UPDATE re clueless GP

[52andblue]

My( female!) GP is clueless but I'm rural Scotland so not much choice.

Background: I'm 54. Asked about HRT 4 years ago but GP said 'I'm sailing through it, go to the chemist and ask advice if you're struggling'. Grrr.
Anyway. 6m ago she finally agreed to try some HRT. I was still getting my periods, 10m out of 12. but lots of peri symptoms. Complicated by clinically low iron (i have IV iron 2x year) also B12 (injections ev 8 wks) also clinically low vit D & calcium as a result of roux en y bariatric surgery which means i no longer absorb via my gut (big mistake)

I was put on Eveorel Sequui conti at the 50 strength. 1st 3m v heavy periods. Prescription then messed up by a week so all out of synch. just ending the 2nd 3m. hot flushes are reduced a bit but still feeling pretty wiped in every other way. GP blames it all on 'other issues'.
I have asked for the strength to be increased. I saw the GP 10 days ago. She said she 'didn't know, but would get back to me'. My current prescription ends in 4 days now. I just got a letter in the post. (I live 15ft from the practice and the letter posted from 40m away, stupidly)

'I have been doing some further reading. Unfortunately your HRT patch is a fixed dose which contains both estrogen & progesterone. There is more flexibility with an estrogen patch alone but this would mean a separate supply of progesterone. As discussed at your appointment this would mean either the Mirena coil or anoral progesterone. Quite sensibly you had reservations about either of these options but there is no easy alternativge. Please let me know what you wish to do'.

I have had gut surgery so cannot absorb tablets. I have
fibroids so don't want a coil (had one in my 20's that was painful too).

Grrr. At this point I'm tempted to ask for a new script for my current prescription and a referral to a Menopause clinic.
There is one in Edinburgh but I don't know if she will refer me?

So, I need a Plan B if she says no?

Well, she's right in terms of what is available. If you want a higher dose of estrogen, that will be an estrogen only patch with either the Mirena, or micronised progesterone. This can be used off-label vaginally, so would not affect your guts.

Fibroids are not a contraindication to a Mirena, unless they are in a place that would prevent coil insertion.

You won't be offered anything else via a menopause clinic, as what she's offered is what's available.
All that could be suggested is using micronised progesterone which is a capsule for oral use BUT off label you can use it vaginally.
Private specialists offer this (not NHS clinics) but to be honest, who would know if you used it that way :) It's how it's used in Europe, it's just that the UK licensing is behind the times.

@JinglingHellsBells that's very helpful thank you.
No point taking up specialised clinic time if they won't offer any different.
I'd read a bit about gels etc and 'gold standards' of diff types of HRT but I've got very confused (brain fog from meno, apnea, & low iron is a horrible combo so concentrating for more than 2 mins is a big feat)

I guess I just want someone here to tell me what I should ask her for.
I'd like more of the 1st half of my patches.
So it seems I now need to split that into two meds rather than combi?

Which is prob a bit of an AIBU post really!

Happy to help.

What you might want to ask for and consider is gel. This is because it's easy for you to adjust the dose (which can be anything from the equivalent of a 25mgs patch to a lot more.
)
You try a dose for maybe 3-4 weeks and if it's not enough, add a bit more.

But alongside that you need progesterone, called Utrogestan.
It's taken 12 days per cycle ( a cycle being a month.)

As you can't absorb from tablets, you would use it vaginally. (Just pop it in, at night, as high as you can reach.)

Can she not just issue you an oestrogen only patch to use in addition to the current combined patch you use?

@BernadetteRostankowskiWolowitz

that's a thought ???

@BernadetteRostankowskiWolowitz

Can she not just issue you an oestrogen only patch to use in addition to the current combined patch you use?

Well, yes, but only if someone is happy to use 2 patches at once. It' s also important that the amount of progestin in the patch is suitable for a higher dose of estrogen.

I defo would be happy to use 2 patches at once & would prefer that to other methods unless they are much more effective / better quality??

I think she will try to help but I do need to know exactly what to ask for, including doses it seems as she was getting me to check her textbooks with her during my appointment ?

I'd ask for a referral to be honest.

you need progesterone, called Utrogestan

As Jingle says, the vaginal version would see a sensible option

@52andblue

I defo would be happy to use 2 patches at once & would prefer that to other methods unless they are much more effective / better quality??

