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[pepperminty]

Hi Ladies,

 why is Utro licenced to be taken for 25 days in the leaflet and not the full 28 when on a conti regime? What would be the point of taking it for just the 25?

many thanks PM x

[bombsh3ll]

I know that the traditional 7 day break in the contraceptive pill, and the original sequential HRT preparations were historically designed that way in order to patronise women with an artificial period so that they wouldn't think they were pregnant.

Whilst I don't know the same applies to 25 day utrogestan, it wouldn't surprise me if the rationale was likewise to induce a monthly withdrawal bleed.

In France this 3 day interruption in the progesterone is referred to as a "breast break" due to the belief that this is better for breast health.

Whilst there is evidence suggesting lower breast cancer incidence with cyclical vs continuous progestogen, I have not seen any evidence that a 3 day gap is enough to make a difference in this regard (and personally I doubt it does).

[sheila99]

It can be useful in late peri as it allows a bleed if there's been a build up, maybe also for those with a cycle who sleep better when they take it. Once you know you no longer have periods most people don't take the break, I think this is the 'old' version of conti.

[pepperminty]

Thanks Ladies,

that makes sense, I am on sequi Femosten at the moment, but it isn't working anymore. My SHBG is sky high and I think I am not absorbing due to this. Changing  is causing anxiety , but I have to  as I can't go on indefinitely like this. So I am not sure whether to do Conti or sequi regime  with the gel or patches and utro.

Pmxx

[jillydoll]

I wondered why my meno doctor told me to take the last 3 days off utrogestan.
She told me, ‘it resets everything’.
Had no idea it was for Breast Health. 🤷🏼‍♀️ ( I’m postmeno)
So thanks for that bombsh311. 👍

[joziel]

I don't know if 3 days off is enough to reset things receptor-wise, but the "25 days out of 28" regime was the "old" continuous regime. And yes it was because they thought women should have a bleed every month.

However, there's an interesting angle on this.... coming from Dr Felice Gersh on YouTube if you watch her vids on estrogen dosing.

Essentially: IF you take sufficient estrogen for anti-aging and health benefits, it WILL cause uterine lining build up. It has to, because estrogen is growth proliferative. It's not going to have that effect on one part of your body and not on other parts. So if you want all those optimal health benefits and anti-aging stuff, you need to take decent doses of estrogen and not tiny microdoses which just treat hot flushes and not much else.

AND... if you do take those decent doses, what builds up must come out. As Dr Gersh says.

So it's best to schedule a bleed with a few days off progesterone.

So this whole idea of women being on HRT post-menopausally and on continuous progesterone with zero bleeding, is just not a great idea. Either they are going to be on tiny doses of E to achieve that so the uterine lining is not building up at all, or they are going to have spotting and bleeding randomly problems with many referrals for investigations and hysteroscopies.

Far better to schedule a bleed, know when it's going to happen, and not have unwanted investigations.

[pepperminty]

I don't know if 3 days off is enough to reset things receptor-wise, but the "25 days out of 28" regime was the "old" continuous regime. And yes it was because they thought women should have a bleed every month.

However, there's an interesting angle on this.... coming from Dr Felice Gersh on YouTube if you watch her vids on estrogen dosing.

Essentially: IF you take sufficient estrogen for anti-aging and health benefits, it WILL cause uterine lining build up. It has to, because estrogen is growth proliferative. It's not going to have that effect on one part of your body and not on other parts. So if you want all those optimal health benefits and anti-aging stuff, you need to take decent doses of estrogen and not tiny microdoses which just treat hot flushes and not much else.

AND... if you do take those decent doses, what builds up must come out. As Dr Gersh says.

So it's best to schedule a bleed with a few days off progesterone.

So this whole idea of women being on HRT post-menopausally and on continuous progesterone with zero bleeding, is just not a great idea. Either they are going to be on tiny doses of E to achieve that so the uterine lining is not building up at all, or they are going to have spotting and bleeding randomly problems with many referrals for investigations and hysteroscopies.

Far better to schedule a bleed, know when it's going to happen, and not have unwanted investigations.

Interesting , I wonder what constitutes a decent dose? And indeed what are micro doses of estrogen ? So unless your lining is nice and thin when you start a continuous regime then that will cause issues?

PM x

[joziel]

With what is a decent dose, it's between 400-800pmol really. 600-800pmol is very optimal for bone regeneration and recovery from osteoporosis.

Where as women are put on HRT and not tested at all if their symptoms resolve. And we know that resolution of symptoms doesn't necessarily equate with what is cardio-protective and bone protective and best for future health and longevity. A very very low dose will fix hot flushes, for eg - for most women.

With 'unless your lining is nice and thin when you start a continuous regime...' - it's not really about how things are when you start. You can start with a nice thin lining, but because you are taking a protective and optimal estrogen dose, your lining will still build up. Your choice is either to take a break to schedule a bleed every month (some women can go every 2 months) OR to take it continuously and accept you will get unpredictable and random break through bleeding and probably get referred for hysteroscopies and invasive tests OR to take a very low dose of estrogen so your lining doesn't build up and you never bleed. (But then you will lose the other benefits of it....)

