HRT decision ... and future exit plan?

[floatmaboat]

I'm 53 and have had Mirena Coils for about 15 years, originally to help manage heavy periods, but now as part of my HRT. I've been using Oestrogel for about 3 years. Everything is currently stable. I have a little bit of spotting every 2-3 months but no concerning menopause symptoms. I'm approaching my 5 year Mirena expiry date, so need to decide whether to replace it or switch to an alternative. I don't need the coil for contraception, so if I get another it will just be for the HRT. I'd ideally prefer not to get another, but I've read bad things about the side effects of alternative progesterone treatments, and obviously don't want to destabilise my hormonal balance. Does anyone have experience of making the switch in these circumstances?

I'm also wondering about an HRT exit plan ... at what age do people stop taking it, and how do you know when it's the right time?

I had my last Mirena taken out a few months ago in my late 50s having never used HRT. However my hormones then started playing up and I was getting hot flushes (I know they are caused by low estrogen so maybe it was a coincidence). Anyway I went to the GP to discuss HRT, started on gel a month ago which has zapped the hot flushes and we discussed having another mirena for the progesterone part as they have suited me but I agreed to wait a few months till I had seen whether the estrogen worked / suited me so I am on the micronised progesterone capsules nightly now as well. All good so far, no side effects, not decided about another Mirena.

I don’t have an exit strategy, I dont see the point, I’ll just take things as they come, but I think the long term benefits for bone strength etc are important especially for me as I have started late.

By the way at your age you can keep the Mirena for 10 years, I did.

I was coming here to say, I don’t know about the other stuff but I had Mirena put in and was told it lasted 8 years!! I’m 43

Assuming you're getting your coil changed in the NHS they might not do it for you. My area won't change the coil for HRT only for contraception and as it's now licenced for 8 years for contraception I have to take progesterone on top for the next 2 years. It's to do with central government funding.

8 years for contraception, 5 for HRT

I’ve switched the other way. Was on progesterone capsules plus oestrogel, then combined patch, but now have mirena and gel. The reason is because I kept bleeding, so the progesterone wasn’t doing its job properly.

Even though they didn’t stop me bleeding, I still felt better on the tablets, as I swear they helped me sleep!

I started with Mirena during peri-menopause. I am now on my 4th and have no intention of ever coming off HRT. I will go through the hideousness of replacing it every 5y because it works for me. I wish I could also have an oestrogen implant. As it is, I use transdermal oestrogen. I don't want to add another drug to keep track of. Also, the dose of progesterone in the Mirena is much tinier than in the pill.

I’m considering doing the same and getting a Mirena for the contraceptive element and to help with ongoing heavy periods etc. but I’m reluctant cos I love the tablets as they definitely help me sleep!

I switched from Mirena to utrogestan and didn’t notice any difference.

i am taking my HRT to my grave.

I took HRT by tablet - sorry, can't remember what it was. My GP advised me to have an HRT holiday after a year, to see if I still needed it. I holidayed after 18 months and all was OK, never went back.

I should say that that my single symptom was being woken up once an hour at night by a hot flush - no sweat, just a rush. Not good when I had full-time job to do. Never happened in the day time.

I got off very lightly indeed.

10 years for contraception if inserted at age 45 or later, but only 5 years if for HRT.

You don't ever need to come off HRT though. You need it for your bones amongst other things.

Apols for misleading Mirena advice upthread, I had forgotten it was only 5 years if as part of HRT, I’m still getting used to all things HRT related. 10 years is only for contraception and only if you are over 45 when you get it inserted (I used to have mine replaced every 5 years but then had one from 47 to 57).

My area will still do the Mirena for HRT, I have recently been offered it by my GP and as I struggle to remember to take tablets/capsules and have found insertion/removal straightforward in the past I will probably take them up on that. It seems silly for them not to, I would think one Mirena is considerably cheaper than 5 years of Utrogestan but funding can be very mysterious.

It's a very personal calculation - your risk of breast cancer does increase the longer you take HRT, but it's pretty small (less than say having 2 units of alcohol per night or being overweight) so needs to be kept in perspective and weighed against the benefits.

I'd say the main evidence based benefits for taking HRT are to relieve symptoms and to protect bones. (There are possibly other benefits e.g. heart health but the evidence on these seems much more mixed, and most of the big menopause societies focus on symptoms and bones). So as a first step I'd get a DEXA scan (they can be done privately for about 150 if NHS won't fund one) and check your bone health. If you have exemplary bone density, an active lifestyle and no risk factors (e.g. family history, medication history, periods of low weight), then your bones are probably OK though it's worth keeping an eye on them as density can decline rapidly post menopause! In which case the main reason for taking it is symptom control. Which unfortunately you can only check by coming off HRT for a bit and seeing what symptoms you have and whether they're manageable. Some women find their symptoms get better after menopause, some find their symptoms remain for life. I wouldn't hesitate to take HRT if it helps you feel good and live a full, active life.

Vaginal estrogen is useful whatever you decide about systemic HRT as this has minimum downsides and can prevent all sorts of genitourinary problems.

Personally I have osteopenia so I'm planning to stay on HRT as long as I can or until new evidence emerges, though I may come off it briefly when my mirena expires so I can see whether my periods resume, as otherwise I'll have no idea when I went into menopause.