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[mzh140]

Hi all, has anyone had any experience of transitioning from the COC (the pill) to HRT? I was put on the pill, taken continuously, in my late 40s to help with the symptoms of adenomyosis and suspected endometriosis and have just had the healthiest three years of my life. But now at 50 I have to come off it as it is not licensed for women over 50 due to blood clot concerns (my weight and blood pressure are fine and I've never smoked). There seems to be no advice on how to do it - take a break in between? Take the progesterone part continuously or with a bleeding break? What symptoms can I expect? Will my adeno/endo return? All I keep coming up against are the words "lack of high quality research". Has anyone done this transition and if so, how was it for you? Thanks so much :-)

[bombsh3ll]

Ok so firstly the UKMEC criteria which your doctor is following, which recommend discontinuing COCP at 50 apply to contraceptive use only.

The FSRH state that where the COCP is being used for a therapeutic indication, ie to treat a condition, and where it remains the best or only treatment for that condition, then extending use beyond 50 should be based on an individual clinical decision.

Your use of the pill, taking it continuously to manage the conditions you describe, has never been within the product's licence.

So I personally will be continuing my combined pill until my mid 50's barring any medical contraindications.

There is also the argument that if arbitrary age based cut offs are to be used, then FFS go by my biological rather than my chronological age!

In many other countries including the US, the WHOMEC criteria are used regardless of why the pill is taken, which have menopause as the much more reasonable recommended cessation point.

However the principle is the same whenever you, and it should be your decision, choose to make the switch.

You simply take the last birth control pill one day, then take your first HRT pill the next.

Hopefully this takes place after the point at which your own periods have stopped in the background.

[mzh140]

Thank you so much for this reply, bombsh3ll! My GP (female, and menopause specialist at the practice) said I had to come off the pill so I took my last one on Wednesday. Thursday morning I used the oestrogen gel and by the afternoon I started to feel weird and 'periody'. Took the progesterone that evening. Started bleeding on Friday. I've now stopped the progesterone in order to let myself have a bleed. It's so hard to get hold of my GP, it can take ages even to get a phone appointment, I want to go back on the pill but I don't know how or whether she'll even let me!

[bombsh3ll]

I would suggest printing off the relevant section of the faculty of sexual and reproductive health (FSRH) guidelines regarding therapeutic use of the combined pill beyond 50 years in healthy women.

This can easily be searched up on Google and will help support your case.

Your GP may still be uncomfortable and may refer you to gynae or you may have to get it privately, but it absolutely is still an option.

Also what brand of pill are you on? I take Zoely with body identical estradiol. This is even safer than the already very safe traditional combined pills.

If they say it is not licenced for women over 50, remind them that it is not licenced at all for the conditions that you are using it to treat, and this is off label therapeutic use which is still medically indicated.

[mzh140]

Thank you so much, I've found the FRSH guidelines and downloaded them. I did ask her about Zoely, but she said it's not on the Formulary for my area so she wasn't able to prescribe it :-/
What if I asked  her for the mini-pill (progesterone only) and continued with the Oestrogen gel, is that an option? I really don't want my endo/adeno symptoms to come back.

[bombsh3ll]

That is an option but you would have to take a double dose of desogestrel to achieve the same degree of menstrual suppression as a combined pill.

A single daily dose of 75mcg is contraceptive but doesn't necessarily shut down your own cycle or get rid of bleeding.

75mcg is also not considered adequate for endometrial protection, however there is evidence that 150mcg  is effective for this (off label).

Also obviously you would need to use a separate estrogen product

[CrispyChick]

Just thought I'd add to this. I've had endless hell for the last 7 years.

At 49 I've mentioned possibly going back on a combined pill, but I knew 50 was my cut off. My GP was very supportive and said I could defo use the combined pill beyond 50 as there are mitigating reasons.

What they are not happy with us desogestral as the P part of HRT, irrespective of desogestral dose.

Basically everything becomes a fight. So, if it were me, I'd go with the one you really want - which sounds like the combined pill.

[joziel]

mzh140, just to reassure you that your endo hopefully won't come back on HRT - but I totally understand the anxiety, because it was also mine. (Had a lap for endo in 2013 and then was on desogestrel ever since until my early 40s, when I got hit by peri and stopped the desogestrel for HRT.)

Even though I am on an astoundingly high dose of estrogen (300mg Estradot patches plus currently 4 pumps of gel - I am gradually trying to come off the gel) and my estradiol is pretty high around 850pmol, I have ZERO endo symptoms.

