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[KBIOW]

 :DHello again

I’m 51. I’m not quite sure where I’m at really.

My last period was July 24, in July 25 I had an appointment with the GP who advised I went onto the combined Everol HRT patch I thought she was quite pro HRT. I have been on this for three months, I didn’t really have any symptoms to start with, apart from the odd hot flash, I also suffer with dry eyes but am with the hospital eye department for that. I was advised it would be a good idea to go on the patch to help with the hot flashes and for bones and cardiovascular health in the future.

During the three months I have had various spells of spotting/periods which just come and go as they please. But otherwise I don’t think I have seen any real benefit, I’ve always been an anxious person and this got worse for me during Covid and has continued. I was always very 50 50 about taking something but there is so much to read etc that I have found it very confusing. My three month review for the beginning of November. I saw a different GP and she felt as I wasn’t taking it for any symptoms that it wasn’t really of a benefit to me I also exercise and eat pretty well so she feels that is enough. I asked for a test for my oestradiol levels and then we could make a decision. My levels came back Serum oestradiol level: 89 pmol/L. The GP said this is low considering I am on the patch but felt as it wasn’t really doing anything, I should come off the patch for eight weeks and see how I feel. If I feel I need the patch I would then go back on a higher dose.
Has anybody been in this situation?
How do we possibly know what the right thing to do is?
I appreciate the GP‘s honesty as if I can, I don’t want to take anything but it really is quite different to the first GP I saw. Any feedback or help would be greatly appreciated.
Thanks as always in advance.

[CLKD]

True about protecting heart and bones, mayB keeping a mood/food/symptom diary until the New Year would be of use.

Which symptom would you like to ease?  A good diet and regular exercise is important with/without HRT.   It is a personal choice, personally I've not had any symptoms after the initial itching of feet and back of the shoulders.  Vaginal atrophy however, another kettle of fish [what ever that means? ] 

As oestrogen levels drop the body may become dry: inside and out; deep in the ears, eyes, vagina, anus, skin, scalp ...... and muscles may become lax = aches and pains.

Blood tests are reliably un-reliable 

[bombsh3ll]

That is a low estradiol level, however the suggestion to come off treatment altogether is perverse - how does the GP think that will help your bones heart and brain etc?

Whilst individual treatment objectives vary, the first thing I would do is to become really well informed - read up about the role of ovarian hormones and menopause, plus the up to date scientific evidence around treatment so you can have a really clear idea in your own mind about what you are hoping to achieve.

Once you are clear on what your goals are, you can then navigate the appropriate treatment options, hopefully with a more knowledgeable provider.

If you are only looking for symptom palliation then blood tests are not generally helpful as treatment is titrated clinically.

Your estradiol level is very low however this is commensurate with a 50mcg patch in a postmenopausal woman.

[Mary G]

CLKD, hormone blood tests are not unreliable once a woman is post menopause. That might be true in peri menopause but blood tests post menopause are a good way to find out how well someone is absorbing their HRT.  You are not getting oestrogen from anywhere else at that stage so it's safe to assume that most of it will be from HRT.

89 pmol is a very low level of oestrogen and there's no way it's going to be that low at the time of the blood test and then shoot up too 300 pmol in the afternoon.  89 pmol is the type of level I had when I stopped using HRT to get baseline hormone levels (something I will not be doing again) and I was about 15 years post menopause at the time.

I can't see the point of stopping HRT and risking the return of symptoms.  Also, you won't be getting bone or cardiovascular protection so it's a very strange thing for the doctor to suggest.  You are only 51 and if you stop HRT now, you are leaving yourself wide open to developing other post menopause symptoms even if the early stage stuff like hot flushes disappear.

Personally, I would continue with HRT and not take the risk.  If anything, you probably need a higher oestrogen dose because a 50 mcg conti patch is often not very effective. 

[KBIOW]

Thank you for your messages and support.
I more confused than before…. I really appreciate you taking the time to reply.
I’m reading stuff all the time, and every time I’m not sure what to do.
I lost my Mum a few years ago and realise just how much I relied on her to help.

If anyone has any advice of what and where to read that would be great.

I’m going to keep off the HRT for 8 weeks see how I feel and make another appointment then. Although now concerned as been on it for 16 weeks and just stopped…. Is this even right…. Ahhhhhhh.

I will keep a diary of everything as recommended, which I do already for my eyes…
I have noticed they are reluctant to do blood tests and seem to go more on how I feel…, so not sure what will happen when the 8 weeks are up.

Also I was on microgynon from the age of 14 to 47!

