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[Ladybird13]

Hi, been on sequential HRT then moved to combined 18 months ago, I am 50 (started my periods at 10 and have been on sequential since 2018). I was on everol 50 patch and 100 mg of ultrogestan. This was working fine but then I felt rubbish so the DR increased to 75 patch. Last January after seeing her again we moved to a 100 patch and 2 100mg tablets at night. This stopped the light monthly bleed I was having but I felt swollen and not as good. She then did a blood test that showed my estrogen at 890 so advised to go back to a 50 and 100mg tablet. I saw a different Dr a few months after this who said I wasn't feeling good as I need a 75 patch. I was going to try this after my holiday at the end of June. I am now 6 months of the 50 patch and 100mg tablet but still having light bleeds every 3-4 weeks for 3-4 days. Has anyone else had this? I was thinking that it would only carry on if I got the higher estrogen patch? I feel good other than this light bleed but I know when it's happening as I get pmt symptoms (hot flashes, sore boobs, spots etc). I have never had more than 3 months without a bleed and it now looks like it may happen while I on my beach holiday  . Anyone else had a similar experience that could offer any advise? Thank you

[joziel]

Firstly, there is nothing wrong with an estrogen level at 890pmol, if you felt good at that dose. Personally, I need my estrogen to be around 850 - and if it goes any lower, I get symptoms back. Please don't feel anxious about estrogen. If you need that dose and if you have adequate endometrial protection with progesterone, you shouldn't worry.

Secondly, if you are going to take HRT in post-menopause, you have a choice. The choice is either:

1) to take a tiny dose of estrogen which keeps your symptoms mainly away - but may not be sufficient for health and longevity because it's far less than what your body is used to, when you were younger. If you do this, you probably won't bleed much if at all - because you are simply not taking enough estrogen to cause any build up in the uterus. But since you are not taking enough for growth and proliferation of the uterus, you are likely also not taking enough for your brain, your heart, your bones, and on a cellular level. Because the effects which estrogen has (increasing cell turnover, mitochondrial action, growth proliferation) are not going to act on all those other parts of you without also acting on your uterus.... (If you want more info on that way of thinking, look up Dr Felice Gersh on YouTube and specifically her 'estrogen dosing' video there.)

Or:

2) to take a decent amount of estrogen to get your serum levels up to around 600-900pmol, which is far more likely to have beneficial health effects and improve longevity - but which IS GOING TO CAUSE A BLEED. Because those growth proliferative effects are going to act on the uterus too. Since you ARE going to bleed, you can either 1) bleed randomly, all over the place, without much pattern to it, by trying to take progesterone continuously or 2) you can schedule when the bleed happens by taking progesterone for days 15-26 of your cycle and then stopping to 'force' a bleed. Then everything which has built up that month will come out at once, meaning you don't bleed unpredictably at other times, you don't bleed during holidays (unpredictably) and you don't get referred for investigations because the bleed is happening in response to the progesterone withdrawal and not at other times.

The fantasy which has been sold to so many women is that they won't bleed at all, post-menopause, on HRT, if they take utrogestan continuously. This is only true if you take tiny amounts of estrogen which may well not be the best option, health-wise. (When it comes to bones, for sure we know that the beneficial effect is dose-dependent.)

Furthermore, taking oral HRT isn't a good idea unless you can't take transdermal and have tried that first. I can't see any reason you can't take transdermal so really it seems like your doctors don't know what they're doing with you....

When you 'stopped the light monthly bleed... but felt swollen', I'm guessing you were on continuous utrogestan? So everything was just building up in there and not coming out...

If I were you, I'd use at least a 75 patch and 300mg utrogestan on days 15-26. (You can do that if you are not taking it earlier in the month, you'll have enough.) Then you will stop the utrogestan and some days later, that will trigger a bleed (day 1 of your next cycle). And so on....

[Ladybird13]

Ah right ok. I did panic when she said they shouldn't be that high so went to the next Dr and she said it's fine like you. I agree that everything you read implies that once you have continuous you won't bleed after 3-6 months which is not true like you say. To be honest, although I didn't bleed on the 200mg I did feel swollen all over and put on almost a stone over the 6 months (this has come off a bit now) and my boobs were so sore/ headaches returned etc that's why she said go down to a lower amount. Not sure I could cope with 300mg of progesterone. Looking back, I wish I had gone to a 75 patch then 100mg first as it felt terrible dropping down to a 50 and 100 after the bigger dose.

When you say 'Furthermore, taking oral HRT isn't a good idea unless you can't take transdermal and have tried that first.' are you taking about the progesterone? I did fine on the combination patches when I was on sequential but was sold on the 'no bleed' continuous hrt after so long of the other. I just want to be settled for longer than 3 months!

[bombsh3ll]

It sounds as if your own periods have never really stopped, but may have been switched off by the higher dose of hormones (similar to the effect of a birth control pill)

As you are bleeding quite regularly you could take the progesterone cyclically which may be better tolerated than constantly.

Alternatively if being period free is your priority you may choose to switch to a bleed free progestin such as the mirena IUS, desogestrel 150mcg daily or Slynd daily.

The latter two are off label but supported by evidence and increasingly used.

You could always switch back to micronised progesterone in the future when you are postmenopausal.

[joziel]

" although I didn't bleed on the 200mg I did feel swollen all over and put on almost a stone over the 6 months (this has come off a bit now)"

This can be due to the progesterone, as it can cause bloating in some women. If you couldn't cope with the 200mg orally, it would be good to try it vaginally first off. Many women find they don't get the same systemic side effects if they use it vaginally. You can insert the exact same utrogestan capsules vaginally as orally and it is actually better absorbed that route (to the uterus) and less absorbed systemically.

Like bomb says, there are other options too - the Mirena coil for eg might suit you well. If you did fine on the combination patches, those contain a synthetic progestin - and you can get that in other ways as bomb describes. It might be worth having a consult with a menopause clinic privately to get set up on the right combination of things for you and then get your GP to continue whatever they prescribe.

"my boobs were so sore/ headaches returned etc" - changes in estrogen levels can cause these side effects but they are usually temporary and resolve as your body adapts. Sore boobs for eg, usually go away within 3 months. Headaches can be caused by either high or low estrogen or sudden changes in estrogen. A stable decent dose should help. How long were you on this dose for?

"When you say 'Furthermore, taking oral HRT isn't a good idea unless you can't take transdermal and have tried that first.' are you taking about the progesterone? "

No, I mean oral estrogen. Utrogestan is usually taken orally and that's fine (although you might prefer vaginally).

[Ladybird13]

Thank you both