Menopause Matters Forum
Menopause Discussion => All things menopause => Topic started by: Eastside on May 04, 2025, 04:18:16 PM
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Hi all. I hope you are well. I finally succumbed to trying HRT: Evorel 50 and 200mg Utrogestan cyclically. It's only the first month, so I'm not totally sure what to expect. I finished Utrogestan on day 26, which was 4 days ago. But no bleeding of any kind yet. I have painful boobs, which is normal, but that's it. My periods were always quite regular anyway. So I'm getting a bit twitchy. Perhaps this is normal at first to have delayed bleeding or no bleeding? Also, I'm now very confused about what I should consider as day 1 of my new cycle, as I haven't bled yet. Does anyone have any thoughts? Many thanks!
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Hi,
I am also on the same dose of utrogestan as you with a 75 Evorel Patch, and since increasing to this level one month ago I’ve completely missed my period that was due 2 weeks tomorrow. I’m not pregnant as I’ve tested a few times but my boobs have been sore also. I wonder if that’s a side effect. I’m thinking it might take a little while to settle down
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Thank you for replying. Hmm, perhaps so. I just find there are lots of information gaps like this. The Utrogestan leaflet just says you will normally have a few days' withdrawal bleeding after this time e.g day 26. It also says elsewhere in the leaflet 'you will have a bleed once a month'. It doesn't say when, or the normal window in which to expect that, what to do if it doesn't happen, and what to then count as your next cycle if you don't bleed. I've just spotted elsewhere on the leaflet it says "you might get some bleeding at the end of each month, like a period'. So which is it? Who wrote this thing?!😊
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Yes I agree it’s not really clear is it! We aren’t told adequate information I don’t think. I wasn’t even told when I first went on HRT not to stick the patches above my waist. Yes it’s on the information leaflet but 9/10 people don’t read it all and I would have thought with the risks etc a GP would think to relay that information to a patient in the surgery. I’m thinking also maybe with periods they are all over due to the fluctuations in peri anyway so even HRT may not regulate this to once a cycle at the end of the progesterone dose.
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Oh gosh, you should have been told that. Mind you, come to think of it, I wasn't either! I scrutinised the info leaflet.
There is another forum post on a similar topic https://www.menopausematters.co.uk/forum/index.php/topic,66654.0/prev_next,next.html#new
if that's the correct link. Not sure it exactly answers the question, though. Although the poster said she had a bleed after 5-7 days or something. As for me, my periods were always quite regular, give or take a few days, up until a month ago, so I'm presuming any irregularities are down to the Utrogestan.
I am loathed to bother the GP/nurse again, but I kind of feel I may want to do it out of principle now as I think there shouldn't be so many important info gaps leaving us guessing and making possible errors. If I find out anything else, I'll post it.
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Thank you, I’ll have a look at that other post. It does seem fairly common, especially if your periods were regular before starting HRT. Mine were too, and even when I started on Evorel Sequi (50 and conti) my periods still came when they were meant to it’s just this first one since the increase I’ve missed. Don’t worry about bothering your GP, it’s their job plus even if it’s just to put your mind at rest :)
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Thank you. I just wish we weren't left guessing. I read the leaflet again and it does list lack of periods/irregular periods as a side effect - for other HRTs rather than Utrogestan. It also says to talk to a doctor or pharmacist about any side effects.
Also found this online on NHS. If I was reading between the lines, I would maybe think that you ignore whether you've had a bleed or not, in terms of calculating the dates of your monthly cycle, and just go with 28 days, whether you have a bleed or not. But, that could of course be wrong:
Sequential combined HRT is taken in 28-day cycles. This means that you take oestrogen every day, but you only take it with progestogen for 10 to 14 days of your cycle. You then repeat the cycle without a break.
You'll usually have withdrawal bleeding at the end of each course of progestogen.
And this from the NHS suggesting one should have a bleed:
Sequential combined HRT
You'll usually be recommended to take sequential (cyclical) combined HRT if you have menopause symptoms but still have periods.
There are 2 types:
monthly HRT if you're having regular periods – you take oestrogen every day, and take progestogen alongside it for the last 10 to 14 days of your menstrual cycle every month
3-monthly HRT if you're having irregular periods – you take oestrogen every day, and take progestogen alongside it for around 10 to 14 days every 3 months
You should have a period at the end of each progestogen cycle. If there is no bleeding at these times, speak to your doctor.
