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[joziel]

I think you probably need a higher dose rather than stopping. It's normal for younger women to need higher doses....

[Eastside]

Thank you. I've messaged my doctor this morning as I've just had enough of second guessing. I do have the tell-tale ovary ache today so maybe it's coming and my body is just readjusting.

[bombsh3ll]

If you are under 50 and very keen on having a regular bleeding pattern then a combined pill taken in the standard 21/28 regime may be a better option for you.

Alternatively you can just take the combined pill every day without a break like I do and not bleed at all 😁

There are multiple options, I personally am not a fan of sequential HRT in peri as it causes a while world of chaos and angst over bleed pattern.

Probably 50% or less of women experience the clockwork 28 day cycle they were expecting on it - trying to time it with a perimenopausal cycle is like trying to time the stock market.

[GraceM]

Just be aware that you could bleed heavily so have sanitary protection with you wherever you go.  Once you finish the utrogestan days, consider the next day as day 1.  Waiting for a period to start in order to count that from day 1 is not a good idea as your bleeds could be erratic and you need to know you are getting your 12/15 days of utrogestan per 28/30 days, regardless of bleeding.

[Eastside]

Thanks so much guys. Thankfully a bleed arrived yesterday after 7 days. So far it's lighter than usual, but more painful 🤔.
I'd already sent my message to the GP. He called this morning and said my questions were very valid, which was validating!
He asked me questions about my periods before HRT, why I went on HRT etc.
His conclusion was that I was on the right HRT regime, that our bodies can take some time to adjust, especially at first, and that day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed. So it just needs reviewing after 3 months.
I'll update you if I hear back from the manufacturer.
I'm sad that I had to bother my GP surgery again, but I just felt it was necessary. I don't think women should be left flailing around in the dark unnecessarily, and I simply don't have the tolerance I used to for pretty much anything, including inadequate information provision on important matters 😁!

[joziel]

bomb, it's not my experience at all that utrogestan in peri causes erratic bleeding at all. Women just need to be empowered to use it to fit with their cycle instead of in some robotic way....

[Eastside]

Reply from the Utrogestan  manufacturer, in case of any interest to anyone:

While a withdrawal bleed can occur, there is no guarantee this will happen in all individuals as bleeding patterns may differ depending on various factors. Therefore, we cannot specify a specific timeline to expect a bleed apart from what is mentioned in the PIL ‘you might get some bleeding at the end of each month , rather like a period’ - as stated in section 1 ‘What Utrogestan is and what it is used for’.

Regarding your query about when/how to calculate a cycle length. The cycle is typically 28 days which essentially mirrors a menstrual cycle. A new cycle is considered to begin on day 1 of the regimen, not necessarily in the first day of a bleed. The cycle would continue regardless of whether a bleed occurs or not. Bleeding (if it occurs) tends to be a response to hormonal changes but does not determine the start of a new therapeutic cycle.

While a common side effect of the progesterone capsules is irregular or intermenstrual bleeding and vaginal bleeding. It is important to note that in section 2 ‘What you need to know before you take Utrogestan’ it states the following:

“Unexpected Bleeding

You may have irregular bleeding or drops of blood (spotting) during the first 3-6 months of taking this medicine. However, if the irregular bleeding:

Carries on for more than the first 6 months;
Starts after you have been taking Utrogestan more than 6 months;
Carriers on after you have stopped taking Utrogestan;
You should see your doctor as soon as possible.”

We hope this information is useful and do not hesitate to contact us again if you require anything further. 

 

[joziel]

"day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed."

Er, that bit is rubbish Eastside. Look, rather than contacting the (clueless) manufacturers and (equally clueless!) doctors (going by that statement), why don't you do what most of us do, and listen to the educated menopause doctors online who know what they're talking about?

Day 1 of your cycle is the first day you bleed. This is not going to be the day after stopping progesterone for 99% of women. Body identical hormones do not override your natural cycle if you are still getting one. They need to be taken to complement your cycle. Having said that, after you stop utrogestan, it can take 5-6 days (might be 7 for you) for a bleed to start. The progesterone levels need to drop enough that the process of shedding the lining is started. That doesn't happen instantaneously, because we're talking hormones here...

The only thing you need to be concerned about, is that you are getting 12 days of progesterone in, for each cycle. Whatever your own cycle is, you need to start it early enough that you get the 12 days in. Someone whose cycle is 23 days, will need to start it on day 12. Someone whose cycle is 35 days might start it later. Use it to fit with your cycle. If you consistently bleed early, you need to stop taking it to allow the bleed - but note the day your bleed started and start taking it earlier next cycle so you get it all in. But when you stop it, there will be a no-(wo)man's land of many days before the bleed starts.