[bombsh3ll]

I love Felice Gersh's work too. She has practiced from the time when women were treated therapeutically and not with the very low, fear based doses used today.

I am also keenly following the evolving evidence regarding cyclical progesterone postmenopause being more favourable across multiple outcomes than continuous, although this obviously does result in withdrawal bleeding.

I think if it were me and I was going to have the bleeding anyway I would rather do cyclical than 25/28.

[pepperminty]

I love Felice Gersh's work too. She has practiced from the time when women were treated therapeutically and not with the very low, fear based doses used today.

I am also keenly following the evolving evidence regarding cyclical progesterone postmenopause being more favourable across multiple outcomes than continuous, although this obviously does result in withdrawal bleeding.

I think if it were me and I was going to have the bleeding anyway I would rather do cyclical than 25/28.

I suspect any evidence regarding cyclical P post meno  wont be acted on for years.  they are hell bent on continuous - I was told " well you are taking a big risk ".

[bombsh3ll]

There is a small increased risk of endometrial cancer with long term sequential but it is numerically minuscule, and not an issue in those who are willing to pay for an annual pelvic scan.

As with everything it is a case of balancing the risks on both sides of the equation rather than just panicking about one side and ignoring the other as often happens more generally around menopause hormone therapy.

I have always thought the right balance hasn't quite been struck between protecting the endometrium with high dose, continuous progestogen at the expense of multiple other outcomes such as breast and cardiovascular health, and in some cases quality of life.

[joziel]

bomb, is there some more research on this? When you say "I am also keenly following the evolving evidence regarding cyclical progesterone postmenopause being more favourable across multiple outcomes than continuous, "

One major benefit for me is, since I take my P vaginally, it means that for half the month I don't have to stick anything up there morning and evening 

And with the research that found a slightly increased risk of endometrial cancer, we don't know things like the serum estradiol level as compared to the serum P level. It's all going by doses administered, which seems crazy. Because there is probably zero increased risk if that ratio is right....

[juliaC]

I love Felice Gersh's work too. She has practiced from the time when women were treated therapeutically and not with the very low, fear based doses used today.

I am also keenly following the evolving evidence regarding cyclical progesterone postmenopause being more favourable across multiple outcomes than continuous, although this obviously does result in withdrawal bleeding.

I think if it were me and I was going to have the bleeding anyway I would rather do cyclical than 25/28.

really interesting!  I would have thought a cycle followed natures rythyms.  I'm still on sequential at the moment.

[bombsh3ll]

bomb, is there some more research on this? When you say "I am also keenly following the evolving evidence regarding cyclical progesterone postmenopause being more favourable across multiple outcomes than continuous, "

I don't know if any of these are already familiar to you but if not here's some bedtime reading

https://pmc.ncbi.nlm.nih.gov/articles/PMC7096310/
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31709-X/fulltext
https://pubmed.ncbi.nlm.nih.gov/15908197/
https://pubmed.ncbi.nlm.nih.gov/7807658/
https://pubmed.ncbi.nlm.nih.gov/37591444/
https://pubmed.ncbi.nlm.nih.gov/21856917/
https://www.ahajournals.org/doi/full/10.1161/01.CIR.98.12.1158

This tiny, 15 year old rodent study caught my interest more than anything else - whilst this is not human level evidence I think this really needs further exploration:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2875823/

And a nice summary of existing evidence by Dr Gersh and colleagues:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2875823/

Whilst none of these studies have actually gone head to head with cyclical vs continuous micronized progesterone in postmenopausal women, the conclusion that I have come to at this point is that cyclical progesterone is probably better for cardiovascular, brain and breast outcomes, although may slightly increase the risk of endometrial hyperplasia (mitigated by periodic scans) and potential quality of life issues - withdrawal bleeding and having to take a higher dose than continuous.

Vaginal also appears to be more favourable in terms of maintaining the vascular benefits of estrogen vs oral which appeared to reverse these. This needs to be balanced against improved sleep for some with oral (although only for part of the time if used cyclically).

Personally I will be remaining on continuous COCP for medical reasons until menopause can reasonably be assumed, however I am leaning towards cycling vaginal micronised progesterone thereafter alongside probably oral estradiol due to personal choice.

[laszla]

This tiny, 15 year old rodent study caught my interest more than anything else - whilst this is not human level evidence I think this really needs further exploration:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2875823/

And a nice summary of existing evidence by Dr Gersh and colleagues:

https://pmc.ncbi.nlm.nih.gov/articles/PMC2875823/

This is all very helpful Bombshell, I think perhaps the final citation of Gersh's evidence might be missing though and I'm dying to read it -  the final link seems to be the rodent one again? Many thanks if you could add in the link to her summary.