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[Peach8]

I'm struggling with hot flushes. My chest, neck and face are red a lot, the rest of me is pale so it's very obvious and it's embarrassing. Is this due to too much or too little estrogen?  Also, I feel hot in general a lot of the time, is that normal in peri? I'm starting to get anxious about it which isn't helping.
Level was 233 in January on 1mg sandrena, increased to 301 in July on 1.5mg sandrena. NHS menopause consultant said I'm on a high dose and should consider lowering it whereas Newson clinic said I could consider increasing it. It's so confusing and I'm worried about getting it wrong.

[bombsh3ll]

301pmol/L isn't a high level at all.

It is just above the 300pmol/ threshold for bone protection (as per prof Studd. NHS cites 250pmol/L)

Some women require more than this to ease symptoms.

Another issue with gel is it results in a peak after absorption then drops quite quickly after that, resulting in unstable levels even though your average is reasonable.

This can be helped by splitting the dose into twice daily morning and night, or trying patches which theoretically deliver a more stable level (assuming you can keep them on).

You can't "get it wrong" if you take too high a dose and get symptoms of overtreatment you just reduce it. It is gone from your body in a day.

I'd be inclined to listen to Dr Newson's clinic who are really knowledgeable in this field and have the time to assess someone fully and provide individualised care, ie a therapeutic dose of your chosen treatment, rather than an 8 minute NHS appointment where everyone gets the lowest available dose of whatever is cheapest.

[Peach8]

Thanks Bombsh3ll. I tried patches but got horrendous bleeding. I might try your suggesting of splitting the dose.
What are the symptoms of high estrogen?
I agree that the Newson Clinic advice is probably the way to go but the problem I then have is getting my gp practice to prescribe the higher dose when they don't agree. I'm also progesterone intolerant and don't want to increase my provera to match higher estrogen.

[bombsh3ll]

High estrogen can lead to breast tenderness, water retention, heavier periods (if you are having them) and headaches in some people.

Provera is much stronger than progesterone - it is literally progesterone on steroids - and provides robust endometrial protection so depending on your dose an increase may not be necessary - your specialist will be able to advise on this.

It can be challenging getting what you need on the NHS - I have to pay privately for my combined pill - however I made the decision to opt for the best treatment for me rather than take something less suitable just because it's free.

What I would say is find out what really works well for you, then look at what of that you can get on the NHS and potentially self fund the difference.

Alternatively don't overlook oral estradiol as an option if gel isn't getting you to where you need to be.

Oral estradiol is more stable than gel as it is absorbed more slowly through the gut so it doesn't peak as quickly.

The real world difference in clot risk is absolutely minuscule for healthy women without any risk factors, literally an extra 1 or 2 per 10,000.

It is sometimes easier to get a therapeutic dose of oral prescribed on the NHS as 2mg is considered a standard dose, and if you are self funding it's cheaper than transdermal.

[Peach8]

Oral estrogen has always made me a little nervous due to the clot risk so good to know, thank you.

[sheila99]

Newson is looking at what's in your bloodstream whereas your gp is seeing what goes on your skin. It may be that you absorbed oestrogen from the patch better, hence the bleeding and it might be worth revisiting that on a lower dose. It's the progestogen that keeps your lining thin so you could continue with what you use atm and use an oestrogen only patch. Your level isn't high so I think it's low oestrogen not too much. Anxiety is also a symptom of oestrogen deficiency.

[Peach8]

Thanks Sheila99. In addition, I usually get a bleed about 4 days after stopping the provera but this month I'm on day 8 and still nothing. I have breast tenderness, very bloated and my mood is terrible, in an angry way. I really need this period to hurry up to get rid of these symptoms. I'm not sure whether this is a separate issue or connected to the low estrogen. Any idea?

[bombsh3ll]

Taking the provera continuously may be a better option than cycling it.

Depending on the dose used, unlike micronised progesterone, provera is able to suppress endogenous ovarian activity and achieve amenorrhea in premenopausal women.

This negates the need to keep stopping it trying to synchronize with your own cycle.

[Peach8]

Hi All. Just revisiting this after a gp conversation. My hot flushes are my biggest issue at the moment. Currently on 1.5mg sandrena with a blood reading of 300 estrogen a few months ago. Gp won't increase sandrena and says my symptoms may be from too much estrogen. Is that likely? I've suggested I try 1mg oral tablet to see if I absorb that better. They say I don't have an absorption issue with the gel at 300 level of estrogen. I had low mood on 1mg of sandrena and I'm concerned about going back to that if I reduce the gel. Newson Clinic said I could increase the gel if I felt it would help. I don't know what to do for the best. Any suggestions please?

[sheila99]

Assuming you saw a specialist at Newson get them to write to your gp. A go shouldn't go against the advice of a specialist. Do you have enough to try the higher dose for a couple of weeks? Then you'd have your answer. I haven't heard of too much oestrogen causing flushes, only too little. You can add anxiety, particularly feeling wired and palpitations to the list of oestrogen overdose symptoms (as well as deficiency symptoms).

[Peach8]

Thanks Sheila. I hadn't thought of just upping the dose myself. Might be worth a try.

[Gnatty]

If it helps, I take 3mg of Sandrena and I split the dose so 1.5mg in the morning and the same at night. If they won't let you increase, you could try changing the location of where you apply the gel. For instance I think I get better absorption on my forearms than thighs. I know some think we shouldn't be putting it on our arms there but it makes no sense as that is exactly where you would spray Lenzetto, which is obviously estradiol too!

[Peach8]

Thanks Gnatty. Do you find you get a better result by splitting the dose?

[Gnatty]

Definitely. I guess a blood test would show from a split dose a lower circulating oestrogen level than someone who whacks on 3mg all in one go but I don't really understand the mechanism tbh.. Maybe someone can help with that? I'm not sure what the implications are though. I imagine it's probably a good thing as we don't want our levels too high. On the other had we want them high enough to help prevent osteoporosis....
I also sleep better when I split the dose.

[Peach8]

Thank you