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[Autumn27]

I thought I'd post an update:

Unfortunately at my Meno Clinic I only got to see a research fellow, not one of the main consultants who are more experienced. She is the one who has been talking to me on the phone.

She wanted me to up my continual Utrogestan to 300! I can barely cope with 200. It's that or the Mirena Coil. Which I really don't want.
No further investigations have been arranged.

I had recently decreased my patch to the original 75 and Utrogestan to 100, in an attempt to stop the bleeding, and it worked for a week. But now the bleeding is back.

I have no future Meno Clinic appointments until April, the GP doesn't know what to do, and I have to decide for myself.

Meanwhile I have a busy, full time stressful job to contend with.

I have no answers, no one does!

[Conolly]

Hello Autumn27,

So sorry your appointment wasn't helpful. Did she tell you why she want to up Utrogestan to 300 mg? What about oestrogen?

Thank you for the link above, very helpful.

I have already told you my opinion based on that article, ie decrease both oestrogen and progesterone until the bleeding stops and after that increase them gradually if symptoms are not controlled or to help with osteopenia. It's clear that your body is not coping with this regimen.

Conolly X

[Autumn27]

Hi Connelly,

I did decrease both Estrogen and Progesterone, and the bleeding stopped for one week, then started again.

The woman I saw suggested 300 of the Progesterone to counter the Estrogen.

Thanks.

[Conolly]

Hello Autumn27,

I don't get it. If you have to increase progesterone to counteract oestrogen, wouldn't it be wiser to decrease oestrogen instead? You have gone back to your previous regimen, 75 patch and 100 mg Utrogestan, right? After so many years on this regimen I would decrease to 50 patch and 100 mg Utro.

Also, increasing prog to counteract oestrogen would be useless regarding the osteopenia. Are you on other medication or exercises for that?

Conolly X

[Hurdity]

Hi Autumn27

Thanks for the update

Sorry to hear that you have not had satisfactory treatment from the menopause clinic and you had to see someone less experienced.

I quite understand your not wanting to increase the progesterone further. Most women do not want to take this high a dose - with the exception of women undergoing fertility treatment who take high doses vaginally - but this is for an entirely different purpose so a clear greater willingess to put up with side effects if a baby could be the outcome!

Are you using 200 mg vaginally?

Normally when using continuous combined HRT, as you know eventually bleeding stops for the majority of women and especially if post-menopausal and should be invesitgated if not. There is cearly something amiss with the way the uterus lining is dealing with the effect of progesterone.  From what I've read, under the influence of oestrogen and progesterone, different parts of the endometrium can be proliferative ( the effect of oestrogen alone) as well as secretory (the action of progesterone on the stimulated endometrium) and when this all works properly - there is no bleeding.

Often when it's not working and the balance of oestrogen and progesterone is out of whack - the lining can thicken and can cause spontaneous bleeding as these thickened parts of the endometrium break away. Abnormalities such as fibroids and polyps and as I understand (I think) - adenomyosis - can also cause bleeding.

As your lining was not thickened then this can't be the case - however as I suggested in my previous post I would still ask the GP to refer you for a hysteroscopy - not involving the menopause clinic - especially if you are not able to tolerate such a high dose of continuous progesterone.

Once this has been done then take it from there.

My suggestions thereafter and provided all is OK, are firstly as the menopause clinic - a Mirena coil, or as I suggested earlier - going for a cyclical regime when your bleeding will be most likely predictable. To start with you would take 200 mg utrogestan 12 days per cycle and see how you got on - and would be good to have your doc's approval of this  - at least if s/he doesn't seem to have much of an idea you can propose what you would like to try!

Hello Autumn27,

I don't get it. If you have to increase progesterone to counteract oestrogen, wouldn't it be wiser to decrease oestrogen instead? You have gone back to your previous regimen, 75 patch and 100 mg Utrogestan, right? After so many years on this regimen I would decrease to 50 patch and 100 mg Utro.

Also, increasing prog to counteract oestrogen would be useless regarding the osteopenia. Are you on other medication or exercises for that?

