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[Fianna]

Hi, hoping for advice as my GP's seem to need me to tell them what I want!

No periods for several years due to chemo.

Tried Evorel 50 + Utrogestan, Evorel combi patch, Femseven, all of which have caused bleeding which gets worse over time. Inceasing to 200g Utrogestan and the Evorel conti caused drowsiness.

Tried to have a coil fitted but they said my anatomy/angle of my uterus meant they couldn't even see my cervix.

I've requested an appointment at a different surgery in the medical practice where they have a local anaesthetic product to see if they can insert the coil.

If not, is there anything left to try? I don't really want to go down the route of the old fashioned tablet hrt as, for me, I feel the risks outweigh the benefits.

Thanks for any advice.

[CLKD]

MayB a referral to a gynaecologist for the fitting?

As well as referral to a dedicated menopause Clinic?

[Fianna]

MayB a referral to a gynaecologist for the fitting?

As well as referral to a dedicated menopause Clinic?

Do I just ask my GP to refer me to a gynae or menopause clinic? At the last attempt they said they couldn't refer me to the local sexual health clinic because they will only see me if it's for contraception.

[Dotty]

Hi there are other synthetic progesterones to try. Provera is an alternative.

[joziel]

Fianna, when you tried the utrogestan increase to 200mg, did you take that orally? Did you try taking it vaginally or rectally? Usually this way your body absorbs it directly into the bloodstream and it isn't processed by the liver - which is what creates the metabolites that make some women sedated and have other side effects.

I now take 300mg at night and 200mg in the morning, sequentially, and have no drowsiness....

That would be my first suggestion. You use the same utrogestan capsules as orally, just insert them as far up the vagina as you can with a finger.

The other thing to say, is were you trying to take the utrogestan continuously (every day)? If so, I'd take it sequentially - for the second half of the month - as for peri-women. This way, you will have a break completely from it to allow the bleed. This 'schedules' the bleed so you get something like a period. If your body needs/wants to bleed and you are not allowing that through how you are taking the progesterone, it will just spot and bleed randomly all over the place. Which then freaks out doctors....

If you can schedule the bleed so it occurs at expected times, once you have stopped the utrogestan, then it won't worry doctors - and you'll know when to expect it. If you do this, you need to take at least 200mg from day 16-26 of your cycle (and none, the rest of the time). If you don't know when your cycle is, just take one of the bleeding episodes as day 1...

[bombsh3ll]

Why not try an oral progestin with your transdermal estrogen?

There typically provide superior endometrial control at much lower doses than micronised progesterone.

These include desogestrel 150mcg daily, slynd daily (both off label but endorsed by BMS), norethisterone or provera.

Alternatively you could try tibolone.

[CLKD]

U can self refer to a GUM clinic.  U can ask your GP for a referral to an appropriate Clinic of most specialities.  They might not like it and apparently referrals may be refused 

How R U today?

[Fianna]

Thanks all, I am reluctant to take the older tablet forms of hrt because of the known risks.  When I took Utrogestan I tried orally and vaginally 100mg and there was no difference I noticed. When I tried 200mg I took one tablet orally and one vaginally at night, I only tried it a couple of times because it was so bad - I couldn't work I was so drowsy and woozy.

I had 5 years without periods after chemo, before I persuaded the drs to let me have hrt, would there be any risks or benefits to me trying sequential and having a period?

Last question- I thought the marina coil delivered lower doses of progesterone than patches/oral but according to the web it delivers 21mcg per day and femseven conti patch delivers 7mcg per day. I'm concerned because I'm suffering low mood and anxiety on femseven and don't want to make it worse.

[CLKD]

R U able to explain which 'known risks' worry you? 

[joziel]

Research shows that for most women the progestin released by the Mirena stays local to the uterus, however in the first few weeks after it is fitted it does release higher doses - but this then reduces. However, some women do get systemic effects from it. You could have it removed if that happened.

You could also try utrogestan rectally. If you're going to try it vaginally or rectally, you want to put the whole dose up there - not also take some orally or you are not really giving that application a fair trial. Research shows that it actually absorbs better vaginally or rectally anyway.

You can try sequential HRT, but you will need to take high P doses in the 2 weeks you take P, than you would if you take it continuously. For eg, the standard dose of P is either 100mg continuous or 200mg for the last 2 weeks of each cycle. If you are worse when taking more, that's not really going to help you.

Whilst there are slight risks to taking synthetic progestins, they are very slight - and arguably offset by the benefit of being able to actually take HRT...

[Fianna]

R U able to explain which 'known risks' worry you?

Blood clots and breast cancer. I have a family history of breast cancer (not estrogen sensitive though!) which is why I had a long battle to get HRT. I understand the newer types have little or no increased risk of clots and cancer associated with them.

[Fianna]

Thanks Joziel, that's really useful information. Interestingly my GP said there's very little evidence about how much Utrogestan is absorbed via the vaginal route. But it's prescribed for IVF I think so there must be some evidence?!

[CLKD]

Who did U have to battle with to get proper advice?  There was advice years++ ago which freaked the medical profession and many women stopped HRT, however those 'results' have long been discredited.  Quality of Life is important.

[joziel]

Fianna, there is loads of evidence and research. See the wiki article: https://en.wikipedia.org/wiki/Pharmacokinetics_of_progesterone

"Advantages of intravaginal progesterone over oral administration include high bioavailability, rapid absorption, avoidance of first-pass metabolism, sustained plasma concentrations, and a local endometrial effect, while advantages of intravaginal progesterone relative to intramuscular injection include greater convenience and lack of injection site pain.[13]" https://doi.org/10.1111%2Faogs.12765

Scroll down to the entire section on vaginal progesterone, referenced fully. You might want to print some papers out for your GP.

"There is a uterine first-pass effect with vaginal progesterone, such that progesterone levels are far greater in the uterus than in the circulation.[48] Full secretory transformation of the endometrium was produced by vaginal progesterone administration that resulted in circulating progesterone levels of 1 to 3 ng/mL, whereas other parenteral routes (intramuscular and intranasal) were less effective in comparison.[149] The difference can be attributed to the endometrial first-pass effect with vaginal progesterone.[149]"

[bombsh3ll]

This is absolutely true and I can vouch for vaginal progesterone as an IVF patient, where the stakes are a lot higher if it wasn't being absorbed reliably.

Whilst there isn't much evidence that any progestogen modifies hereditary risk of breast cancer, dydrogesterone is also on a par with micronised progesterone with regards to breast safety. It is a retro isomer of progesterone with a single bond making it much more potent hence tiny doses can protect the endometrium.

This is available in oral combination products only in the UK, but may be worth exploring if other options haven't worked out.