration dependent.

Progestins are associated with a marginal increase in breast cancer risk, and are theoretically less favourable for long term health in older ages eg heart brain vascular metabolic etc.

However i am not suggesting you use them indefinitely, none of these risks are clinically significant with short term use to bypass perimenopause.

I will be taking my combined pill continuously until I am about 55 for menstrual suppression, then by that stage when natural menopause can reasonably be assumed, I will switch to either micronised progesterone or dydrogesterone alongside my estrogen, or tibolone.

There is some evidence that cyclical progesterone long term is better than continuous for some outcomes, which I am keenly watching evolve.

However the light, generally painless and predictable bleeding that would occur when taken cyclically after menopause is likely to be a lot more tolerable than suffering a natural menstrual cycle in peri.

[JessWare]

Hello, I am having a similar thing happen now where my period was getting shorter before hrt. Then I started using oestraadiol gel and utrogestan for 14 days from day 28 of my cycle, or the first day of my period when I first started. My periods went back to 28 days but now they have been 23 days and most recently 21 days.
Should I stick to day 28 or should I go from day 21-23 (when my period starts)?

I am sensitive to progesterone so this formula of hrt is the best for my other symptoms (migraine, night sweats, anxiety).

[bombsh3ll]

If it's that chaotic and you are really wedded to using cyclical micronised progesterone, it may be better to just use the first of each calendar month to start your 14 days progesterone.

This is simpler to manage and ensures that regardless of your own bleed pattern you are taking enough to protect your endometrium.

[JessWare]

Thank you, that's what I've been doing and hoping it will even out again but I guess it won't 🙃

[bombsh3ll]

I think cyclical micronised progesterone is often prescribed under the misapprehension that it will magically create a textbook 28 day cycle in a perimenopausal woman - it won't.

It is not strong enough to override your own ovarian activity, but is strong enough to induce withdrawal bleeding if taken sequentially.

The belief that cyclical HRT produces a regular cycle dates back to its original use in postmenopausal women, in whom it does usually produce regular bleeds, because they are only having withdrawal bleeding, not an increasingly erratic ovarian cycle as well.

[Fusseh]

Hi Bombsh3ll
I am a bit confused. What do you mean by  'progestins' and 'micronised progesterone'  and 'bleed free options'?
Sorry probably daft questions..I am easily confused!

[joziel]

JessWare, I experienced about 6 months where my cycle went to around 20-21 days. Looking back, I now think it was that my estrogen dose was too low to sustain the cycle and the progesterone was causing the shed too soon after I started it. I increased my estrogen quite substantially and my cycles are now back to 28-30 days.

Anyway, what I did (which worked, before getting my estrogen up), is this:

- You need to get 12 days of progesterone 'in' before your bleed starts (for endometrial protection) if you want to sync things.
- That means counting back from (say) 21 days and starting progesterone then.
- For eg, if you are bleeding day 21, then you would start progesterone on day 9. This enables you to get in 12 doses of it before you bleed, so you can be sure you're getting enough and everything stays synced.

If you bleed earlier than expected, count that as day 1. Stop taking the progesterone and re-start using the above calculation. This worked excellently for me. Unfortunately it's far too complicated for doctors to get and even if they did get it, they would think it is far too complicated for patients. But it isn't really...

[bombsh3ll]

Progestin = a synthetic cousin of progesterone that has been modified to get a more potent effect for a smaller dose. Examples include norethisterone, desogestrel, levonorgestrel provera etc.

These can be used in combination birth control or hormone therapy products, or as standalone agents such as oral progestin only pils or the mirena IUS. Some of these can be used for endometrial protection alongside a separate estrogen product.

Micronised progesterone = "body identical" progesterone capsules taken orally or vaginally eg utrogestan. Exactly the same molecule as that our ovaries make.

Bleed free options = the ones where you can wear white pants 365 days a year 😉** ie any hormone regimen that doesn't involve having episodes of vaginal bleeding, either natural menstruation or artificial withdrawal bleeding. Examples include the combined pill taken continuously in a pre or perimenopausal user, the mirena IUS, continuous combined HRT or tibolone in a postmenopausal user.

**Note that whilst most women will achieve amenorrhea this is not 100% guaranteed.

[Fusseh]

Thanks bombsh3ll. You should write a glossary for this website!

[JessWare]

Thank you very much Joziel! I was wondering if I should up my oestradiol when they got shorter again. I'll try the new routine youve outlined for my utrogestan.
I am currently on 1 pump of oestraadiol, do you think I should just go to two?

[joziel]

Oh for sure, 1 pump is almost nothing. 2 pumps is the regular starter dose, but even that isn't very much. No wonder you are getting shorter cycles with that little estrogen.

Look up Dr Felice Gersh on YouTube and find her video about estrogen dosing...

[JessWare]

Wonderful, thank you very much!