Conolly X

Conolly - just to explain - the progesterone does not counteract the oestrogen in the way you are thinking. The systemic levels of oestrogen and its effect on target tussues - such as its effect on bone resorption  - is entirely dose dependent, and independent of the progestogen which does not diminish it (and from what I dimly recall some prog preparations may even enhance it ie oestrogen + prog combo had even greater positivie effect on bone density in one study - but I might be remembering that wrongly!). Progestogens are only used to "counteract" oestrogen with respect to endometrial protection and as such, in a dose dependent manner.

Autumn27 has been told she is osteopenic despite 75 mcg patch and testing of oestrogen levels confirm lack of absorption. Therefore her bone health will only be improved by an increase not a decrease in oestrogen ( systemic levels) and it is stemming the bleeding to enable higher oestrogen levels to be achieved which is the main focus of any future treatment.

Hurdity x

[Conolly]

Hello Hurdity,

Thank you for the explanation, but that wasn't my point (maybe I have expressed myself poorly). I was thinking about what Autumn27 had already stated in her first post:

"For the first time in August I had a bit of light bleeding. The clinic gave me an ultrasound, my womb was OK so they upped my Estrodot patches from 75 to 100. All seemed good, but then after a few weeks, bleeding started again.

A doctor I spoke to over the phone upped my micronised progesterone, from 100 to 200. I had a phone call appointment in a month's time.

In that entire month I bled more than before. I also didn't feel too good on the new regimen of continual high dose Progesterone and increased Estrogen. I was worn out by the bleeding.,"

Increasing progesterone and oestrogen has already been tried and it didn't work. Increasing progesterone further won't be a good idea, first because it won't address the osteopenia that clearly hasn't changed on the 75 patch and second because it has many adverse side effects.

Not all osteopenia is caused by low oestrogen levels. If Autumn27 has an oestrogen absorption issue, increasing to 100 patches would not make a big difference and it would need extra progesterone.

That's why I said that decreasing oestrogen to address the bleeding, which is Autumn27 main complaint, would be wiser, and just after her endometrium had achieved a proper balance, ie no bleeding, further action could be taken regarding osteoporosis, even a change of HRT.

There is this almost unanimity regarding oestrogen, that the more the better. I find it disconcerting because my worst days pre-menopause were when I had extremely high oestrogen levels which triggered migraines (much worse than hot flushes) and they certainly have increased my breast cancer risk, so maybe it is time to forget the hype and think wisely because you don't want to get rid of hot flushes and osteoporosis (again, not primarily caused by oestrogen deficiency) at the expense of other future problems (including hemangioma). That's why professional guidelines are reticent when it comes to long term use of high doses of oestrogen after years of menopause, there aren't sufficient long-term studies to sustain such claims. Of course, in the end it's a personal decision.

Conolly X

[Autumn27]

Hi Both Hurdity and Connolly,

Thanks so much for your thoughts on this.

Conneolly, I take your point, but as I am not absorbing the oestrogen on the 75, in my opinion decreasing any further would make no difference to the bleeding. My blood levels showed barely a trace of Estrogen. On the 100 Estradot and 100 Pr I felt a noticeable improvement in wellbeing- until bleeding started in earnest 3 weeks later.

In answer to your suggestion Hurdity, at the clinic I asked about switching to cyclical treatment, but the research fellow woman said no, they didn't do that with women who were post menopausal by x years. She wouldn't discuss it further.

I am taking 200 Progesterone vaginally, because I tried orally and felt bad on it. At the same time vaginally not great either. I don't know which method absorbs more? Apparently orally you absorb just 10% of micronised progesterone(I read somewhere)

I don't know which is the higher risk thing for me-mirena coil or synthetic progestin. Neither are things I want. Yet I can't sustain this bleeding.

I have a GP appointment  on the 25th but am wondering if I can get an emergency appointment before then. I will ask about a hysteroscopy, maybe I can get a referrel to a gynea clinic.

If I tried a synthetic progestin, are there any recommended ones? At least that could work in the short term I suppose.

[Conolly]

Hello Autumn27,

I understand that having a Mirena coil or switching to Evorel conti patches (the progestin is norethisterone) is not going to make any difference regarding risks. I would prefer Evorel conti patches, because I can't even think of the coil, but that's me. You can also try Estradot patches and Utrogestan but then you would have to put up with a bleed (sequential Utro) or take it continuously (I couldn't stand it, had suicidal thoughts).

