Post-meno bleed

[Tex171]

I’m 51. LMP March 2020. Started HRT (Estrogel & utrogesten) in Dec 2020. All went well. Symptoms disappeared. No spotting or bleeding until…

2 Jan 2022 started bleeding, like a heavy period. Spoke to the GP, referred to gynae.

1 March 2022 had a hysteroscopy with removal of one small fibroid (2cm). Light bleeding for about 7 days afterwards. Quick recovery, all good.

Then on Sunday (26 March) I was standing in the kitchen and felt of whoosh of warmth. Bleeding again! It’s like a very heavy period and is even heavier today.

Speaking to the gynae next week, but worried sick. I’ve been Googling and I can’t find any useful info. My estrogen levels were checked and I’m in the normal range thanks to the HRT. Cervical smear was clear. No polyps. The small fibroid was removed. The gynae said my uterus was ‘bulky’. I don’t know what that means. He said it during the post op chat and I was still coming off the GA and not thinking clearly.

Anyone had this issue with bleeding? Any suggestions? Of course, I’ve considered endometrial cancer (lots of cancers in my family) but wouldn’t the consultant have contacted me if anything like that was found?

Sorry you are going through this.

The only thing that comes to mind is maybe you are not actually post menopause and this is a natural period.

You said LMP March 2020. Started HRT (Estrogel & utrogesten) in Dec 2020

So you started HRT 9 months after your 'last' period.

The thing is, you won't know if it was your last period. Post meno is defined as 12 months at least with no period. And taking HRT would mask any natural periods you might have had.

When you started HRT I'd assume you used it cyclically? (On a cycle of 12 days Utrogestan each month.) That is the regime for women who are not post menopause (and you weren't as it was only 9 months.)

If not , and you used it daily, then what you are getting now is most likely a period. Otherwise you'd have been post meno at 49 which is a bit early ( 51 is average.)

What can happen if you are not really post menopause, is your own cycle can override the effects of Utrogestan (especially if it's just 100mgs a day) , and you get a bleed.

A bulky uterus can be caused by adenomyosis (like endometriosis but the lining grows into the muscle of the uterus- giving heavy bleeding and a larger uterus. I have this- diagnosed on transvaginal scans.)

I've also used HRT (same kind as you) for almost 14 years.

I think if there was any sing of endo cancer, your dr would have seen it very clearly (I've had that investigation) and it's obviously not there.

From what you have said, I'd guess it's your own hormonesand you are not quite post meno.

Thanks, jingling. That is so interesting. It does feel like a period.

I was put on the daily HRT, not the cyclical, by the Newson Clinic. I did think that wouldn’t be the case since it hadn’t been a whole year, but assumed they knew best. I’ve wondered if I’m just not post-menopausal yet. March 2020 and the following year were incredibly stressful with lockdown as well as financial and marital problems. I’ve wondered if I wasn’t having periods due to the stress. I was definitely peri. My periods had become erratic, with cycles as long as 100 days apart a couple of times. But maybe it wasn’t my time and it all got confused in the stress of the pandemic.

Oh, bum. Will put this idea to the gynae and see. My only question would be why my estrogen levels are still normal. I’m on 7 pumps of Estrogel a day but my levels are still normal. Wouldn’t they be high if my body was still producing it too?

Cycles 100 days apart (3 months or so) is really common in peri and many women go much longer. You can't count yourself as post meno until you have missed 12 months. Some women go 11 months then have another period and go right back to the start of counting from 1 again!

7 pumps a day! If it's not a daft question- why that much?
I'm on 1.5 pumps (although older than you.) Max ever used was 2.5 for a short time.

Have you worked up to that from the starting dose to get symptom-control?

Is this all through the Newson clinic?

Sorry, I don't want to sound confrontational here, but that is a huge amount for someone your age (compared to women with premature meno who are 30-somethings.)

TBH I'd be a bit worried using that amount of gel and only 100mgs daily Utrogestan. The amount of blood loss / lining is directly linked to the amount of estrogen used.

So if this is NOT a period, it could simply be that the estrogen dose is much too high for the dose of Utrogestan.

The British Menopause Society published a paper/ report in Jan 2022 on progesterone use. They said there may be times when some women need 200mgs daily if it's not controlling the bleeding.

If it IS a period of your own, what happens is the ovaries have a final last 'Hurrah' and push out an egg = period. It only happens now and then, so any blood tests are meaningless.

When you say your blood levels are 'normal' what does that mean? Normal for 7 pumps which is 0.75mgx x 7= a very high dose ove r 5mgs a day.

Most HRT is either 1mg or 2 mgs a day and sometimes 3mgs for younger women.

Sorry to ask so many questions but over the years I've asked my gynae a lot and read a lot. (He's a very good gynae who actually trains people like Dr Newson- she rates him very highly.)

I'm trying to help :)

Thoughts are:

1. As Jingling says you weren't 12 months post-menopause when starting HRT and it might be periods haven't truly stopped. I have a friend who had a period 11 months later and had to wait another year before knowing she was truly there.
2. Some women experience bleeding in the first few months after starting HRT and this generally settles down. Might be the case for you.
3. Some women experience bleeding on HRT due to an imbalance. Decreasing the estrogen component/increasing the progesterone can resolve this. Another option is to have a Mirena coil installed instead which can be more effective in controlling bleeding if there's no other cause found.