If you started on sequential HRT during perimenopause your doctor may recommend changing to continuous combined HRT post-menopause.
So my conclusion is to wait until Tuesday and then, if no bleed, get on to my GP!
I do hope something falls into place for you
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I've submitted an enquiry to the company that makes Utrogestan (Besins Healthcare). I'll post any reply of any use. I just have zero tolerance for shoddy information provision these days! 😂
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Why question good fortune?!
Not everyone bleeds when they "should", or at all, on sequential hormone therapy.
If you have finished the course of progesterone, just start counting again from day 1, rinse and repeat.
If you find you are largely bleed free after several months to a year on this regimen, you could consider moving to continuous progesterone at 100mg daily.
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Thank you! It's great that you've been able to find out that not everyone bleeds. I've only seen patchy/mixed info about that, which is exactly my point. According to an NHS site I saw, I should be having a bleed..so who knows 🤔😜
Sadly, it's not really good fortune for me as I feel like crap, have extremely painful boobs and a stomach ache. But, you can't have everything, I guess. 😂 Thanks again for replying
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I suppose it does say you “should” have a bleed ie not everyone does. Hopefully it’s just our body getting used to the increase in hormones and things will settle. I too feel bloated, sore boobs and achy like I want to come on, it just hasn’t happened. Like bombshell said I’ve just started again counting from day 1 when I stopped the progesterone and will see what happens again next month. Let us know if you hear back from the company I’d be interested in their response.
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If you have a cycle of your own it's very likely your own cycle will determine when you bleed, I found my own cycle was always stronger than the hrt one. Medical advice is to stick to the 28 day cycle regardless of when you bleed but I started counting again on day 1 of my bleed, otherwise the two cycles get further and further out of step.
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Thank you both. Ok that's useful to know about counting day one as being after you stop progesterone. That's also interesting to hear about the natural cycle taking precedence. Mine tend to come early rather than late, so according to my natural cycle, I'm two days late. So I'll see what happens and will post anything further I find out.
I hope you feel better soon, LittleClaire
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Eastside, one major reason many women don't bleed on HRT is because they are not taking enough estrogen. 50 is a pretty low dose of estrogen. There is mass hysteria around estrogen in traditional menopause care and the upshot of that is tiny micro doses of estrogen (much less than a woman would have pre-menopausally in a normal cycle and much less than even in the combined pill, although that is synthetic) and then usually a heavy-handed dose of progesterone....
The end result is estrogen receptors get down-regulated from continuous progesterone use when women use that (which is not something ever occurring naturally, since we only make progesterone at ovulation and have it for half the cycle) and the tiny dose of estrogen in licensed doses of HRT means that not enough endometrial lining is built up to be shed when you then stop the progesterone.
I experienced all this myself. Only when I increased my estrogen to around 400-650pmol did I begin to bleed again. If you're not taking enough estrogen to cause a bleed, then you also won't be taking enough to get the other growth proliferative benefits of it. If you want to check out this perspective in more detail, look up Dr Felice Gersh on YouTube especially her estrogen dosage video there.
Having said that, it can take up to 5 nights off utrogestan before you start to bleed. That's what it routinely takes for me, at the moment.
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Thanks so much joziel. There's so much to learn. Before starting HRT I was having very regular, fairly heavy in part periods. So there must have been enough of a balance. The nurse did explain that I was on a low dose, and that was much lower hormone ratio than I would have had in my 30s. I think it's probably worth getting back in touch with them if no bleed after today (today is day 5). Like you say, the balance might be off, or perhaps I don't really need it at all. I was deffo having some symptoms, but I only went on HRT to try to establish what might be hormonal and what might be psychological, given I have previous trauma and generalized anxiety. So far, after a month, HRT has made little, if any, difference. Anyway, thank you. I'm sure it'll become clear at some point! 🤪
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I think you probably need a higher dose rather than stopping. It's normal for younger women to need higher doses....
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Thank you. I've messaged my doctor this morning as I've just had enough of second guessing. I do have the tell-tale ovary ache today so maybe it's coming and my body is just readjusting.
