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[Winterangel]

Hello ladies. I’m really hoping someone can offer some advice as I’m really struggling at the moment and can’t see any way out.

I’m 57, been on HRT (2 pumps Estrogel and 100g Utrogestan daily) for about 7 years. In that time, I have had several bouts of unscheduled bleeding and have been investigated 3 times - transvaginal scans leading to hysteroscopy with biopsies taken 3 times. All is ok other than a ‘large’ submucosal fibroid. This fibroid, along with my HRT is the culprit for the bleeding. However, I’m not given any help or advice on how to manage it. I’ve consulted Newson Health but they just always recommend increasing my estrogen, which seems counterintuitive.

I have currently been bleeding on and off for 8 weeks now and I’m really struggling with it. I took advice from someone on here and upped my Utrogestan to 200mg daily via the vaginal route but I’m still here with pelvic pain and bleeding.

I’ve been trying to get a GP appointment but it’s almost impossible to get one with the 8am scramble. So, my question is, while I’m waiting to finally speak to a GP, should I stop the HRT? Should I reduce it? I really can’t go on like this.

Any advice would be much appreciated.

[CLKD]

MayB try filling in the Surgery Triage form - which got me an appt in less than 12 hours.  I went to reception and explained that I had to C someone that day ....... so was advised to fill in the form.

GPs cannot not see patients or they wouldn't be paid. Our surgery waiting rooms are almost empty when ever we attend  .  U may find that Nurse Practitioners are more accessible.

The government of the day is, supposedly, stopping this 8 a.m. scramble.  Which symptom were you hoping to ease with HRT?

[Winterangel]

Thank you for your reply CLKD. The whole NHS is such a mess at the moment, isn’t it? I’ll do the triage form tomorrow, thank you!

My worst menopause symptoms are hot flushes and night sweats leading to lack of sleep. Without HRT, I only get around 2 hrs of sleep per night. Also brain fog, mood swings, weepiness, low mood and anxiety. I really don’t want to stop the HRT but I can’t carry on with this level of painful bleeding. Thanks again!

[joziel]

Winterangel... Are you still getting menopausal symptoms (hot flushes and night sweats, insomnia) on the 2 pumps of gel? If so, I can see why Newson might have advised you to increase. You do need adequate estrogen - although also that isn't going to deal with the bleeding.

My thoughts are: Switch doctors at Newson. I have found some to be WAY better than others. I'm currently with Dr Jane Robertson and I'd recommend her.

But also, you have MANY options before you should even be thinking about coming off HRT:

You could add in a POP (progestin only pill) such as desogestrel. This is licensed for use with HRT for contraception purposes but will also have the effect of keeping the endometrium thin. (You may bleed constant dark stuff for a few weeks, then it will stop.)

Or you could try the Mirena coil. This almost always stops all bleeding for women and doubles as your progestin for HRT so you don't need to take P separately (unless you need it for sleep etc).

You could try increasing the utrogestan further, to 300-500mg. It's not clear from what you write if you are on sequential utrogestan or continuous? If you are trying to take it continuously but you are getting a lot of build up, it's not going to work and you're going to get random breakthrough bleeding which makes everyone worried and end up with referrals for scans etc. Instead, stop taking it on day 26 and wait for a bleed to start. Allow that 5 days to come out, then start taking it again. This way you 'schedule' a shed rather than having it coming out randomly and unpredictably....

[Winterangel]

Hi Joziel. Thank you so much for your kind reply.

No, on my 2pumps of Estrogel, I don’t get any menopause symptoms at all. I’m on continuous HRT as I was advised that this offers better endometrial protection for women with fibroids. When the bleeding first started (around 2019), the gynaecologist told me to go back onto sequential for a year. I did this and all was well for about 8 months, then bleeding went haywire again. I think it would be quite difficult to change to a sequential regime again as I’m just bleeding randomly so I can’t imagine getting a routine, scheduled bleed. The fibroid just seems to want to bleed when it fancies it. I’m not averse to trying sequential again though but the specialists say no.

Of course, I’m also worried about hyperplasia/uterine cancer and don’t want to miss anything there.

I will look at booking an appointment with Dr Robertson, thank you for the recommendation. I’ve never seen the same dr twice at Newson. They seem to have a revolving door. However, I’m sure she’ll just put me back on the ultrasound/hysteroscopy/biopsy merry go round. It’s all just draining!

[joziel]

Hmm, that hasn't been my experience with Newson - I've had the same doctors every year, unless I've requested the change.

I'm not suggesting you go back on sequential - that would be taking P from days 16-26. I'm suggesting you schedule a break to bleed, so you take P from day 5 to 26, then stop to allow the bleed to happen. It can take about 5 nights before the bleed starts after you stop the P - and then you need to allow a few days for the blood to come out, before you re-start it.