By the way, in some patronising way, this is considered WAY too complicated for women to understand. Which is why we have the Mickey Mouse dosing we currently have and all the inadequacies that go with it.

The other thing personally I'm concerned about, is ensuring that you are absorbing enough of the progesterone to provide uterine protection. The UK doesn't care about this and prescribes blanket levels of it, and can't even test because it's taken orally and that invalidates the results. I take mine vaginally so that I can use UK tests to get a reliable result and know that I am taking enough. By the way, even 300mg vaginally at night was NOT enough. I had to increase by adding in 200mg vaginally in the morning as well to get my levels to offer me the protection I need.

[GraceM]

"day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed."

Er, that bit is rubbish Eastside. Look, rather than contacting the (clueless) manufacturers and (equally clueless!) doctors (going by that statement), why don't you do what most of us do, and listen to the educated menopause doctors online who know what they're talking about?

Day 1 of your cycle is the first day you bleed. This is not going to be the day after stopping progesterone for 99% of women. Body identical hormones do not override your natural cycle if you are still getting one. They need to be taken to complement your cycle. Having said that, after you stop utrogestan, it can take 5-6 days (might be 7 for you) for a bleed to start. The progesterone levels need to drop enough that the process of shedding the lining is started. That doesn't happen instantaneously, because we're talking hormones here...

The only thing you need to be concerned about, is that you are getting 12 days of progesterone in, for each cycle. Whatever your own cycle is, you need to start it early enough that you get the 12 days in. Someone whose cycle is 23 days, will need to start it on day 12. Someone whose cycle is 35 days might start it later. Use it to fit with your cycle. If you consistently bleed early, you need to stop taking it to allow the bleed - but note the day your bleed started and start taking it earlier next cycle so you get it all in. But when you stop it, there will be a no-(wo)man's land of many days before the bleed starts.

By the way, in some patronising way, this is considered WAY too complicated for women to understand. Which is why we have the Mickey Mouse dosing we currently have and all the inadequacies that go with it.

The other thing personally I'm concerned about, is ensuring that you are absorbing enough of the progesterone to provide uterine protection. The UK doesn't care about this and prescribes blanket levels of it, and can't even test because it's taken orally and that invalidates the results. I take mine vaginally so that I can use UK tests to get a reliable result and know that I am taking enough. By the way, even 300mg vaginally at night was NOT enough. I had to increase by adding in 200mg vaginally in the morning as well to get my levels to offer me the protection I need.

I disagree regarding the progesterone.  You cannot necessarily tie a cycle in with your HRT regime.  If I bleed today and consider it to be day 1, my next bleed may not happen for 40 days, and the next cycle 50 days.  If I only take progesterone after counting from day 1 of those bleeds then chances are I'm not getting enough progesterone.  In peri periods can be erratic and that is why you are better to take your HRT in its own cycle of 28/30 days and not be relying on a period to start so you can start counting that as day 1.

[Eastside]

Hnm. Interesting. Thanks so much for your perspectives. I obviously haven't got a clue, which is why I have tried to find answers.

What happens if you don't bleed at all, though, given that I've been told that not all women bleed after progesterone?

Anyway, I do thank you and I'll try to process it all and take it on board.

Do you have examples of educated experts I can look at online? I'm aware of some, but also thought there was some controversy surrounding them as well. But maybe that's propaganda. I haven't got the budget to see anyone privately, unfortunately.

[sheila99]

I think you need to apply common sense here. If your periods are erratic and irregular it makes sense to stick to the 28 day schedule. If you have a strong cycle of your own (and particularly if your normal cycle isn't 28 days) it makes more sense adjust the hrt to your own cycle. If you regularly don't bleed you could be ready for a conti regime.
The 'unexpected bleeding' comment from the manufacturer may be true for post meno women on a conti regime but they're living in cloud cuckoo land if they think your own irregular or unsynchronised cycle is suddenly going to become regular just because you're using utro, it isn't strong enough to override your own hormones.

[joziel]

Grace, if you are taking enough estrogen, then you WILL bleed.

Fact.

You will either bleed randomly and erratically with breakthrough bleeding (because you are trying to take your progesterone continuously) OR you will schedule the bleed by stopping the progesterone to cause it to happen, so you know it is happening due to the progesterone being withdrawn and not for any other more concerning reason.