I think she will try to help but I do need to know exactly what to ask for, including doses it seems as she was getting me to check her textbooks with her during my appointment ?

This is beyond what she can offer you:) Clearly from the fact she has to keep looking things up.

The important point is that in a patch (as with a tablet) the doses of estrogen and progestin are in a ratio, so that they are effective.
Usually, the higher the estrogen, the higher the dose of progestin is needed (to avoid the lining building up.)

I doubt very much your GP would know if the mcgs of progesterone is appropriate for an increase in estrogen. It's easier with tablets to work out a dose, but patches release the hormones over several days.

Utrogestan is safer if you think you will be using it in the medium to long term.

So, I can ask for a Estrogen patch supplemented with an Utrogestan dose of Progesterone? this can be in tablet form which I can use as a pessary (is this likely to cause vaginal atrophy / cancer in the longer term?)

conscious that, as @JinglingHellsBells says, GP doesnt seem very confident about options or dosing ? Any idea what I should ask for (sorry ... how long is a piece of string...) I have had a heavy period each month so far on the Evrorel Conti - or is it better to ask for clinic referral to try to get a more accurate idea?

probably will be using it med to longer term as didn't get bad peri symptoms till age 50 & still having regular periods age 53 & 3/4 ?

You can ask for utrogestan to be used vaginally, but you may struggle to get it because it is not licensed for that purpose. If the GP cannot prescribe it, a consultant can.

@52andblue

So, I can ask for a Estrogen patch supplemented with an Utrogestan dose of Progesterone? this can be in tablet form which I can use as a pessary (is this likely to cause vaginal atrophy / cancer in the longer term?)

conscious that, as @JinglingHellsBells says, GP doesnt seem very confident about options or dosing ? Any idea what I should ask for (sorry ... how long is a piece of string...) I have had a heavy period each month so far on the Evrorel Conti - or is it better to ask for clinic referral to try to get a more accurate idea?

Certainly in Edinburgh GPs can't prescribe utrogestan.

Also if you get referred to the menopause clinic you will just get a letter back to the GP suggesting oestrogen plus mirena or provera.

It's actually really hard to fiddle with the doses due to what is available on the prescribing formulary.

You can't double up on the oestrogen without having the right amount of progesterone.

I sometimes feel very limited in what I can prescribe. I'm using oestrogel 1mg daily plus 5mg provera (continuous combined as I'm older) seems to be working.

Hi @Musicaltheatremum
Im not Edinburgh but Borders so prob same criteria?
no point wasting specialist clinic time if they will just bounce me back

What is provera please?

still muddled about what best to ask GP for (sorry to be dim)

Lots of info here

www.newsonhealth.co.uk/resources/

Good luck op

Provera is medroxyprogesterone. One of the progesterones used to protect the uterus.

Thanks @itmaybe
That looks a good site.
I'm not 'taking in much atm as my Mother is ill & I just found out a very close friend has terminal cancer.
I've enough patches to last till Monday but really need to call GP tomorrow as have to travel to see friend & Mother Weds onwards. I can't seem to think straight let alone research effectively.

@CorrBlimeyGG

You can ask for utrogestan to be used vaginally, but you may struggle to get it because it is not licensed for that purpose. If the GP cannot prescribe it, a consultant can.

@CorrBlimeyGG Many women who use it that way take it into their own hands- literally :)

The product is the same whichever way it's used.

It's only in the UK it's not licensed for vaginal use but 1000s women use it that way and don't tell their GP.

If it's consultants' preference ( mine prefers it used that way) then it's certainly safe.

@52andblue

Hi *@Musicaltheatremum* Im not Edinburgh but Borders so prob same criteria? no point wasting specialist clinic time if they will just bounce me back

What is provera please?

still muddled about what best to ask GP for (sorry to be dim)

If you go to the website Menopause Matters, it's run by a Scottish gynaecologist Dr Heather Currie. She's NHS and I think she is based in Dumfries/ Galloway.

For £35 she will answer questions by email.
www.menopausematters.co.uk/contact-the-doctor.php

She will also know what is available in Scotland.

Can't you use a second patch but cut in half?

I'm not in the UK and we often have supply issues so we are often advised to do this.

@Partyintheusa2012
Thank you for your very sensible suggestion.
I have asked my GP. She is still 'looking into it'.