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[RosieOscar]

A bit of background: I'm 42 and in Peri. I've been on hrt for a year. I've switched to patches a month ago because I'm on Mounjaro and the BMS guidance suggested that might be a safer option.

I've just had my first month on Evorel Sequi patches. My GP suggested I start with the progesterone patches because of where I was in my cycle. I've now done all four progesterone ones and I'm on the last of the four oestrogen ones. In all the time I've been on hrt I've never had a withdrawal bleed ands my periods have continued in the background. I have long cycles, shortest is 36 days, all the way up to 80 days.

My question is, I'm on the last oestrogen patch now and due to change to the progesterone ones on Thursday, but my period has started this morning. If I use the progesterone patches, they're going to be right at the beginning of my cycle. Is that right? Do I just continue the 28 day cycle regardless of where I am in my natural cycle? My concern is that I'll have two weeks of progesterone patches, and then after another week I'll be in the progesterone phase of my cycle too. Or should I do another two weeks of the oestrogen patches and then when I start the progesterone ones they will roughly line up with where I am in my cycle. I'm confused, so any advice is appreciated, thanks.

[Eastside]

Hello. Hopefully someone else will come along who knows a bit more about your specific situation. I've recently started on hrt and was told by my GP and the manufacturers of the progesterone pills (Utrogestan) that the cycle continues according to the 28 days, regardless of when or if you've had a bleed. So you get to the end of the 28 day cycle and then start a new cycle the next day. But I don't seem to be having natural periods so far, and my cycle is currently all messed up e.g I had a tiny bit of bleeding that wasn't a period before my progesterone was due to stop. So I'm not really the authority on this. My philosophy is to check out anything I'm worried about with my GP.  Did your GP suggest a 3-month review? E.g to come back after 3 months to check how it's been going? I think others on here have suggested going more with your natural cycle. But perhaps it's best to check with your GP if you're not sure.

[RosieOscar]

Yes she did suggest a three month review and I will ask, but I'm not confident that she knows best sadly. She has already given me wrong advice.

[bombsh3ll]

Cyclical hormone therapy in perimenopause often does result in chaotic bleeding, and more days spent bleeding overall than untreated women.

You could consider an estrogen only patch with a mirena IUS, or with a bleed free progestin such as desogestrel 150mcg or slynd taken continuously.

The latter two are off label as endometrial protection but supported by the BMS based on available evidence.

If your BMI is below 30 you may also be able to consider the Nuvaring as an alternative.

If kept in for 4 weeks instead of 3, then changed without a break, this can also keep you bleed free.

[RosieOscar]

I'm not having more bleeding, I'm having less. I don't have a withdrawal bleed and periods between 36 and 80 day cycles.

[bombsh3ll]

That's great, however the cyclical progestin still needs to be taken on a regular schedule rather than trying to fit it in with an irregular and infrequent menstrual cycle.

Otherwise you risk undertreatment with the progestin.

The reason I suggested options that are completely bleed free are that it gets rid of this problem and can make for a better overall quality of life in perimenopause with stable hormones and no periods.

[sheila99]

Medical advice is to keep to the 28 day hrt cycle regardless but that isn't what I did. I have a natural 5-6 week cycle and with patches I had my own bleed as well as (usually) the hrt one. I changed to utro and was then able to sync it with my own cycle. I get sore boobs with prog so I started 12 days utro then and bled to my cycle. If I hadn't got prog symptoms by 6 weeks I started it anyway, then I didn't always bleed, if I did it was short and light. I don't know if this will work for you, I tended to have missed cycles more than random variable length ones. My lining remained thin on a 6 week cycle but if you go longer it might be wise to have the occasional scan to check. Alternatively you could use conti and accept the breakthrough bleeding on your own cycle or use a bleed free prog.

It can be hard to manage in peri. There aren't many advantages to being meno but it does make hrt easier to manage.