Do you have any idea if you have polyps or fibroids? I guess you will find out anyway after hysteroscopy. If polyps are the source of your erratic bleeding you could have them taken out during hysteroscopy (make sure to tick that option beforehand), if you have fibroids, then Mirena coil is the best option because it helps to shrink them.

I really hope you can find a definite solution for the erratic bleeding. Hugs.

Conolly X

[SueLW]

Hello Autumn27

I think your body has had enough of the Utrogestan.

I switched to Oestrogel and Utrogestan 100, initially ever other night vaginally, 6 months ago. I felt great for about 3 weeks. So much better than previously on compounded bioidentical hormones. Then the bleeding started. And wouldn't stop.  I'd stand up and feel it running out of me.  I had PMT symptoms aplenty. Bloated, water retention, exhausted, emotional. I spoke to my private specialist and she said to increase the Utrogestan to every night. I did. The bleeding stopped for a week, perhaps 10 days and then restarted. And with the exception of a few days here and there I've been bleeding ever since. It has a pattern, I bleed heavier during the day, less in the evening and hardly at all at night.  I know what you mean about exhausted, I've basically been having a pretty heavy period for 6 months!

My doctor says Utrogestan doesn't suit me, that it suits many women, but not all by any means. And therefore I must change. There is another progesterone they would recommend, it begins with P, but I don't remember the name right now. But I'm having a Mirena coil fitted in a months time. It can't come soon enough. I've had one in the past for BC.  It took about 4 months to settle, then it was fine. No bleeding at all for me. I'm hoping history repeats itself.

I have family history for thinning bones so I want as much oestrogen as necessary to keep my bones strong. I too haven't been absorbing the gel very well, so I either need more of it or a combo of a patch and gel.  But it's impossible when loosing this much blood and having almost continuous PMS, to try that.

Why are you against a coil?

[Autumn27]

Hi Sue,

Thank you so much for sharing your experience. 6 months of bleeding must have been awful. I a heading in that direction, and I have arrived at a similar conclusion about Utrogestan and my body's reaction to it after 7 years of continual use.

Re the coil, it's the real fear of all the things that can go wrong, sepsis, coil getting lost in body, the pain of insertion, that it may not stop the bleeding anyway. I have a slightly inverted (backward facing) cervix, and have never had children, so it wont be a straightforward insertion. A colcoscopy in the past was incredibly painful and took 3 different nurses to do it.

On top of that I am keen on the idea of only using bioidentical hormones, and not synthetic progesterone as in the coil.

[Autumn27]

Hello Autumn27,

I understand that having a Mirena coil or switching to Evorel conti patches (the progestin is norethisterone) is not going to make any difference regarding risks. I would prefer Evorel conti patches, because I can't even think of the coil, but that's me. You can also try Estradot patches and Utrogestan but then you would have to put up with a bleed (sequential Utro) or take it continuously (I couldn't stand it, had suicidal thoughts).

Do you have any idea if you have polyps or fibroids? I guess you will find out anyway after hysteroscopy. If polyps are the source of your erratic bleeding you could have them taken out during hysteroscopy (make sure to tick that option beforehand), if you have fibroids, then Mirena coil is the best option because it helps to shrink them.


I really hope you can find a definite solution for the erratic bleeding. Hugs.

Conolly X

I do have a small fibroid, have had it for years, the clinic fellowship woman  said it wasn't the cause of the bleeding.

I could try evorel conti I suppose, it's worth a try, before going for my least favourite option of the coil.

Thanks for your suggestions x

[Hurdity]

Hi Both Hurdity and Connolly,

Thanks so much for your thoughts on this.

Conneolly, I take your point, but as I am not absorbing the oestrogen on the 75, in my opinion decreasing any further would make no difference to the bleeding. My blood levels showed barely a trace of Estrogen. On the 100 Estradot and 100 Pr I felt a noticeable improvement in wellbeing- until bleeding started in earnest 3 weeks later.

In answer to your suggestion Hurdity, at the clinic I asked about switching to cyclical treatment, but the research fellow woman said no, they didn't do that with women who were post menopausal by x years. She wouldn't discuss it further.