Guidelines for Oestrogel are up to 4 pumps though I understand Newson clinic will prescribe to quite a lot more to see if it resolves symptoms and do blood tests. Some women don't absorb in at whatever dose and often a different treatment can be more effective.

I'm surprised they removed the small fibroid as post-menopause on the NHS they're usually left. I'm in this situation and had a scan last year which showed a small (35mm) one as the cause of my bleeding - was told they wouldn't remove it and suggested I either live with it or perhaps consider stopping my HRT.

Thanks so much for all the questions and info. Many of these are things I’ve wondered myself but just assumed I was in the hands of professionals and put my trust in them.

7 pumps is definitely a lot. I’ve worked up to that from two pumps a day because some symptoms, like night sweats, would come back and then reduce with an increased dose. I’ve never increased the Utrogestin though and did find that odd. This was all through the Newson Clinic. I don’t know the actual numbers from the blood test, conducted through Newson. I was just told that my estrogen is ‘within the normal range’ which is good as, due to my symptoms, they were concerned that I might not be absorbing it. I’ve asked for an appointment to discuss the dose and maybe move to a patch as I’m using so much gel that my clothes stick to me through the day, even after it’s dried.

It sounds like I need to discuss my HRT dosage and the balance between the two hormones, and discuss the possibility that I’m not actually post-menopausal (god, I really hope that’s not the case!).

Over50, the fibroid was removed through Bupa. It’s the fourth time I’ve had fibroids removed. I tried to talk him into a partial hysterectomy to be done with them once and for all, but he said he couldn’t justify it,

Thank you so much Jingle & Over50.

I'm a little confused.
Are you seeing a gynae who is someone different to the drs who prescribe HRT?

I agree with @over50andfab, that small fibroids are usually left alone unless they are causing huge bleeding and are very big.

I was diagnosed with a small fibroid- 3cms- years ago when I was also having a small ovarian cyst monitored. There was never any discussion over removal. (All this was privately) More recently, I had a scan and the gynae (different one) said it wasn't a fibroid but an area of adenomyosis, and that there were a couple of small areas of adeno.

I hate to suggest it but are they removing fibroids as a means to make money ? Sometimes (although never personally) you do hear of some private consultants being scalpel happy, to increase their income.

My understanding is that fibroids are only ever removed if they are so big they press on the bladder, or cause heavy bleeding. Otherwise it's a case of leave well alone. They usually shrink post-meno, although not on HRT as sometimes it can 'feed' them and they grow.

I'd definitely query your estrogen dose. (I can't imagine applying that amount!) Where do you put it all out of interest? Were you told to increase it gradually, with an extra pump every few weeks?

I wasn't post meno till 53 so it's really quite possible you are not. Some women aren't till 55 (and sometimes older.)

Yes, Jingles. I only started seeing this gynae in Jan when I had the first bleed. An ultrasound showed there was something there so I had a hysteroscopy. The consultant thought it was a polyp that caused the bleed and the plan was to remove it. It turned out to be a fibroid and I guess they decided to go ahead and remove it while they were in there.

The other fibroids were removed over a period of about 25 years (twice on NHS) due to discomfort and heavy bleeding. The only one I would question would be this last one, but I was totally up for a partial hysterectomy to just be done with it (I told him it was probably a fibroid due to my history). He refused. I assume a hysterectomy would be more expensive?

Lord, the Estrogel! It really is ridiculous. I do two pumps for each thigh in the morning then three over my arms at bedtime. When it finally dries, it’s fine. Then if I sweat, my clothes start sticking to me. I increased it by a pump at a time over the last 15 months as my symptoms started to come back under the guidance of the Newson Clinic.

Have you ever used the patches? As I rethink all of this, I’m wondering if patches might be better than the gel.

Ok- get it all now :)

You might be someone who gets on with a Mirena coil which would stop new fibroids- with a bit of luck- and end the bleeding. Doesn't suit everyone (I didn't want one as the progestin in it gave me acne spots - in the Pill- in my 20s.)

I don't envy you with all that gel! I use 1 pump divided between two upper arms, am, and half - one a pump on thighs at bedtime.

Never had patches as just don't fancy a sticky patch on my bum all the time :)

My gynae is a surgeon and a meno expert so that covers all bases.

It's your choice but I'd be tempted to reduce the gel to less and see how you go.

The bleed is either an imbalance of estrogen/ progesterone, and the lining is shedding spontaneously as it's getting thick, or your own periods.

You won't know which unless you make some changes.

One thing to consider is a sequential regime, so that you have - as far as possible- a predicted monthly bleed.

(I still do that after all these years as daily Utrogestan makes me feel headachy.)

Cut back one pump on the Estrogel Tues night. Had a horrendous bleed Wed morning. Kept to just six pumps yesterday and woke up to almost no blood this morning!

Seeing the gynae on Wed and will discuss it more with him, but I definitely think my HRT is out of whack. Thanks so much for pointing me in the right direction.