a few questions about sequential and continuous at different stages

[menopauseadventurer]

Hello everyone. I'm joining this forum to try and educate myself. I'm actually genuinely excited also because I've gone onto HRT and I'm feeling an awful lot better. I am perimenopausal. I have a question about continuous and sequential HRT. I decided on oestrogen patches plus micronised progesterone pills (utrogestan) after doing a lot of reading. I was initially put on sequential regime and whilst I felt improved in some ways - I had a lot of problems with it. I tried taking the utrogestan vaginally as I read about and this didn't work for me at all - I had cramping and the feeling like I was starting a UTI. I also - frankly - found it messy and annoying and thought I'd really not like to do this long term.

So I then tried one pill of the utro rather than two and immediately I felt - well great! So I went back to the specialist and for the last two months I've been doing the continuous regime - which means a lower daily dose but continual of the utrogestan. It has been totally transformative for me. Particularly in terms of my anxiety. I can't even explain to you how much better this is. In addition my sleep is great and now consistent and I'm not peeing throughout the night as I did on the progesterone part of the sequential regime. I don't have bloating and cramping which I was getting on the sequential. Or period pains which I was getting.

I've read on here a few people with similar symptoms to what I was getting. I had assumed I was over-sensitive or intolerant to progesterone. I'm now wondering if I'm intolerant or oversensitive to changes and the chopping and changing of the sequential regime.

When I see the specialist there isn't huge amounts of time to talk or go into lots of studies etc. From what I could gather, I couldn't find a medical reason why perimenopausal women are put on sequential rather than continual. What I read is more to do with "compliance" due to potential bleeding. But I am worried in case I've missed anything here.

As I am under the eye of a private specialist I can hopefully keep an eye on things going forward and I'd even be prepared to get a yearly scan if necessary if I can continue to feel this good. But I wondered from all the people on here who really seem to know a lot about it - can you tell me why sequential is the go-to for perimenopausal women? Is there any medical rather than compliance reasons why these regimes are used for the different stages or anything else I need to know about that I can ask the specialist about next time? Is there any additional risks I should be aware of? Is there anyone else who has a similar experience in terms of sequential regime not suiting them? I can't really find anyone talking about this.

When I look on the internet there is very little information I can find about why these regimes are recommended in this way or any of the above. I found on the Newson site that it says women can change to continuous after being on a year of sequential. But it does not explain why or what the thinking is about that. It does not say why the year of sequential is necessary or why it isn't necessary after the year? I also can't find this after a year thing stated elsewhere.

Obviously I'm not an expert and don't want to put up anything that influences anyone to do anything ill-advised. I'd be grateful for any knowledge or experience in this area or pointers to where to find some.

From what I could gather, I couldn't find a medical reason why perimenopausal women are put on sequential rather than continual.

There is a reason :)

It's that for women with some ovarian function (even if it's just irregular periods now and then) using continuous too early can result in erratic breakthrough bleeding. This is because a surge in their natural estrogen along with the HRT estrogen means that the progesterone isn't enough to control the growth of the womb lining. So it sheds at odd times.

Combined continuous regimes work because after a certain length of time, the 2 hormones are working together to prevent any build up of the lining.

There is also another reason why some women prefer sequential and that's because- unlike you- they don't get on well with daily progesterone.

Another reason that is not discussed much is that research shows that there is a slightly lower risk of breast cancer with sequential regimes (not huge but about 1.3%) compared to continuous. This is because some progestins cause proliferation (growth) of breast cells and they are never given a 'rest' which they are in sequential regimes.

Utrogestan is supposed to cause less proliferation than the synthetic types of progsestin ( eg MPA and Norethisterone).

My specialists believes in keeping any progestin to the minimum so it protects the womb but doesn't increase risks to the breasts. Women on estrogen-only HRT have less breast cancer than women not using any HRT.

If you are using HRT for 5 years this may not be that important, as the risk with Utrogestan is no greater than not using HRT over 5 years, but if you use it long-term, it might be relevant.

Hi OP, from my understanding, the sequential progesterone is to do with keeping a monthly bleeding order to protect the health of the uterus. Not sure why this is medically the case, but I believe it’s what studies have shown to be the case.

I get you in terms of feeling better though, I’m on sequential and have the best sleep when I’m taking the progesterone! On the other nights I sometimes take melatonin, which helps.

I use the gel rather than patches as it’s easier to adjust the dose.

Have you tried any vaginal oestrogen? I’ve found it’s made the whole area more comfortable, and far less dry. Less prone to irritation and UTIs too.

Also, Yes vaginal moisturiser and the lube!

Out of interest, did you choose to see a private specialist yourself, or were you referred?

It's worth knowing if you don't already that private specialists are not bound by NHS /drug licensing and can make their own judgements on doses.

My HRT regime differs from the usual one in that my specialist is happy to suggest something slightly different, to the usual monthly sequential regime but I have (private) scans to check things.

Thanks both for your replies.

Hi Jinglinghellsbells

Just to say my private specialist also works for the NHS so definitely works within that framework. The reason I went was because during pandemic it was difficult to even talk to my practise about this and also there was patchy attitude from different GPs in my practise. I wanted to speak to someone I thought would be up with the latest information. One of the reasons I'm continuing with the private specialist is because the NHS will not prescribe utrogestan in my region. I decided to try that after the reading I did and also because I read it had fewer side effects and I've always had a certain amount of PMS etc.

Thanks about the breast cancer advice. I have not seen any studies saying that - is it possible to point me towards where that information comes from? Being on Utrogestan I've also found it quite hard to work out what studies there are and how relevant they are to my particular regime also. But I'd appreciate any further info you have on this.

