Menopause Matters Forum
Menopause Discussion => Personal Experiences => Topic started by: Dancinggirl on September 24, 2015, 04:47:03 PM
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Hi all
I thought I would share my recent experiences with you all in the hope it might be helpful.
I started back on HRT last autumn after having a one year break from HRT. During the year without HRT I was a struggling with burning urethra/UTI type symptoms (despite using local oestrogen) and the flushes, loss of sleep etc. were making life tough - because of my age, the GP was relieved when I suggested I see a gynae privately for advice. I went to see a lovely eminent gynae in Norwich who specialises in meno - I have to say that if every women was given such excellent advice and treatment as I've received from this man, then the menopause would be a much easier journey.
I suffered an early menopause so have used HRT for over 20 years - I've tried just about everything and have always found the progesterone a problem. In my mid 50s I had a Mirena for 4 years which wasn't too bad but I still found I felt a bit sedated on this.
This lovely gynae started me off with Oestrogel (between 1-2 pumps per day) with Utrogestan, allowing me to try a longer cycle with only 100mg of Utrogestan for 14 days every 6 weeks. This was OK for the first couple of cycles but I did start to get some erratic spotting and the withdrawal bleed became rather longer and painful - he warned this might happen with a long cycle and this very low dose of progesterone.
At my next appointment he suggested I increase to 200mg of Utrogestan on a slightly shorter cycle. I did this for a couple of cycles but this also resulted in some erratic bleeding and spotting.
I saw him again today and he did a scan to check everything and my lining was fine (a relief to know). Through all my visits he has explained the reasons for balancing the amount of hormones to give relief of symptoms with minimal side effects and, as I'd done my research on this site and learned so much from the many knowledgeable ladies that post on MM, this enabled me to understand all that he explained.
He has now suggested I try using Utrogestan continuously as I'm finding I feel quite good on this particular type of progesterone - such a relief to find something that doesn't make me feel I want to kill people!!! ; :o
My new regime will be one pump of oestrogel with 100mg of Utrogestan daily. If the bleeding continues I have to increase the Utrogestan to 200 mg daily.
How do I feel overall being back on HRT? Well, calmer and more in control. My burning urethra has improved so I now don't need the local oestrogen. Though I haven't actually lost weight, my muscle structure is better, my joints ache less and because I have more energy I get more exercise. If I can sort out this erratic bleeding then for me it's a 'no brainer' - HRT brings far more benefits. Oh, I forgot to mention - libido has definitely returned a bit so I have a happy husband - I have to say it feels great to feel feminine again.
We hear so many horror stories about HRT and I still have to find the right balance of hormones but it is worth persevering.
Hope this info is useful for you all and I'll keep you posted about who I get on. DG xxx
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:thankyou: for the up-date! Your Gynae sounds knowledgeable and seems to be OK about working with you.
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I do get the impression that the gynae I'm seeing is one of those trying to educate the GPs and promote appropriate treatment of the menopause. I know he is particularly concerned about women who experience early menopause or have had a hysterectomy when still young and are not given HRT to protect them in the long run.
It is very refreshing to be listened to as well - lovely man. Dg x
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:medal: he could be a Travelling Showman ;)
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Great post , glad your on the up (;D) and wonderful that you have a doc that is supporting you :)
:-*
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Hi DG, only just seen your post and I'm glad that you too saw an understanding consultant and that it's working for you. In my post re gynae, I'm not sure if mine is so clued up on hrt but he seemed to know all about it and quite happy for the customised route. Could I ask if taking Utrogestan everyday prevents you from having bleeds? I'm a bit worried about this long cycle; mine has said 90 days! Oh dear, I know it's trial and error but it does get scary!
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Hi Sunnydays
I am certainly no expert but having learned so much from MM it has enabled me to move forward in a positive way.
Re: Utrogestan - this is a bio identical progesterone and is seen by many as the best form of progesterone to use - especially when older and at 59 my gynae seems keen fro me to stick with this. However, for some it may not be ideal and I think there are issues around absorption which I think can lead to a greater chance of problematic bleeding.
Whilst MM members like Hurdity have managed a longer cycle (5-6 weeks) using Utrogestan it may not be the ideal progesterone to do the longer cycle of 3months (or just 4 bleeds a year). My gynae explained that to get the uterus to shed properly then it is not just the right dose but also using it for long enough to make this happen. Provera is stronger than Utrogestan and if you are using progesterone to induce a bleed only 4 times a year then Provera in a high dose over those 12 days will probably be used to ensure the lining does shed properly.