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If you are under 50 and very keen on having a regular bleeding pattern then a combined pill taken in the standard 21/28 regime may be a better option for you.
Alternatively you can just take the combined pill every day without a break like I do and not bleed at all 😁
There are multiple options, I personally am not a fan of sequential HRT in peri as it causes a while world of chaos and angst over bleed pattern.
Probably 50% or less of women experience the clockwork 28 day cycle they were expecting on it - trying to time it with a perimenopausal cycle is like trying to time the stock market.
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Just be aware that you could bleed heavily so have sanitary protection with you wherever you go. Once you finish the utrogestan days, consider the next day as day 1. Waiting for a period to start in order to count that from day 1 is not a good idea as your bleeds could be erratic and you need to know you are getting your 12/15 days of utrogestan per 28/30 days, regardless of bleeding.
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Thanks so much guys. Thankfully a bleed arrived yesterday after 7 days. So far it's lighter than usual, but more painful 🤔.
I'd already sent my message to the GP. He called this morning and said my questions were very valid, which was validating!
He asked me questions about my periods before HRT, why I went on HRT etc.
His conclusion was that I was on the right HRT regime, that our bodies can take some time to adjust, especially at first, and that day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed. So it just needs reviewing after 3 months.
I'll update you if I hear back from the manufacturer.
I'm sad that I had to bother my GP surgery again, but I just felt it was necessary. I don't think women should be left flailing around in the dark unnecessarily, and I simply don't have the tolerance I used to for pretty much anything, including inadequate information provision on important matters 😁!
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bomb, it's not my experience at all that utrogestan in peri causes erratic bleeding at all. Women just need to be empowered to use it to fit with their cycle instead of in some robotic way....
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Reply from the Utrogestan manufacturer, in case of any interest to anyone:
While a withdrawal bleed can occur, there is no guarantee this will happen in all individuals as bleeding patterns may differ depending on various factors. Therefore, we cannot specify a specific timeline to expect a bleed apart from what is mentioned in the PIL ‘you might get some bleeding at the end of each month , rather like a period’ - as stated in section 1 ‘What Utrogestan is and what it is used for’.
Regarding your query about when/how to calculate a cycle length. The cycle is typically 28 days which essentially mirrors a menstrual cycle. A new cycle is considered to begin on day 1 of the regimen, not necessarily in the first day of a bleed. The cycle would continue regardless of whether a bleed occurs or not. Bleeding (if it occurs) tends to be a response to hormonal changes but does not determine the start of a new therapeutic cycle.
While a common side effect of the progesterone capsules is irregular or intermenstrual bleeding and vaginal bleeding. It is important to note that in section 2 ‘What you need to know before you take Utrogestan’ it states the following:
“Unexpected Bleeding
You may have irregular bleeding or drops of blood (spotting) during the first 3-6 months of taking this medicine. However, if the irregular bleeding:
Carries on for more than the first 6 months;
Starts after you have been taking Utrogestan more than 6 months;
Carriers on after you have stopped taking Utrogestan;
You should see your doctor as soon as possible.”
We hope this information is useful and do not hesitate to contact us again if you require anything further.
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"day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed."
Er, that bit is rubbish Eastside. Look, rather than contacting the (clueless) manufacturers and (equally clueless!) doctors (going by that statement), why don't you do what most of us do, and listen to the educated menopause doctors online who know what they're talking about?
Day 1 of your cycle is the first day you bleed. This is not going to be the day after stopping progesterone for 99% of women. Body identical hormones do not override your natural cycle if you are still getting one. They need to be taken to complement your cycle. Having said that, after you stop utrogestan, it can take 5-6 days (might be 7 for you) for a bleed to start. The progesterone levels need to drop enough that the process of shedding the lining is started. That doesn't happen instantaneously, because we're talking hormones here...
The only thing you need to be concerned about, is that you are getting 12 days of progesterone in, for each cycle. Whatever your own cycle is, you need to start it early enough that you get the 12 days in. Someone whose cycle is 23 days, will need to start it on day 12. Someone whose cycle is 35 days might start it later. Use it to fit with your cycle. If you consistently bleed early, you need to stop taking it to allow the bleed - but note the day your bleed started and start taking it earlier next cycle so you get it all in. But when you stop it, there will be a no-(wo)man's land of many days before the bleed starts.