So if you bleed today and consider it to be day 1 and then your next bleed doesn't happen for 40 days or 50 days - despite you stopping your progesterone for it to happen - then it means you are not taking enough estrogen. Take a look at the work of Dr Felice Gersh on YouTube for more information, especially her video on estrogen dosing. Or join the FB group called 'Bio-Identical Hormone Therapy' which has flowers as its icon. It's one of the largest FB groups for HRT and is US based along the lines of optimal HRT and not micro-doses at suboptimal levels.

Estrogen is proliferative. That means that IT WILL cause endometrial build up, if you take enough of it.

And you want to take that much of it, because you need those aspects of it - it is about cell turnover, anti-aging and mitochondrial health amongst so much else. If you are not taking enough to cause endometrial build up (to the point that nothing comes out when you stop progesterone) then you are also not taking enough for all those other health benefits, at optimal levels.

Eastside - yes, see Dr Felice Gersh on YouTube and Instagram (she has longer videos on YouTube). And as above, if you don't bleed (when you stop the P, given enough days for the hormone shift to happen) then there hasn't been enough build up which means the estrogen has been too low. (This happened to me, by the way.)

Conti regimes are dead in the water as far as HRT goes. At no point, ever, in our entire life cycle, do we continuously have progesterone. Never. It is not bio-identical to take progesterone continuously. The only way it can happen (without bleeding) is when the estrogen dose is so low, there is no build up happening and the progesterone is heavy-handed and suppressing that. In which case, you are not getting the other benefits of the estrogen elsewhere in the body either. Continuous progesterone down-regulates the estrogen receptors as well.

You have to understand that HRT (and the guidelines and the info on the packets etc) is still based on the mass hysteria originating from the WHI. Even now that doctors are begrudgingly prescribing HRT again (in many cases), they are doing so with great nervousness around estrogen, being worried about too much of it, and as if it is somehow dangerous. It results in micro doses which may well reduce the baseline risk for various health conditions, over someone who doesn't take ANY HRT, but it's not 'optimal' because they are scared of it. So the approach is these tiny micro doses of estrogen and heavy handed huge doses of progesterone (partly because they can't even test levels of progesterone accurately in the UK since most women take it orally). There is far more estrogen in the combined pill they happily prescribe everywhere like smarties, (albeit synthetic estrogen) than there is in standard HRT doses, yet they don't even realise the hypocrisy of this....

[bombsh3ll]

If you look at the history of menopause hormone therapy, it was initially just estrogen alone, then when that started to result in increased rates of endometrial cancer, it was realised that a progestogen had to be added if you have a uterus.

At that time, around the 1970s, hormone therapy was exclusively given to postmenopausal women. If you were still having periods, you were imagining your symptoms and if you were lucky you got some valium. The word perimenopause may or may not have existed, but was seldom used.

The progestin, which in those days was medroxyprogesterone acetate, was given in a cyclical regime, to these postmenopausal women, to patronise them with an artificial menstrual cycle.

There were no known health benefits to withdrawal bleeding (although much more recent evidence supports benefits of not taking the progestogen continuously) it was done for paternalistic reasons only at that time.

It stopped the endometrial cancers but had high discontinuation rates as women didn't want their periods back.

So in the 1990s the progestin started to be given continuously alongside estrogen to avoid the fake periods.

Nobody then knew what to do with the fixed dose combined sequential preparations, mainly Prem-pro that had been expensive to patent, so it was decided cyclical HRT should be given to perimenopausal women with symptoms, because of course we all have a 28 day cycle right?!

The point is that cyclical HRT was never developed for use in perimenopause, it was repurposed for economic reasons with the assumption but no actual evidence that it would result in a regular 28 day bleed pattern.

[Eastside]

Wow. That's fascinating to know that history. I don't think I would have liked to have been around in those early days. It's hard enough now! It obviously is a bit of a minefield, and a journey for us all.

[Banjo1973]

Hello,

I am very interested in this thread - not because i have anything useful to add, more because i have always wondered about bleeding, because i hardly bleed.

I've been on hrt for maybe 3 years, love being on Oestrogen, but absolutely hate the Utrogestan part. So i only took it every 3 months. I know not good, My meno doc increased my oestrogen, i felt great, still couldn't face monthy utro, so i buried my head in the sand took my high dose of oestrogen and 3 monthly utro for 12 days. I never blead more than a drop for 1 day.. Couldn't even call it spotting. I have had a scan and my lining was thin.

I've had 2 children, always had very light periods, in peri my periods got even lighter.

Is it possible that some women just dont bleed that much?