It is normal when starting a continuous HRt regime to get bleeding or spotting in the early weeks but now I'm using Utrogestan 100mg every day I'm hoping this will settle in the next 6-8 weeks - my gynae if expecting this to happen. If it doesn't then I've been told I should double the dose which I am not keen on as Utrogestan does make one feel a bit sleepy on the higher dose. I would rather go back to having a 4-5 week cycle if this conti regime doesn't work.
I did respond to you on your post and my feeling is you should try the longer cycle first - use an oestrogen patch and the Provera progesterone for the 12 days and see how you feel. Over thinking things is not good sometimes and you do sound very scared but I think you have everything to gain and nothing to loose - especially as the oestrogen will really help with the discomfort you are getting around your 'lady parts'.
You will probably feel much better being just on oestrogen patches for 3 months but do try to use 50mcg patch to really get the benefits. 12 days on Provera may be a bit tougher but as you've only used the really strong synthetic progesterones so far, Provera may not be as bad. You have been told to have a scan after the first bleed which is good and you will have a better picture of whether this is working well for you. If it doesn't suit you then you could try Utrogestan continuously.
Do be prepared for some tingling and strange sensations as your whole vaginal area wakes up and welcomes the oestrogen - it can feel strange. You may get sore breasts as well but this will all settle.
You are doing the right thing so go for it and enjoy the benefits. DG x
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You give me hope. Particularly with the urethra/bladder symptoms. I hope one day to post such a positive post :)
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DG:
What does your estrogen dose come out to daily do you think....25mg, 50, 75, or 100mg?....or in between those?
Are there days that you have to use more of the gel? You said 1 to 2 pumps, so I am curious as to the avg daily dose you use with the continuous oral 100mg utro.
Andius
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Hi andius - I use only one pump per day now. What dose that would be as a patch I'm not sure - possibly around 30mg. I know that my oestrogen level is around 400-500 when on 2 pumps per day and I'm hoping my levels would be about 300-400 on one pump which is probably just right. I apply to my inner thighs at night and take my 100mg Utrogestan at the same time. I have found I feel better on one pump rather than 2 pumps, which seems strange as so many women feel they want and need a higher dose. We are all different and I think each women will absorb oestrogen differently. When I tried a patch I felt as though I got a big boost to start with and then it tailed off really quickly. I am now into my 5th week of continuous Utro and still getting some spotting which is a bit of a nuisance. I have been told I should increase to 200mg of Utro daily if need be to control any spotting but I'm hoping that in a few more weeks things will settle and I won't need to increase the dose.
I have to say I'm feeling really good generally - much calmer, less discomfort around my lady parts and fewer trips to the loo at night. Really glad I tried conti Utro. Dg x
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Wow Dancinggirl - if my levels could be 300-400 on one pump of oestrogel I would change to this like a shot! That is quite high for such a low dose of gel isn't it? No wonder you feel so well!!! Last time mine were measured on a 50 mcg patch they were 212!!! I think I've left it too late to increase now....
Hurdity x
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Hi Hurdity - I don't know for certain that my oestrogen levels are that high. All I know is that when I was tested before I was advised to come off HRT at age 57, my level on 2 pumps per day was 600!!! After I went back on HRT and had been on 2 pumps per day for around 4 weeks my levels were already about 475 so this is why I assume I must be at about 300 as I do feel good. I think I must absorb the gel well!?? Dg x
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DG, I have only just seen your comment on here that was intended for me - thank you. I'm glad that you feel you are getting sorted to!
A couple of things (don't want to detract from your thread) when you talk about your levels- what levels are these? I looked back on the only blood tests that the GP did for me re the meno when i'd had no periods for about 6 months and the serum oestrodial was less than 50 pmol/L, the serum FSH 109 u/L and the serum LH 49.3 u/L. Gosh knows what these mean except the GP said "menopausal profile" Which one of yours is about 300/400?
This is purely interest, I'm not overthinking; just again realising how little I knew/know about the meno haha!
x
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Hi Sunnydays - I think the first one 'Oestrodial' (yours was 50 pmol/L which would indicate a very low level) would be the oestrogen level and FSH is another indicator for menopause. I'm not sure what the LH one is??
I know that the FSH level is more significant as if this is high then, even if your oestrogen levels are not bad, it shows that your ovaries are struggling to produce oestrogen - or at least that is my understanding. So you could have a reasonable level of oestrogen but a high level of FSH and this might indicate peri meno. Having said all this, blood tests can be misleading as in the peri meno stage they will fluctuate greatly so it is only in post meno that oestrogen levels will bottom out about 2 years after your final period.