By the way, in some patronising way, this is considered WAY too complicated for women to understand. Which is why we have the Mickey Mouse dosing we currently have and all the inadequacies that go with it.
The other thing personally I'm concerned about, is ensuring that you are absorbing enough of the progesterone to provide uterine protection. The UK doesn't care about this and prescribes blanket levels of it, and can't even test because it's taken orally and that invalidates the results. I take mine vaginally so that I can use UK tests to get a reliable result and know that I am taking enough. By the way, even 300mg vaginally at night was NOT enough. I had to increase by adding in 200mg vaginally in the morning as well to get my levels to offer me the protection I need.
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"day one of the cycle is indeed the day after stopping progesterone, regardless of whether there is a bleed."
Er, that bit is rubbish Eastside. Look, rather than contacting the (clueless) manufacturers and (equally clueless!) doctors (going by that statement), why don't you do what most of us do, and listen to the educated menopause doctors online who know what they're talking about?
Day 1 of your cycle is the first day you bleed. This is not going to be the day after stopping progesterone for 99% of women. Body identical hormones do not override your natural cycle if you are still getting one. They need to be taken to complement your cycle. Having said that, after you stop utrogestan, it can take 5-6 days (might be 7 for you) for a bleed to start. The progesterone levels need to drop enough that the process of shedding the lining is started. That doesn't happen instantaneously, because we're talking hormones here...
The only thing you need to be concerned about, is that you are getting 12 days of progesterone in, for each cycle. Whatever your own cycle is, you need to start it early enough that you get the 12 days in. Someone whose cycle is 23 days, will need to start it on day 12. Someone whose cycle is 35 days might start it later. Use it to fit with your cycle. If you consistently bleed early, you need to stop taking it to allow the bleed - but note the day your bleed started and start taking it earlier next cycle so you get it all in. But when you stop it, there will be a no-(wo)man's land of many days before the bleed starts.
By the way, in some patronising way, this is considered WAY too complicated for women to understand. Which is why we have the Mickey Mouse dosing we currently have and all the inadequacies that go with it.
The other thing personally I'm concerned about, is ensuring that you are absorbing enough of the progesterone to provide uterine protection. The UK doesn't care about this and prescribes blanket levels of it, and can't even test because it's taken orally and that invalidates the results. I take mine vaginally so that I can use UK tests to get a reliable result and know that I am taking enough. By the way, even 300mg vaginally at night was NOT enough. I had to increase by adding in 200mg vaginally in the morning as well to get my levels to offer me the protection I need.
I disagree regarding the progesterone. You cannot necessarily tie a cycle in with your HRT regime. If I bleed today and consider it to be day 1, my next bleed may not happen for 40 days, and the next cycle 50 days. If I only take progesterone after counting from day 1 of those bleeds then chances are I'm not getting enough progesterone. In peri periods can be erratic and that is why you are better to take your HRT in its own cycle of 28/30 days and not be relying on a period to start so you can start counting that as day 1.
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Hnm. Interesting. Thanks so much for your perspectives. I obviously haven't got a clue, which is why I have tried to find answers.
What happens if you don't bleed at all, though, given that I've been told that not all women bleed after progesterone?
Anyway, I do thank you and I'll try to process it all and take it on board.
Do you have examples of educated experts I can look at online? I'm aware of some, but also thought there was some controversy surrounding them as well. But maybe that's propaganda. I haven't got the budget to see anyone privately, unfortunately.
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I think you need to apply common sense here. If your periods are erratic and irregular it makes sense to stick to the 28 day schedule. If you have a strong cycle of your own (and particularly if your normal cycle isn't 28 days) it makes more sense adjust the hrt to your own cycle. If you regularly don't bleed you could be ready for a conti regime.
The 'unexpected bleeding' comment from the manufacturer may be true for post meno women on a conti regime but they're living in cloud cuckoo land if they think your own irregular or unsynchronised cycle is suddenly going to become regular just because you're using utro, it isn't strong enough to override your own hormones.
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Grace, if you are taking enough estrogen, then you WILL bleed.
Fact.