I have understood that continual is more protective than sequential for endometrial cancer. But - again - I'm very confused as to how the different regimes at different stages might affect this.

The dosage overall for progesterone is the same whether sequential or continual - as it's the same monthly dose only it's taken either at a continual dose for the whole time or doubled up for 2 weeks. So I'm not sure why it would affect progesterone levels in terms of breast cancer therefore.

Can I ask what kind of regime you are on? Are your specialists operating within or referred to by the NHS? Are you doing a kind of long sequential? I have read about that and considered that before I kind of chanced on this which just seemed to make me feel so good. I find the whole thing incredibly confusing to be honest with you and it's taken me a while to even start to get my head around things.

I understand that the continual too early might cause some bleeding. But I'm still uncertain as to if there are medical reasons rather than reasons of convenience or compliance that sequential is recommended? I'm very unclear whether the endometrial lining is more or less protected on each regime or depending on the stage you're at for example. I am still confused about the Newson advice of switching after a year.

@oreosoreosoreos I found the sequential sleep was too much for me during the progesterone part of the cycle. I felt like I'd been stungunned and I also had a lot of nightmares. And I peed constantly through the night. This has all disappeared since changing to continual which seems to be the right amount of sleepiness for me. I realise we are all so very different in how we respond to these hormones and regimes which makes it even harder.

I suppose I thought I'd ask these questions and also just see if anyone had a similar experience.

The dosage overall for progesterone is the same whether sequential or continual - as it's the same monthly dose only it's taken either at a continual dose for the whole time or doubled up for 2 weeks. So I'm not sure why it would affect progesterone levels in terms of breast cancer therefore.

It's not.

The dose on sequential is 12 days x 200mgs per calendar month (there is a choice of either 12 days or 14 days depending on the amount of blood loss some women have.)

Women who are intolerant can also go down to 10 days per month under supervision. One type of tablet form is called Tridestra, for women in peri. It's an 84 day cycle, with 14 days of progestin in those 3 months.

The dose on continuous is 365 days a year x 100mgs

I don't have time to answer all your points today and some of it's not for a public forum anyway, but I will reply to some points by private message if that helps.

I'd say you are worrying unnecessarily about the lining of the womb. It's protected on both regimes. It makes no difference when either is started except for the risk of erratic bleeding if started too soon.
Longer term, sequential has a slightly higher risk of hyperplasia, but as long as women are aware of this (and their drs) it can be monitored.

Just to answer one more point.

I tried continuous after around 7 years on HRT and it made me bleed daily ( spotting) , I also felt very tired, I got a migraine each day as the progesterone levels fell off, so I decided it wasn't for me.

There is a quite a lot online regarding the risks of BC with sequential and continuous, so if you search it ought to come up. Bear in mind that in many of these stats, the number of women on micronised progesterone is very small.

Thanks for the replies again and sorry for not answering @JinglingHellsBells. I did but the post didn't seem to post and it was quite long so I couldn't face writing it all out again. The jist being that the dosage and regimes I was going on were for Oestrogen patch plus Utrogestan and the ones told me by the specialist and the gp. So they were 14 days out of 28 at 200mg or continual at 100mg which is 28 out of 28. So that to be is roughly the same monthly dose (or same dose every 28 day cycle). The leaflet says 12 days and 25 out of 28 - or at least I think it's 28 as it says "therepeutic cycle". I have NO idea why this is different - but I've noticed many on here say they are advised the same number of days as I was so it must be quite standard in many GPs it seems.

I don't know about the other treatment you mention. I have only really looked into the ones offered and talked through with me and that didn't come up.

Thanks for the breast cancer info. As you said it becomes very very hard for me to work out how any of the stats or studies applies to micronised progesterone as opposed to the other sorts, the progestins. Thank you for clearing up about the endometrial side of things as I think that was concerning me and I wasn't too sure how to think about that. You sound a lot more familiar with all this than me. It's early days for me so I'm still grappling with the basics! Hopefully I'll feel a bit more confident as time goes on. Thanks again.

One issue with the number of days on progesterone is that many GPs are very new to prescribing it (it's only become 'mainstream' choice in the last few years) and are following the leaflet, which has been overridden by some specialists.

I've used it for around 8 years and it was prescribed by a menopause/ fertility consultant, who's used it for years with women. The dose he suggests is 12 days per month (that being a full month, not 28 days) often starting on Day 1 of a cycle to make it easier.

There is info (small print) in guidance for GPs prescribing HRT (I can't find the link just now but it's out there!) saying that as a minimum to prevent hyperplasia, a progestin must be given for 14 days out of 84 days. (2 weeks per 12 weeks.)

So you can appreciate the extending 28 days to the days in a calendar month ( 30-31) is insignificant.

It's only very recently (the last year or so) that a certain private GP in the media has tried to simplify it for women by saying '2 weeks on, 2 weeks off.'

Going back to your original point about sequential and continuous. It's a matter of preference. It seems to be established that continuous is less safe re. breasts but in the long term there is a slightly higher chance of hyperplasia with sequential (but this can be monitored and treated as there are usually stages before it becomes cancerous.)

If you plan to use HRT for a short time ( 5years or so) none of this really matters, but for women using it for 10 years or more, it's all a consideration.

I'm 48 and perimenopausal. Was still having regular periods but experiencing a lot of unpleasant symptoms. My GP (I'm not in the UK) offered me continuous HRT (Kliogest). I asked about risks and she said there weren't really any, the main concern she seemed to have was that I needed to remember that I could still get pregnant and that it was not a contraceptive pill. I don't have a partner and I am not currently sexually active so this doesn't concern me. Now on my 5th month and feel better than I have for years.