Your reading seem to indicate post menopause as you have low oestrogen and very high FSH. My oestrodial levels on one pump of Oestrogel per day I believe are between 300-400 but that is only my guess based on my levels when on 2 pumps per day.
Hope that makes sense. DG x
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LH is luteinising hormone. It usually spikes at ovulation. If it is constantly high, that is another indicator of menopause, like the FSH.
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DG:
Is this what your pump device says?:
1 pump depression of EstroGel 0.06% delivers 1.25 g of gel containing 0.75 mg estradiol. Taken once daily this is 0.75mg/day.
If so, here is the pkg insert levels info:
"EstroGel 1.25 g (containing 0.75 mg of estradiol) was administered to 24 postmenopausal women once daily on
the posterior surface of 1 arm from wrist to shoulder for 14 consecutive days. Mean maximal serum concentrations of estradiol and estrone on Day 14 were 46.4 pg/mL and 64.2 pg/mL, respectively. The time-averaged serum estradiol and estrone concentrations over the 24-hour dose interval after administration of 1.25 g EstroGel on Day 14 are 28.3 pg/mL and 48.6 pg/mL, respectively."
I tried to post the graph but cannot copy it individually to paste it, but estradiol level hovers around 30pg/ml. Conversion tables pg/ml to pmol/l show:
46.4 = 170.3 pmol/l 28.3 = 103.9 pmol/l
64.2 =235.7 pmol/l 48.6 = 178.4 pmol/l
I am with Hurdity!!! :o I am assuming your guess is a little high if the 300-400 number you guessed is in pmol/l. This is probably because you had your own estrogen from ovaries in the mix back when 2 pumps gave 600, and now that is gone in post menopause.
The reason I looked this up is I haven't tried the estrogel type of hrt myself and was curious if we have it in US and what the data showed. ::)
I think these blood levels are quite similar to what you get with a .05 mg patch. At first I was thinking if it gives .75mg day and you can take with 100mg utro, it sounds like something I would like to try. In US .075mg/day patch is considered high dose and usually the utro is pushed up to 200mg/day for continuous pattern. Wonder why estrogel gives .75mg/day but blood levels are similar to the .050mg patch? Clearly the answer is different technology between gel and patch....NOTICE .75mg/day gel and .075mg/day patch!!!!! IN CASE ANYONE ELSE WAS CHECKING THIS OUT ALSO!
The Minivelle (like estrodot) estradiol only patch gives a max conc of 56.6 pg/ml for the .050mg/day patch and for .1mg/day patch it is 117pg/ml (429 pmol/l). They don't give the info for the .075 patch in the package insert. I tried the .050 patch with 100 utro for a while and the utro burned my bladder/urethra. It would be nice to try a higher estrogen patch or gel without having to up the progesterone!!! (what I thought this might be, but apparently isn't)
Havw I succeeded in confusing myself and everyone else too??? ;D ;D
Andius
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Hi andius - Thank you for the feedback - very interesting info about the actual dose received with Oestrogel. When I quoted my level at 600 with approx 2 pumps per day (I usually applied slightly less) this was at the age of 57 and I had been post menopausal since my early 40s!!!! I believe that one pump of Oestrogel daily would give an approximate equivalent of between a 25 to 37.5 patch but again this is just my guess.
Maybe I absorb and store more oestrogen than most??!! There does seem to be a problem with absorption with many women; I often read on MM of women on as much as 4 pumps per day still showing very low oestrogen levels when tested!!! Your info only shows levels after 14 days and I also assume that levels within the body will build over time as we surely store some oestrogen?
I had had a one year break from HRT before I started back on HRT last autumn and my gynae recommended I start with one pump per day for 2 weeks and then increase to 2 pumps per day after that; he then wanted my GP to test my hormone levels soon after 4 weeks on Oestrogel and the blood test at this stage showed a level of 475. He then wrote to me and said I could increase if I needed, as he wanted me to be at around 600!!! I want to be on HRT for the long term and thought I should keep to as low a dose as possible provided my symptoms were under control so actually reduced down to one pump per day and I feel good on this amount. I can only guess what my levels are so maybe I'm one of those women who feel good on an oestrogen level of only 200-300!!
The other issue for me ( that I think is slightly baffling my gynae )is the fact I am spotting so much. I had a scan and biopsy taken a month ago and everything was fine. My gynae has recommended I increase to 200mg daily on a continuous basis if the spotting doesn't stop in the near future. Why do I get spotting when on such a low dose of Oestrogen??? I have only been on conti Utro for just over 4 weeks so I don't feel I should increase my Utro dose just yet - after all, when first starting any conti HRT regime it is quite normal to get spotting for the first few weeks or even months.