You will either bleed randomly and erratically with breakthrough bleeding (because you are trying to take your progesterone continuously) OR you will schedule the bleed by stopping the progesterone to cause it to happen, so you know it is happening due to the progesterone being withdrawn and not for any other more concerning reason.
So if you bleed today and consider it to be day 1 and then your next bleed doesn't happen for 40 days or 50 days - despite you stopping your progesterone for it to happen - then it means you are not taking enough estrogen. Take a look at the work of Dr Felice Gersh on YouTube for more information, especially her video on estrogen dosing. Or join the FB group called 'Bio-Identical Hormone Therapy' which has flowers as its icon. It's one of the largest FB groups for HRT and is US based along the lines of optimal HRT and not micro-doses at suboptimal levels.
Estrogen is proliferative. That means that IT WILL cause endometrial build up, if you take enough of it.
And you want to take that much of it, because you need those aspects of it - it is about cell turnover, anti-aging and mitochondrial health amongst so much else. If you are not taking enough to cause endometrial build up (to the point that nothing comes out when you stop progesterone) then you are also not taking enough for all those other health benefits, at optimal levels.
Eastside - yes, see Dr Felice Gersh on YouTube and Instagram (she has longer videos on YouTube). And as above, if you don't bleed (when you stop the P, given enough days for the hormone shift to happen) then there hasn't been enough build up which means the estrogen has been too low. (This happened to me, by the way.)
Conti regimes are dead in the water as far as HRT goes. At no point, ever, in our entire life cycle, do we continuously have progesterone. Never. It is not bio-identical to take progesterone continuously. The only way it can happen (without bleeding) is when the estrogen dose is so low, there is no build up happening and the progesterone is heavy-handed and suppressing that. In which case, you are not getting the other benefits of the estrogen elsewhere in the body either. Continuous progesterone down-regulates the estrogen receptors as well.
You have to understand that HRT (and the guidelines and the info on the packets etc) is still based on the mass hysteria originating from the WHI. Even now that doctors are begrudgingly prescribing HRT again (in many cases), they are doing so with great nervousness around estrogen, being worried about too much of it, and as if it is somehow dangerous. It results in micro doses which may well reduce the baseline risk for various health conditions, over someone who doesn't take ANY HRT, but it's not 'optimal' because they are scared of it. So the approach is these tiny micro doses of estrogen and heavy handed huge doses of progesterone (partly because they can't even test levels of progesterone accurately in the UK since most women take it orally). There is far more estrogen in the combined pill they happily prescribe everywhere like smarties, (albeit synthetic estrogen) than there is in standard HRT doses, yet they don't even realise the hypocrisy of this....
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If you look at the history of menopause hormone therapy, it was initially just estrogen alone, then when that started to result in increased rates of endometrial cancer, it was realised that a progestogen had to be added if you have a uterus.
At that time, around the 1970s, hormone therapy was exclusively given to postmenopausal women. If you were still having periods, you were imagining your symptoms and if you were lucky you got some valium. The word perimenopause may or may not have existed, but was seldom used.
The progestin, which in those days was medroxyprogesterone acetate, was given in a cyclical regime, to these postmenopausal women, to patronise them with an artificial menstrual cycle.
There were no known health benefits to withdrawal bleeding (although much more recent evidence supports benefits of not taking the progestogen continuously) it was done for paternalistic reasons only at that time.
It stopped the endometrial cancers but had high discontinuation rates as women didn't want their periods back.
So in the 1990s the progestin started to be given continuously alongside estrogen to avoid the fake periods.
Nobody then knew what to do with the fixed dose combined sequential preparations, mainly Prem-pro that had been expensive to patent, so it was decided cyclical HRT should be given to perimenopausal women with symptoms, because of course we all have a 28 day cycle right?!
The point is that cyclical HRT was never developed for use in perimenopause, it was repurposed for economic reasons with the assumption but no actual evidence that it would result in a regular 28 day bleed pattern.
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Wow. That's fascinating to know that history. I don't think I would have liked to have been around in those early days. It's hard enough now! It obviously is a bit of a minefield, and a journey for us all.
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Hello,
I am very interested in this thread - not because i have anything useful to add, more because i have always wondered about bleeding, because i hardly bleed.