I am taking 200 Progesterone vaginally, because I tried orally and felt bad on it. At the same time vaginally not great either. I don't know which method absorbs more? Apparently orally you absorb just 10% of micronised progesterone(I read somewhere)

I don't know which is the higher risk thing for me-mirena coil or synthetic progestin. Neither are things I want. Yet I can't sustain this bleeding.

I have a GP appointment  on the 25th but am wondering if I can get an emergency appointment before then. I will ask about a hysteroscopy, maybe I can get a referrel to a gynea clinic.

If I tried a synthetic progestin, are there any recommended ones? At least that could work in the short term I suppose.

Hi again Autumn - your research fellow woman is wrong - you can continue with cyclical HRT for as long as you want provided your system ( and you!) can cope with it. Many post-menopausal women opt to continue with a cycle due to progesterone intolerance - even low grade side effects, like foggy head and lethargy - can be wearing after a while. Also whereas there can be an increased risk of endometrial cancer with long term cyclical HRT, some gynaes still prefer this option (cyclical HRT) over continuous combined HRT due to the latter involving continuous progestogen and the lpossible link to increased risk of breast cancer. It's swings and roundabouts really - but as I said in my previous post - as you are not absorbing the oestrogenfinding a way to maintain an increase to help with your osteopenia and reduce bleeding is the best way forward. (As an aside Conolly - not sure why that comment about the hype when Autumn isn't absorbing oestrogen? Anyway I haven't seen any hype... some women are suffering and have been advised to try to achieve high oestrogen levels by their gynaes especially those suffering from reproductive depression) .

Yes vaginal use of progesterone - much more is absorbed. In fact some research shows that you can use approx half the dose of prog when used vaginally than when used orally, and it also is thought to be held in the uterus making it even more effective. For higher doses of oestrogen I would always use it vaginally because high oral doses are not well tolerated as I previously said.

Hi Autumn - it is not obvious what you should do - since the more usual reasons for bleeding do not seem to apply - ie womb lining settling down to continuous combined HRT, or excess of oestrogen to progesterone causing over-thickening, or the reverse leading to endometrial atrophy.

In your position I would go back to your specialist and push for a hysteroscopy so that they can take a closer look at your womb lining - just to really check all is OK (eg re abnormalities such as fiborids, polyps or other things) - unless you;ve had one already.

Hurdity x

OK I mentioned fibroids and polyps in my earlier post (see above) as a reason for further investigation - and you now say you do have one. Does this mean you have had a recent hysteroscopy? Far be it from me to correct your research fellow but without a recent hysteroscopy you can't say whether it is the cause or not of the bleeding. If it has grown (although maybe unlikely if your oestrogen levels are low) then these can cause more bleeding than from a uniform endometrium without fibroids - that's my understanding anyway.

Re synthetic progestins - the Mirena coil does contain a synthetic progestin - levonorgestrel, and in fact all the HRT progestogens are synthetic except for progesterone itself (Utrogestan). The other one which could be taken with a patch which you could try is Provera - this one can be well tolerated by women and taken orally. You could still also try this on a cycle if you prefer.

Have you thought of writing to Dr Currie for advice? It is only about £30 I think. Although she does not generally favour bleed regimes, she might do given your situation, but may probably recommend a Mirena?

I think my suggestions to you remain the same as before:

Ask for referral for hysterosocopy - and treat anything if found

Maintain the higher dose oestrogen patch

Monitor your oestrogen levels through the doc (ref osteopenia)

Increase patch dose if still not absorbing or change to gel ( or tablet if well under 60)

Have a Mirena coil fitted (I know you might not like the idea...and as you say it may be more difficult especially if you haven't had children) or go for cyclical regime - either 200 mg utro vaginally or Provera at recommended dose.

Sorry I keep repeating myself but nothing you have said has changed my view on the way forward to try! Just my suggestions though 

Hurdity x

[SueLW]

in of insertion, that it may not stop the bleeding anyway. I have a slightly inverted (backward facing) cervix, and have never had children, so it wont be a straightforward insertion. A colcoscopy in the past was incredibly painful and took 3 different nurses to do it.

On top of that I am keen on the idea of only using bioidentical hormones, and not synthetic progesterone as in the coil.

I'm still bleeding.  It will be 7 months by the time I get the coil inserted! 