Previously, in my mid 50s, I had had a Mirena with Oestrogel - this was OK but did give me fatigue, occasional stomach cramps and I did get some spotting as well. So maybe I am more prone to spotting?? I also realise I got more headaches when on other progesterones or even without HRT - since being on Utro continuously I haven't had a headache!!!
I do think that there are real issues around the absorption of Utro but fortunately it does seem to suit me even on a conti basis. I am reluctant to use it vaginally due to my bladder problems and urethral pain, although I will give this a go if I feel I must.
My post is titled "Finding the balance" - I think this is the key thing. If my spotting stops in the next few weeks, I really feel I have found the perfect balance.
Thank you all for your feedback and support - I am so keen to keep feeling this good - I can really feel my confidence growing now I don't get so many rough days. DG x
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Just a thought - Could the bleeding/spotting be because you do not have enough oestrogen to combat the effects of the uterogestan, like you get with progestogen based contraceptives like the implant/mirena/injection/cerezette etc?
I had to take my daughter to the fpc to have her implant removed because of this and read somewhere recently that Annie Evens said that if mirena makes you bleed, you need more oestrogen.
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You are right about it only being 14 days, not enough time for a buildup in the tissues. Also these are usually uncorrected values in these leaflets, meaning whatever your postmenopausal level naturally is PLUS the effect of the drug. Maybe you just naturally have higher levels. Anyway, I'm happy that it works for you so well.
As to the spotting, maybe you're not absorbing the progesterone as well orally. Check the leaflet and see if taking it with food (or without) food might increase the amount of drug in your system, depending on your personal pattern of taking it. Sometimes that can make a difference. I tried 200 oral for a while with a .050 patch and also with the US version of Sandrena gel. It really made my bladder/urethra much worse than with the 100 oral, but I never had vag bleeding on either dose. I was given that because of a timid gyn who was afraid of "low dose" continuous 100 utro not being enough to counteract the estrogen. Most gyns in US don't trust utro (prometrium here), they feel much more comfortable with the synthetic progestins.
Andius
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Thanks andius and dahliagirl
When I was trying a sequi cycle of oestrogel with Utro I was getting spotting when just using the Oestrogel!!!
My gynae did ask me to try increasing the Oestrogel back up to 1.5 to 2 pumps per day to see if this stopped the spotting but it didn't make any difference, I still had spotting. Also, with the sequi regime my withdrawal bleed always started before I had finished taking the 14 days of Utro and tended to last 9-14 days! Whether the spotting would stop with more oestrogen I'm not convinced - my gynae now thinks more Utro may be the answer.
I do think the absorption of Utro could the be issue. The instructions say to take on an empty stomach before bed which I adhere to very carefully. I know some ladies use it vaginally which delivers the progesterone more directly to the area where it's needed but as I mentioned I'm worried this would irritate my bladder and urethra.
Back in my mid 40s when I was using a synthetic progesterone with one pump of Oestrogel (sequi) I didn't get spotting - in fact I got quite a light withdrawal bleed. I'm wondering if it is more to do with my age (59) and perhaps after having a whole year without HRT my uterus is struggling to cope with hormones? I still hope things will settle in time as it is early days on this conti regime. Dg x
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I'd try taking it (100mg) closer to dinner than bedtime for a few days. You might get sleepy earlier though.
Look at this: study from 1993 (small group though)
The absorption of oral micronized progesterone: the effect of food, dose proportionality, and comparison with intramuscular progesterone.
Simon JA1, Robinson DE, Andrews MC, Hildebrand JR 3rd, Rocci ML Jr, Blake RE, Hodgen GD.
Author information
Abstract
OBJECTIVES:
To examine the effects of food ingestion and administered dose on the absorption of oral micronized P (Utrogestan; Besins-Iscovesco, Paris, France) and to compare the bioavailability of intramuscular versus oral routes of administration.
DESIGN:
Prospective, randomized, open label crossover protocol with 7 days between dosages.
SETTING:
Academic institution.
PARTICIPANTS:
Fifteen normal postmenopausal women.
INTERVENTIONS:
All subjects participated in three separate protocols: [1] micronized P (200 mg) or placebo under fasting or nonfasting conditions once daily for 5 days; [2] micronized P (100, 200, or 300 mg) once daily under fasting conditions for 5 days; and [3] micronized P (200 mg) or intramuscular P (50 mg in oil) administered once daily for 2 days.