Thanks

[bombsh3ll]

I would start by looking at the British Menopause Society website, but would also recommend listening to Dr Louise Newson's podcasts and videos because she provides some great education around the role of ovarian hormones in health, the consequences of long term untreated hypoestrogenism and how to approach treatment and advocate for your care.

If you can afford it I would really recommend seeing a menopause specialist as it doesn't sound as if your GP is either very knowledgeable or very approachable.

Additionally, what value is there to be gained by going untreated for 8 weeks? There are no medals for suffering, you don't get a badge, it's essentially self harm and I don't know if you have children or pets, but would you let them go without medical care for a treatable condition for 8 weeks? Would you tell your best friend to just suck it up and white knuckle untreated menopause for 8 weeks? You need to give yourself the same level of care and value that you probably instinctively give to others.

And finally, congratulations for banking 34 years worth of risk reduction for ovarian, endometrial and colorectal cancers on the combined pill 🎂

I was late to the party starting it at 29 (to halve my risk of familial ovarian cancer following risk reducing mastectomies) and I hope to achieve at least 20 years' worth of protection.

[Dr. Heather Currie]

Please don't rely on blood tests. Have a listen to our podcast at https://shows.acast.com/menopause-matters-lets-talk/episodes/measuring-hormone-levels-theres-more-to-it-than-you-think
There are 3 reasons to consider starting HRT:
1. For control of menopausal symptoms--if no symptoms or mild, then HRT unlikely to be needed
2. For premature ovarian insufficiency (menopause under the age of 40), or early menopause (under the age of 45) since then benefit is needed for long term health as well as symptom control, but still recommended in these situations even if no symptoms
3. For treatment of osteoporosis, or prevention of osteoporosis if have risk factors

So if experiencing menopause at age 45 or over, no or minimal symptoms, and no risk factors for osteoporosis, there is no real indication for HRT. Healthy nutrition and lifestyle would still be the focus.
We are all different. I completely understand how confusing at all is with so much information and a lot of misinformation.
Thank-you for mentioning British Menopause Society--the national authority with loads of free resources online. See also Women's Health Concern fact sheets, and all the resources on this website plus our weekly newsletter and podcasts, and of course our quarterly magazine.
Thank-you all for using this forum and please let me know if there are other resources that would be helpful.

[Ayesha]

Some alarmist posts above and I want to redress the balance.

In my fifties I started HRT to relieve hot flushes which had become debilitating, I stayed on it for five years and then came off, no more hot flushes thankfully.
I am now in my mid seventies and have no major issues relating to not being on HRT.  I developed GSM symptoms at 70 but that was easily solved by using topical oestrogen which I am now symptom free.

Its very important to lead a healthy lifestyle, exercise, the right foods, supplements needed for an ageing body as some food is not greatly digested. There were no risk factors in my family through the ages and I have been very happy not to have been caught up in the minefield that being on HRT brings.

 

[Mary G]

I've just completed my extensive annual health checks and there is definitely a direct correlation between the dose of oestrogen I use and my oestrogen blood test results.

I'm not sure how anyone can know whether or not they need HRT unless they have a crystal ball.  My sister was always dead against HRT and has so far developed osteopenia, carpal tunnel and frozen shoulder.  I have been taking HRT for years and have the bone density of a 35 year old.  I don't believe that's any coincidence and in theory I should be at higher risk of osteopenia than her.  My sister has now started using Evorel conti but it's too little too late and it hasn't shifted the dial on her bone density.

I can't see the point not taking HRT and leaving yourself wide open to develop one of the many health issues caused by oestrogen deficiency.  I think HRT should be viewed as preventative medicine unless you have a good reason not to take it.

I'm sorry but I just don't get the lacklustre and apathetic approach to HRT.  Surely women should be strongly encouraged to take it.

[bombsh3ll]

I think the ambivalence is partly down to a medical culture in which women's health and quality of life are really undervalued, particularly mature women who have outlived their perceived societal usefulness as sex objects, baby factories and units of economic productivity.

It is also strongly cost driven with a very short termist approach within state funded healthcare systems. The NHS would frankly collapse if every woman who could benefit from treatment decided to come forward and access it.

[Mary G]

It's shortsighted bomb and it's costing them more in the long run.  Time and time again we have women on here who say they thought they had sailed through the menopause (whatever that means) and suddenly find they have developed a post menopause condition like osteoporosis.

My friend in Australia thought she had "sailed through the menopause" and stopped taking HRT after a very short period of time (less than a year I think) because her hot flushes stopped.  Now she has osteopenia like my sister plus a whole host of other things menopause related. It's incredible just how fast bone density diminishes in those few years immediately post menopause.