If you are on sufficient estrogen to provide all the health benefits you need, you WILL get endometrial build up. You don't get bone being built up and skin cells being repaired and all the other growth proliferative healthy effects of estrogen without the endometrium also building up. The only women who don't get this, are those on piddly low doses. They also don't get the best health benefits. And what builds up, must come out. That is the law of nature. It's not going to go anywhere else. Unless you allow it to come out, it will come out sporadically and randomly and cause alarm. Look up Dr Felice Gersh on YouTube especially her estrogen dosing and recommendations.

[Winterangel]

Sorry, joziel, I didn’t address all of your  thoughts. I really do appreciate your time in providing them x

I will discuss the progesterone only pill with the dr. The GP isn’t great where menopause is concerned. Thank you!

I can’t have a Mirena coil as, due to the size of the fibroid, the gynaecologist was unable to fit it. She was convinced it would have helped too 🥲

Many thanks again for your kindness.

[joziel]

No probs, I replied again above - just in case you missed it...

[Winterangel]

Thanks joziel. How would you suggest I start that routine as I’ve been bleeding for so long? Stop the P now for 5 days, then start again until day 26, then stop again?

[CLKD]

Could it be your own hormones joining in to alter your take up of the replacement?

U don't have to go for scans etc., this is your body.  Advice is what you are after on a number of topics, all of which 'can be considered' ;-)

[Cassie]

Can you not have the fibroid removed, I would imagine its a fairly straight forward procedue that could be done via hysteroscopy?

[Winterangel]

Thank you CLKD. I could refuse but the thing is, the GPs get very jumpy about what they consider to be ‘post menopausal bleeding’ and they put the fear of God into me. Unfortunately the NHS don’t do advice as there is no money in it for them, they want to give drugs. I think I might come off the HRT for three months and see what happens. Sadly, in this country, you can’t get HRT help and support unless you pay a fortune.

[Winterangel]

Hi Cassie, thanks for your reply. Removal has never been offered. If I ask for a gynaecologist referral, I’ll be waiting over a year to even see them.

[joziel]

Winterangel, I think it's best to consider the long-term here. I mean, yes coming off HRT might stop the bleeding and the fibroid issues. But at what cost? If you go on to develop osteoporosis (as one of of 2 women not on HRT do), at a later age? Or heart condition? Or dementia? And so on....

I get that the bleeding has to be fixed, but I don't think coming off HRT - given it is stopping the hot flushes and insomnia etc - is best in the long term. Of course, you make that call though - but I don't think you've exhausted the options yet.

With the POP and adding that in: You don't even need to discuss that with your dr (you can if you want), the POP is off-prescription now for contraception and peri-meno women (which you can say you are) need contraception. It is licensed for use with HRT.

See: https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

For all the options. See " Earlier studies have reported that desogestrel 150 micrograms is effective as the progestogen component
of HRT with no increase in the risk of endometrial hyperplasia.33-34 There is lack of evidence on the use of
desogestrel 75 micrograms as the progestogen component of HRT. If desogestrel 75 micrograms is used
as contraception in women receiving HRT, it would be recommended to add further progestogen (e.g.
Utrogestan 100 mg daily or 200 mg for 12 days a month) to provide adequate endometrial protection."

Desogestrel 75 is the POP called Cerazette. You are already taking the additional utrogestan they recommend to take with it, so just add in the Cerazette. Go to a pharmacy and pick some up over the counter.

Have a read through that document and consider what you haven't tried. Print it out if you want and take it to your GP. Ask for referral to a gynae - best to get on the waiting list now, you can always come off it later but at least you are holding a place...

[Winterangel]

Hi Joziel. Thank you again for your kind comment and all of your help.

I am just so drained by it all and I’m too old for this bleeding! The weather really isn’t helping. I tried to get a GP appointment this morning and, guess what? No joy. I went to fill in their triage form at 8:40am and all of their triage appointments had been taken. So no help today.

I’m pretty sure that this is HRT related as I didn’t take my Utrogestan for 5 days at the beginning of May, which led to this bleed. I have since been trying to adjust my doses (and even stopped HRT completely for 7 days earlier this month) to get the bleeding under control. I just need it to stop so I’ve decided to take a break from HRT for a while and see what happens. This was an option put forward by Dr Lewis at Newson. If the bleeding stops, I’ll be certain that it’s only down to the HRT and then I’ll make an appointment with your doctor at Newson to discuss best ways forward. It might be that HRT isn’t right for me. This bleeding is feeding my health anxiety and making me anxious and weepy.

Do you know if HRT is absorbed differently in the summer months at all? As I only ever get the spotting/bleeding in the summer!

I will read the document that you shared. It’s so difficult as there doesn’t seem to be a consensus on whether cyclical HRT is advisable with large fibroids - some say that continuous progesterone gives the best endometrial protection while others say that allowing for a shed it better.

Many thanks again!