MAIN OUTCOME MEASURES:
Serum P concentrations were measured in all groups.
RESULTS:
Concomitant food ingestion increased the area under the serum P concentration versus time curve (AUC0 to 24) and the maximum serum P concentration (Cmax) without affecting time to maximum serum concentration (Tmax) (P < 0.05). Micronized P absorption and elimination were first-order processes and exhibited dose-independent pharmacokinetics between 100 and 300 mg. After intramuscular P, Cmax was higher and Tmax occurred later compared with the oral P preparation. Oral P had lower relative bioavailability (8.6%) than intramuscular P.
CONCLUSIONS:
Absorption of micronized P was enhanced twofold in the presence of food. Both absorption and elimination were dose-independent, dose proportionality being confirmed. Bioavailability of the oral P was approximately 10% compared with intramuscular P.
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Oh Andius - I wish I understood most of that!!?? It very clearly states in the instruction leaflet that Utro should be taken on an empty stomach before bed. I think this study implies that more might be absorbed if taken with food so if that is the case surely one could take it with a snack close to bedtime to actually enhance the effectiveness of a lower dose?!
I have to say this is a very old study and perhaps further studies showed different or negative results.
I know that certain drugs/medications need to be taken on an empty stomach while others should be taken with food - one can take most synthetic progesterones with food (probably preferable) but Utro seems unique in this aspect. I know that many women are using Utro vaginally because it gets absorbs more directly to the area that needs it. This study seems to include an intramuscular preparation as a comparison - what a shame this doesn't exist as an alternative to pills? This is a french study so maybe there is a transdermal version of Utro there? The French do seem to be ahead of the game in some respects when it comes to HRT.
Maybe food encourages not just a faster absorption but also a faster elimination which could also be an issue.
I did question the importance of taking Utro on an empty stomach with my gynae and he actually didn't know that this was how one had to take it!!
I wonder if the dizziness was that much stronger when taken with food? Perhaps it absorbed in the wrong way?
The conclusion doesn't make sense to me really.
Very interesting though. It might be worth trying a little snack at bedtime. DG x
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Re utrogestan and absorption with/without food - this has been discussed several times on here!
Here are some threads:
http://www.menopausematters.co.uk/forum/index.php/topic,26651.0.html
http://www.menopausematters.co.uk/forum/index.php/topic,27722.msg433090.html#msg433090
http://www.menopausematters.co.uk/forum/index.php/topic,26334.msg406200.html#msg406200
In one of them I found a study from 1999 (which I haven't read in detail!) and which quotes the 1993 study you found andius.
http://www.mialundin.se/wp-content/uploads/2012/02/Micronized-progesterone-and-endometrial-cancer.pdf
After a very quick skim through it seems that serum levels of progesterone are increased when taken with food which could give rise to more side effects - but this effect is minimised if taken at bedtime so that you are asleep! I don't actually think women need to worry about the empty stomach thing - just be aware that there may be more side effects - you can't overdose on it at this level.
Re the French study - it is licensed for use vaginally in France and the French instructions permit this. I sent for information a few years ago and the manufacturers sent me a couple of papers about it.
Dancinggirl you mentioned also earlier wondering why you are experiencing spotting with such a low dose of gel but I think you might have answered that question yourself! You say you absorb gel very well and achieve high oestrogen levels with only a small amount of gel - so in your particular case - it may not be such a low dose. In a one size fits all scenario we clearly vary and also body size must come into it. If you are small and light with little body fat ( not sure where you fit in here Dancinggirl - I suspect as a dancer you are light!) then I would imagine that a given amount of gel will give higher serum levels of estradiol and therefore deliver more to the uterus.
There was a discussion somewhere about how much is absorbed on another thread so I think I'll take a look there too if I can find it!
Hurdity x
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Thank you everyone.
Hurdity - I'm not that small any more - used to be 7.5 stone ( sometimes less) in my dancing years and probably underweight - I dread to think what I weigh now - I don't believe in weighing scales - I tend to go on the fit of my clothes but I know I'm not much overweight as I think I've just rounded up a bit all over - in fact being back on HRT has improved my muscle structure as I get more exercise and of cause muscle in heavy.
My spotting has stopped over last few days so maybe things are settling?!!
JoyceBarnaby - interesting that you find you want to kill people on Utro - I got that on the synthetic progesterones but Utro makes me feel really chilled. It struck me the other day that I'm feeling as I did in the mid trimester of my pregnancies - calm, positive and serene - long may this last.
Dg x