I find it unbelievable that people are left to sit back, do nothing and then wait and see if one of the menopause nasties comes along to bite them on the backside later on.  It makes no sense whatsoever to me and it leaves women vulnerable and having to play catch up with bone density and that's if they can recover at all.

More and more evidence is emerging about the enormous health benefits of oestrogen so HRT needs to be encouraged and treated like preventive medicine.

[Ayesha]

If HRT was known to be a safe treatment for all future potential diseases stated, I don't think it would be down to cost factors, it would save the NHS a fortune to prevent such diseases happening therefore one would think, make HRT a preventative treatment. I have always wondered why there is still such a stigma because there always has been when it comes to systemic HRT and why I always call it a minefield.
I found this AI answer whilst researching the subject of why HRT is not used as a preventative treatment.

Hormone Replacement Therapy (HRT) is not used as a preventive treatment for chronic conditions because large-scale clinical trials have found the potential harms often outweigh the benefits for asymptomatic women. While HRT can offer some benefits, its use is primarily recommended for the short-term management of severe menopausal symptoms and for osteoporosis prevention in high-risk cases.
Primary Concerns and Risks
Major health organizations, including the U.S. Preventive Services Task Force (USPSTF) and the American Heart Association, advise against using HRT for the sole purpose of preventing chronic diseases due to the associated risks. These risks include:
•   Blood Clots and Stroke: Oral HRT, in particular, increases the risk of venous thromboembolism (VTE), deep vein thrombosis, pulmonary embolism, and stroke.
•   Cardiovascular Events: Studies, most notably the Women's Health Initiative (WHI) trial, did not find a net benefit for cardiovascular disease prevention and, in some cases, found an increased risk of heart attack and coronary heart disease events, especially when initiated in older women or those more than 10 years past menopause onset.
•   Cancer Risk:
o   Breast Cancer: Combined estrogen and progestin therapy is associated with a small, increased risk of breast cancer, which rises with the duration of use.
o   Ovarian Cancer: There is an increased, though low, risk of ovarian cancer with both combined and estrogen-only HRT.
o   Endometrial (Uterine) Cancer: Estrogen-only therapy significantly increases the risk of endometrial cancer, which is why a progestin is added for women who still have a uterus.
Shifting Perspectives and Individualized Care
The current medical consensus emphasizes an individualized approach to HRT based on a woman's age, specific symptoms, and personal risk factors.
•   Focus on Symptom Relief: HRT is considered the most effective treatment for moderate to severe menopausal symptoms like hot flashes and vaginal dryness, and the benefits usually outweigh the risks for healthy women under 60 years old or within 10 years of menopause.
•   Risk Mitigation: Certain formulations and delivery methods can mitigate some risks. For example, transdermal patches, gels, or sprays generally do not carry the same risk of blood clots or stroke as oral tablets because they bypass the liver's initial metabolism.
•   Alternative Preventive Measures: For chronic disease prevention, healthcare providers recommend focusing on lifestyle modifications, such as a healthy diet, regular exercise, not smoking, and managing other risk factors with proven therapies (e.g., bisphosphonates for osteoporosis, statins for high cholesterol).
Ultimately, the decision to use HRT is a personal one that should be made after a thorough discussion of the pros and cons with a healthcare provider.

[Mary G]

That is American so I would dismiss it out of hand because they are way behind the times on HRT and they have a dysfunctional health service or perhaps I should say non health service.

Most of that stuff sounds about 20 years out of date.

The consensus in the UK and the rest of Europe is the benefits of HRT outweigh the risks.

[Ayesha]

Unless I have misunderstood Dr Currie's post some of what she has said is of the same opinion written in the AI statement.
Its such an individualised treatment, I can never see it becoming a part of preventative medicine because its all too complex.

[bombsh3ll]

It's the upfront cost vs kicking the can down the road.

The appointments, the prescriptions, the (often inappropriate) investigation of breakthrough bleeding etc.

Large numbers of women presenting in droves for desperately needed and evidence based treatment due to improved awareness and education, is overwhelming the system. It is seen as a nuisance by increasingly irate clinics and managers who openly label it bandwagon jumping and a "fashion".

Whereas we are not all going to have our hip fracture, premature CVD event, urosepsis or mental health breakdown en masse in the same fiscal period.

When thousands of junior doctors were being made redundant several years back, the NHS staggered the layoffs so it looked politically less bad- some were given 6 months contracts, some 4 months, some a year etc so they didn't all hit the jobcentre (and the headlines) simultaneously.