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[Cassie]

Hi Ladies, I have been following some chats by a Gynaecologist in America, who states that its super important for us ladies to be using HRT the way our bodies "cycled" before menopause. Her theory is that the Estrogen promotes growth in the Uterus and also is beneficial to our arteries, bones etc & taking Progesterone daily, kind of dampers or reduces the benefits of the Estrogen. She also states that if you are taking a beneficial amt of Estrogen, enough to protect the bones etc, you will def need Progesterone to protect thickening of your Uterine lining, which we all know of course, but that taking it daily is not ideal.  Thats all good & well but lots of ladies do not want to be having bleeds in their late 70's...would appreciate your thoughts on this 

[bombsh3ll]

This is something that interests me as well - is it Felice Gersch you are talking about?

I agree with much of what she says.

There is evidence of better health outcomes when the progestogen burden is minimised and not constant.

Obviously the luckiest group of all are those with a hysterectomy who can take estradiol and testosterone only, however that isn't most of us.

As with most things in life there is a tradeoff between do we want intermittent courses of progestogen and accept the light, painless predictable bleeds that come with this, or is the priority amenorrhea at the expense of continuous progestogen negating some but not all of estrogen's health benefits.

I have enjoyed decades of amenorrhea on the combined pill so when I switch to menopause hormone therapy, this will be a nuisance but I have read enough evidence to convince me that sequential is superior, especially as I plan to do long cycle, with 2 weeks of progestogen every 6 or 8 weeks rather than every 4 weeks.

I never had a 4 week menstrual cycle when I was younger, it was always closer to 5 or 6 and frankly I was quite skeptical that God would inflict 28 day cycles on most of us.

I remember sitting in a lecture about it and thinking that's horse shit, they only all think they have a 28 day cycle because they're on the pill and it's artificial!

So I won't personally be recreating a 4 week cycle, I want to get as close as possible to the health benefits and quality of life if estrogen only.

However I will be having annual scans to monitor my endometrium and wish to point out this is not standard practice and not am I advising anyone else to do a long cycle without monitoring.

Additionally having been on continuous birth control for decades my risk of endometrial cancer is significantly lower than most people's.

[juliaC]

Cassie thanks for flagging this up. 

Bombsh3ll I thought with your regimen you would have opposed this but you also support it in theory.

I've been sticking to sequential myself because of thinking the cycle is what happens naturally, plus I'm not sure my own is over yet (my periods are not light or totally predictable, just a lot more predictable on evorel sequi), but also my body has been telling me it is better on the estradiol only patch, and health issues surface once back on the combined (crushing fatigue, diarrhoea, sugar cravings due to lack of energy, muscle weakness, low mood and prolapse symptoms which resolve to a significant degree on the estradiol only)

I have wondered about seeing a specialist to see if I could lengthen the days on estradiol only and slightly shorten the combined days.  I know it must be done under medical care, but the effect I'm having from the combined I think it's at least worth the conversation.

[Mary G]

I would say it depends on the individual and the type/dose of progesterone.

If someone is severely progesterone intolerant they have to keep their progesterone dose to an absolute minimum so they will have to be on a cycle. 

If like me they suffer with migraines then a cycle is completely out because it creates too much hormone instability.

That aside, I found the bleeds debilitating as I got older.  Despite never having any problems with them, I always hated periods but they are worse and more draining with age.  There is no way I would want to have them in my 70s. 

Overall I think the problem is about dose and I think progesterone is over prescribed which means it causes terrible side effects and cancels out the positive effects of oestrogen.  If women are unnecessarily dosed up to the eyeballs with progesterone their HRT won't work and that's why so many women give up on HRT altogether. For example why use a high dose Mirena coil when the Jaydess dose is lower and more tolerable?  Does everyone need such a high dose of daily progesterone?  I know I don't so probably most other women don't either.  The point isn't don't guess how much you need, find out via scans and tailor your dose accordingly. 

In most cases it's possible to get away with a lower, tolerable dose.  Obviously it's sensible to have regular uterine scans but that is something everyone should doing anyway.  I think it's possible to take a low dose of progesterone on a continuous basis which is tolerable and avoids bleeds.  There's no harm in having the odd bleed break if you feel like it but I wouldn't want to be stuck with it for life.

[common-lime]

I've heard these arguments too, but I have four different reasons to take mine continuously so I'm going to keep doing so! Quality of life is really important, and neither my mental nor physical health did well with cycling, so I'll take the risk and keep up with my weight bearing exercise for the bone/CV health. Plus I have far fewer side effects using it vaginally, so I'm kind of hoping that works for long term impacts as well as the day to day stuff. Unless anything really dramatic turns up in the research in future, I'm happy.

[bombsh3ll]

There is a case to be made for both sides and I don't think there is one universal "right" way for everyone.

It depends on our individual physiology, medical history, tolerance, preference and treatment objectives.

I have been on the pill continuously for many years, started initially to halve my risk of familial ovarian cancer, then once on it I found my quality of life improved in multiple ways through having no bleeding and a constant, stable supply of hormones, in particular avoiding the release of endogenous progesterone which I don't tolerate well but am fine with most synthetics.

However due to the evidence around various health outcomes, once I am postmenopausal and no longer in need of ovarian suppression, I am willing to try a regime with stable, physiological estradiol levels and intermittent courses of what will in all likelihood for me be a progestin if I don't tolerate vaginal micronised progesterone.

If this doesn't work out for me though I will switch to a continuous regime with the lowest dose of progestogen to control my lining, with regular monitoring. This may well be lower than the dose the NHS recommends, but for me it is about individualisation rather than bog standard one size fits all prescribing.

In the real world I think you have to have both the knowledge of what is theoretically optimal, and the pragmatism and flexibility to change course if the first (or second or third) thing you try isn't a good fit.

[juliaC]

Agree with everyone here that treatments are best individualised and sequential isn't right for everyone.

Mary G, I do think the answers to my current symptoms will lie with the amount of progesterone I'm getting and it's an area to explore with an experienced doctor.