Different doctors, different HRT doses

[crispinglovershighkick]

Due to a recent family emergency abroad I had to see a private GP to get medication refills (two of which were HRT scrips) to avoid running out of usual meds (thyroxine etc).

My NHS menopause GP (via referral from my usual GP) originally prescribed patches (50mcg) and Utrogestan (100mg). She recently suggested a bump up to 75mcg for the patches as I'm still symptomatic but I wasn't able to try the new dose as they've been out of stock since my appointment. She added Vagisil to deal with some bladder issues.

The new private GP did bloods and suggested that I need more progesterone and the oestrogen should remain the same (50). She wanted to raise the progesterone to 200 to see how I go, and I can drop down to 150 if I have side effects (there's an issue getting the 50mg capsules apparently). She was relaxed about the higher dose, saying I could try it if I want. She also gave me Vagisil vaginal tablets.

My symptoms are suddenly very dry skin, difficulty emptying my bladder (takes forever), poor memory, feeling overwhelmed and still waking in the night (but latter two symptoms better on HRT than before).

I wondered if anyone who knows more could comment on why the two different approaches and if one makes more sense than the other. I've actually read several books about the menopause but I still feel completely dim about HRT. I thought progesterone would lead to more emotional chaos rather than less? I'm curious about there being different protocols in different places.

I'm massively confused about HRT. Cants answer your question, but a little bump may help someone else see it!
@jinglinghellsbells may help, if I've spelled her name right!

I'm confused too but not for the same reasons!

I don't have much confidence in what your private dr says- this is not in the UK, yes? Or is she? Is she actually registered as a menopause specialist with the British Menopause Society?

I don't think Utrogestan is available as 50mgs (have used it for many years.)
It comes as 100mg or 200mgs.

Why did you have blood taken? It's not necessary.

The amount of Utrogestan depends on if you are taking it daily if you are post meno (no periods for 12 months) or not.

It's 100mgs daily for continuous / post meno women, or 200mgs x 12 days per month if not.

There is no such thing as Vagisil tablets.Vagisil is an OTC cream and has no estrogen .

Vagifem maybe???

If you're already using hrt, you'll know that the only reason for using Utrogestan is to stop the womb lining overgrowing. It has little other purpose, so it's not 'therapeutic' in the way estrogen is. My consultant recommends using as little as possible - just enough to stop the lining getting too thick.

Sorry this is long winded, but the original prescription is the right one.
I fear you have been ripped off TBH, paying for unnecessary tests and being given a load of tosh !

I have no idea re HRT even though I've been on it for 4 years, but I would have more faith in the Dr that took the blood test, as your blood results will be instrumental in what they have prescribed you ? That would be my theory anyway

sadly that's incorrect@bert3400 and if you did use hrt you'd know why!

HRT alters the level of hormones (it's not measuring your own) and they also change over the day especially in peri.

I have had my hrt from a very top UK meno specialist for 14 years and he says blood tests are a waste of time, except once at the start when they might help but can be unreliable (mine gave a false post- meno result!). The rule for hrt is to adjust the dose until symptoms go away- so increase, or decrease it.

I clearly know more than I thought, @JinglingHellsBells , because I'd have said what you did! Blood tests? Extra progesterone? That's a pay for treatment doctor!

One thing I really trust about the NHS is that they don't over treat!

Thanks for replies. I couldn't see this thread at all on my phone so I've had to wait until I could get to my laptop.

No not in UK at the moment, as in OP I've had to deal with a family emergency abroad.

picklemewalnuts bert3400 I'm glad it's not just me who finds it confusing. I thought I should educate myself so I read books about the menopause and HRT (probably recommended on MN) but apparently none of it stuck.

Apologies, my mistake, it is Vagifem tablets or vaginal estradiol as it says on the box. The tablet comes in an applicator, I thought it would be a cream but it's like a tiny pessary.

The progesterone caps come in 50 but aren't readily available.

"I fear you have been ripped off TBH, paying for unnecessary tests and being given a load of tosh !" As in OP I needed to register with a GP to get meds, there was no other way to refill my usual prescriptions while away. Impossible to get the original scrip in the UK anyway as it's been out of stock for the last 4-5wks.

"That's a pay for treatment doctor!" I needed to pay as I needed the treatment 😀incl blood draw for thyroid meds etc.

"One thing I really trust about the NHS is that they don't over treat!" You can say that again. While I'm grateful for the NHS treatment I've received, it's been a nightmare getting it. I'm not saying the private GP has all the answers, that's why I asked the question here, to see if someone could shed some light on why there may be different protocols. GP's explanation was that the oestrogen and progesterone should be in the correct proportions and the test revealed that progesterone was low in proportion to oestrogen.

@crispinglovershighkick Maybe if you could say what regime you were on in the UK? Was it continuous or sequential?

I'm sorry but this dr you have seen is wrong on so many accounts. They are either trying to make money out of you, or simply not the meno expert they say they are.

There is no 'test' of any value for the ratio of estrogen to progesterone.

Post menopause, we don't have any progesterone. The only reason it is given is to stop the womb lining overgrowing (which could develop into hyperplasia and eventually cancer.)

Otherwise, HRT does not need to include it.
Women with no wombs ( hysterectomy) do not use any progesterone. There is no need.

Even if you are in peri menopause, the role of progesterone is the same.

The amount of progesterone needed is the amount needed to offset the stimulation of the endometrium. That is all.

I am 99.9% sure that a 50mgs capsule of Utrogestan does not exist. Besins who make it, list 100 and 200mgs.

There are some unscrupulous(private) GPs in the UK who run all kinds of tests (to make money) and also to prescribe unnecessary and often incorrect forms of HRT.

If you take a higher dose of Utrogestan, it will in fact reduce the benefits of the estrogen.

I was told by my consultant (who trains other drs on menopause) that ideally, women would only use estrogen, but of course they can't because of the risk to the endometrium.

I’m on continuous HRT.

GP is a GP, not a menopause expert. I am not in the UK at the moment, nor am I actively pursuing private tests and treatment in preference to my usual treatment.

I can only say once again that I needed refills, which she was happy to prescribe as is but asked if I would like to confirm if the dose was ideal, and said that they prefer to increase progesterone rather than oestrogen.

Anyway thanks for confirming that this is not standard.

She sounds confused and verging on malpractice. which country is this?

The dose you were on is the normal one all over Europe. all the research on HRT incl those types was done in Europe (especially France ) so it's rather puzzling she is giving you that advice.

The only reason to increase from 100mgs is to control bleeding which a few women have on continuous. But that would not be seen by blood tests, only by measuring the womb lining and, of course, bleeding. You would possibly feel awful on a patch of 50mcg and 200mgs utrogestan. I use the equivalent on a cycle (12 days) and do not enjoy the utrogestan days at all!

@crispinglovershighkick Jingling's not criticising your seeking treatment, but the GP's desire to give you lots of treatment! I lived in Singapore for a couple of years, and the GP there put my DS on antibiotics, liquid ventolin, and something else I can't remember, and wanted to do a biopsy for coeliac disease. They were very robust in prescribing!
He did have an inhaler a few years after we got back, but nothing else.

I agree NHS can be inclined to undertreat, though.

Thanks @picklemewalnuts You are right, I'm not criticising the OP at all.

I am confused about someone registering on a temporary basis with a dr overseas, and the dr questions the medication they use. All they are being asked to do is re-issue the current prescription. I can't see why it's their place to adjust it. (and the dose they want to prescribe isn't in accordance with prescribing guidance.)