I think you are worrying way too much and unnecessarily about the coil.  I've had one before.  I've never had children either.  My cervix is also tilted.  An experienced practitioner will pop it in easily enough.  You are advised to take pain killers 1 hour before the appointment for the cramping.

The horror stories on the web about the coil are sensational.  But there aren't that many of them and there are millions of coils in use.  Yes it would be great to only use body identical progesterone, but there is only the one of those and it's not working for either of us.  I've tried it at 1 capsule every other night vaginally, and 1 capsule every night vaginally.  I tried 2 capsules once but felt drugged the following day.  I tried it orally for 3 days a few years ago.  Day 1 OK.  Day 2 sluggish, sad and itching from head to foot that drove me mad.  Day 3 suicidal.  I will never swallow one again.  I have given it a good long try and I'm working with a leading menopause expert and feel I'm getting great advice.  So coil it is.

[Autumn27]

Hi Hurdity,

Thank you so much again for your long and detailed response. I'm sorry if you keep repeating yourself (!) but I'm not sure I completely understood previous information you were giving me.  I really appreciate your time and effort. You are amazing!

I am quite keen on the cyclical regime, and asked years ago to be put on it. At that time another (new) doctor at the clinic told me to go ahead and try it, but left me on the low dose of 100 progesterone, so of course it didn't work. I didn't understand that at the time, Mr Panay explained it at my next annual appointment but didn't then prescibe the treatment to try it again.

So I agree with the summary of all your suggestions, and yesterday I was thinking about trying to get a single private consultation with a specialist just to get a considered medical opinion. I am with Nick Panay's NHS menopause clinic in London, and usually see him or Dr Horner, but the last 3/4 times have not beeen seen by them. The last 4 contacts in the past 6 months have been with a pharmacist, and then the research fellow woman who's manner I find cold and she is unwilling to discuss anything in detail. Everything she has done has made things far worse. Which is probably why I feel untrusting of her suggestions for the Mirena. I don't understand why a hysteroscopy was not suggested, or cyclical treatment for a while, for example.

So I think writing to Dr Currie is a very good idea. I'm not sure that if I paid to see Mr Panay, or the Mr Horner, privately for a one off consultation,  he would have access to my medical records to be able to help.

"Yes vaginal use of progesterone - much more is absorbed. In fact some research shows that you can use approx half the dose of prog when used vaginally than when used orally, and it also is thought to be held in the uterus making it even more effective. For higher doses of oestrogen I would always use it vaginally because high oral doses are not well tolerated as I previously said."

I presume, for clarity, you meant higher dose of Progesterone, not estrogen?

My preffered solutions in this order
1. Cyclical regimen with 200 Utrogestan
2. Trying a synthetic progestin hormone patch
3. Coming off all HRT and finding another way to solve all my issues but when I think how good I felt on 100 Estradots...hard to quit.
4. Mirena Coil. Still my grimmest and least favorite option- 1/10


Thanks again, x

[Autumn27]

I think you are worrying way too much and unnecessarily about the coil.  I've had one before.  I've never had children either.  My cervix is also tilted.  An experienced practitioner will pop it in easily enough.  You are advised to take pain killers 1 hour before the appointment for the cramping.

The horror stories on the web about the coil are sensational.  But there aren't that many of them and there are millions of coils in use.  Yes it would be great to only use body identical progesterone, but there is only the one of those and it's not working for either of us.  I've tried it at 1 capsule every other night vaginally, and 1 capsule every night vaginally.  I tried 2 capsules once but felt drugged the following day.  I tried it orally for 3 days a few years ago.  Day 1 OK.  Day 2 sluggish, sad and itching from head to foot that drove me mad.  Day 3 suicidal.  I will never swallow one again.  I have given it a good long try and I'm working with a leading menopause expert and feel I'm getting great advice.  So coil it is.

I think we all have individual preferences. Maybe if I could have a general anasthetic I could go through with it. I hate the thought of it, it makes me feel sick.

One of the horror stories was on this site, someone got sepsis. Of course, I'm sure it's a small percentage. Re the Utrogestan, I've had 7 trouble free years of it on 100 dose, I was lucky I suppose. But the 200 doesn't suit me continually, that's for sure.

Who is your leading menopause expert?