Endo is stirred up by fluctuating hormones so make sure you stabilise on a dose, PLUS you will likely need more progesterone than others. (I am now on 300mg from day 5-16 orally and then I add in 200mg Am and 200mg PM vaginally, so total of 700mg/day). I take a break to allow a bleed to happen, otherwise you'll get unpredictable bleeding. So I stop on day 26 and wait for the bleed, which takes about 5 nights to start up - then I give it 4-5 days to come out and start again.

I am currently very very slowly reducing my gel dose to see if I can come off it altogether, as I am bleeding very heavily for 2 days of my period. (Like - flooding to the point I can't leave the house those 2 days.) But I have no pain with it, which is very weird. I'd like to get to around 600pmol and see if that will still be ok for me.

I would probably take a different perspective to others, here, seeing you have already stopped the COC so it makes sense to give the HRT a go. I would suggest you try what I am... You just stop the progesterone to allow a bleed to happen but you take it continuously besides that. And you might need more P than others. If you have trouble getting your GP to prescribe more, you may need to go private. (I am with Newson.) If you still have probs, adding in desogestrel as well (which you can get over the counter and without your GP's prescription, because it is a contraceptive, and it is licensed to be used along with HRT) will help a lot.

[mzh140]

Thank you so much @joziel, @crispychick and @bombsh3ll. I've been put on two pumps of Oestrogel a day plus 100mg Utrogestan, taken continuously (I have taken two doses of that and then paused it to have a bleed). I want any cycle I still have (and I don't know if I still have one) to be suppressed. It sounds as though that level of progesterone is unlikely to be enough?
Once again, thank you so much for your replies, it is INSANE that we have to try to navigate this without consistent or reliable GP advice!

[joziel]

mzh140, you won't suppress your cycle on utrogestan. Full stop. Or period as they say in the USA, which seems appropriate 

It doesn't matter how much you take (bearing in mind they likely won't prescribe above 300mg anyway), you will randomly bleed all over the place if you try to take it continuously and you still have a cycle. It's not designed to override your own cycle like a synthetic progestin is. It's designed to be used to mimick your own cycle.

However, bleeding/having a cycle and having endo pains and endo are two different things. I still bleed (shed loads at the moment) but I have zero pain from any endo. So - why do you want to suppress your own cycle?

Your choices are either to take continuous utrogestan with just a break to bleed from day 26 onwards. (If you are bleeding now, give it 5 days to finish and then restart utrogestan.) BUT if you choose this option, you will need more than 100mg of it. You should ask for more utrogestan given your history of endo. They should be happy to prescribe 200mg at least daily.

OR - to stay with the 100mg utrogestan and add in a synthetic progestin like desogestrel POP.

[mzh140]

Thank you Joziel, I'm learning a lot as my GP didn't explain any of this to me. I want to suppress any cycle I have, partly as I'm scared of adeno/endo symptoms returning – though as you've pointed out, I may not have a return of pain. But I now realise that I've grown used to being on the COC (taken continuously) and I just don't want the inconvenience of a cycle any more. For the last couple of years, on the COC, I have felt the best I have ever been in my life: suppressing my cycle has kept me well and happy with no detectable side effects. I don't want unpredictable bleeding and spotting, mood changes, headaches or all the other things that might come with its return.

[CrispyChick]

In this case, without a shadow of a doubt, I'd be fighting to stay on the COC a bit longer.

Taking HRT is not designed to supress your cycle, simply top up. So if you're still cycling, there's a high chance your issues will return.

Taking the mini pill, desogestral or slynd should supress your cycle and stop bleeding. But it can take time and doesn't in everyone.

But, the thing is, you don't know if you're still cycling if you don't take a break from the COC. My own sister stopped at 50 and never had a cycle return.

Also, you don't know if you need HRT.

You're obviously testing the waters now. You could give it a 3 month test, if pain etc comes back, you would then have a clear case with your GP.

[mzh140]

Thank you, this is really good advice. On the COC I was having spotting every 70-ish days and would take a five-day break (and stopping it prompted a bleed within 48 hours) but I think these breakthrough bleeds aren't the same as 'having a cycle', right? That is unknown. Basically it's Shroedinger's Ovaries in there right now.

[CrispyChick]

No, it's definitely not the same as a cycle. It's hormonal withdrawl that causes the bleed.

[joziel]

mzh, one thing you could consider is the COC called Zoely. It is one of the very few COCs which use body identical estrogen (same as in HRT) and a synthetic progestin. It may well keep your peri low estrogen symptoms at bay longer and give you estrogen your body can actually make use of instead of synthetic stuff, but also stop your own cycle. You may be able to stay on it a few more years and then transition to HRT.