I've been on hrt for maybe 3 years, love being on Oestrogen, but absolutely hate the Utrogestan part. So i only took it every 3 months. I know not good, My meno doc increased my oestrogen, i felt great, still couldn't face monthy utro, so i buried my head in the sand took my high dose of oestrogen and 3 monthly utro for 12 days. I never blead more than a drop for 1 day.. Couldn't even call it spotting. I have had a scan and my lining was thin.
I've had 2 children, always had very light periods, in peri my periods got even lighter.
Is it possible that some women just dont bleed that much?
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Yes, absolutely some are lucky and can get away with a course of progestogen every 3 months.
Unfortunately though there is no way to tell who is going to be fine on less progesterone and who is going to develop hyperplasia, and as the NHS doesn't have the resources to scan everyone, they just have to err on the side of caution and have everyone on the dose that is known to protect even the highest risk women, usually in a continuous regime once postmenopausal.
Whilst this avoids endometrial cancers, it also means many women are over treated with progesterone.
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Thank you for your reply, there's so much scare mongering that goes on, i sometimes get panicky.
I'll keep doing what I'm doing and get regular scans.
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Banjo, it's very possible you're not absorbing that estrogen very well. I'd want to get bloods done and see what your serum levels are. You want them to be at least 300pmol+ to get the health benefits of HRT.
Personally, on 3 pumps of gel, my levels were around 180pmol. I also wasn't bleeding - because I wasn't getting enough estrogen to cause any build up.
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Last time i was tested they were over 400 and i wasnt bleeding them either. I'm pretty sensitive to the effects of low estrogen as i get hot feet snd brain fog so i adjust id accordingly.
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Hi Joziel,
Judt checked it, it was 587. Like i said, i am very sensitive to low estrogen so i kind of know when things aren't working. When my boobs feel full, my orstrogen is good, when my boobs deflate and my energy and mood is low, then i know i need more orstrogen
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Hmm, it could still be worth doing a check. I mean, your body can put out a spurt of it even early post-meno...
On the same dose I've had between 640 and 890pmol, for eg.
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I mean it's possible, but i always can feel low estrogen vsry very quickly so i don't believe it was a rogue result. Maybe some people dont need much progesterone because their lining doesn't build up?
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When I was on Evorel Sequi with the level 50 patch, I had a bleed when I finished the progesterone part. Since increasing to Evorel 75 and 200 progesterone pill I haven’t bled since, so does that still mean I’m not getting enough oestrogen even though it’s higher than the previous dose I was on? Granted I’ve only missed one period so far but I’m definitely not pregnant, so I need to increase oestrogen again to bleed?
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The only way you can tell for sure is to test your levels. If you do have a cycle, I usually test on day 3 for estrogen - because it's when my own is most likely to be lowest so I'll best see what I'm getting from HRT. But if you don't have a cycle then just any time... I also test every 3-4 months at the moment and don't 'believe' any one test result (due to my own fluctuations).
It might mean for example that your are absorbing your increase in progesterone really well, which is opposing the increase in estrogen...
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I don't really have the time/energy nor funds to get tested regularly. My body really does give a good indication of my oestrogen levels. My periods were pretty much always very light, and got lighter as i hit my 40s.
Maybe sone women just dont bleed much, if at all?
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Assuming you're getting enough estrogen, and assuming you haven't had an endometrial ablation or some other procedure to stop bleeding, you should have a bleed.
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I would say the estrogen should be adjusted to meet your needs and therapeutic goals ie all estrogen sensitive tissues in your body are functioning optimally.
Unless you are getting any therapeutic benefit from the progesterone, I believe the lowest dose that keeps your endometrium healthy is best, and there is evidence that certain longer term outcomes eg cardiovascular, brain, breast health are more favourable when it is not taken continuously.
Any withdrawal bleeding that occurs on a cyclical regime is just cosmetic, it is not an ends in itself and treatment that is working well for you doesn't need to be altered just for the sake of chasing an artificial bleed.
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I totally agree Bombsh3ll.
I've always felt that progesterone dosing is 'one size fits all' and maybe there are a few people who react badly to it because they just don't need that amount. Maybe my body makes it's own progesterone. Maybe my lining doesn't thicken. Who knows?!
As long as i get scans to check I'm not putting myself at risk, I'm going to keep up with my regime.
Thanks again x