Peri and HRT advice

[Kat2106]

Hello ladies. I need a bit of advice.
I am 48, still with regular periods and ovulation. I have had some very mild peri symptoms for a while but nothing to bother me much. But 3-4 month ago it got really bad – mainly anxiety.
I started Lenzetto spray – for the first 5 weeks all was going ok – symptoms were slowly easing. But after 5 weeks I started to feel really nauseated, my boobs started to hurt.
The nausea was getting worse so I came to conclusion one spray is too much for me. So about 8 days ago I started on a lower dose

• about a quarter. The problem is – my boobs are still hurting, my nausea is not gone but my anxiety is getting pretty bad again. I am guessing, I simply unbalanced my system by lowering the dose – any advice how long I should wait it out before I start fiddling with the dose again? My second question – would you say my assessment of the one spray being too much is correct or is that possible that the Lenzetto itself is the problem? My head is spinning with all the different ‘what-if’ scenarios so I would be very grateful some balanced opinion.

Just to add, for the moment I am not taking any progesterone. As I am still ovulating and my body is producing its own, I decided to fix the estrogen part first.

Please talk to a healthcare professional before 'fiddling' with your dose. Also read the leaflet that comes with it.

I'm the same age and on a oestrogen gel and progesterone tablet combination. Seems to work for me but I will have meltdowns and moods. And the occasional 'flash' period (always a delight and keeps me on my toes). Good luck, I hope you find the right balance for you.

It's a bloody nightmare. No pun intended.

@GreenFingersWouldBeHandy I got the Lenzetto prescribed by gynecologist with words - don't be afraid to experiment a little.
My idea was to lower the dose until the nausea and sore boobs disappear and then tweak the dose a bit if needed.
Just sooo confused right now.
In my next life (if there is such a thing) I want to be a man!

@LoveMAFS wow, that's quite some supportive message particularly as you know nothing about my life

You shouldn’t be taking unopposed oestrogen. You should also be taking progesterone (either as oral micronised progesterone) or as a Mirena IUS.

It’s nothing to do with still ovulating, you need the progesterone for endometrial protection.

You can play around with the dosing slightly, but usually after the 2-3 month mark as the surge in oestrogen can initially cause breast tenderness, nausea and headaches. It usually settles.

Please make sure you take some progesterone!

@Sidge i am just about 3 months mark and the problem is the nausea and painful breast started in the second half of that period and was getting worse. Hence the conclusion the dose is too high.
I am not planning to not take pregesterone at all. I just want to fix the estrogen part first - something that was ok-ed by my gyno.

I am astounded that a gynae is letting you take unopposed oestrogen, but then that’s their call I suppose. I do hope they’re going to offer you regular endometrial assessment via scans.

At the three month mark I would start tweaking the dose, it’s harder with Lenzetto but you could take it alternate days?

I am also surprised that you are only taking oestrogen alone. I am also 48 and take a massive dose of oestrogen and have a mirena.

For reasons of an inconsistent GP and oestrogen shortages I've done plenty of tweaking, and found more oestrogen was better than less, testosterone is the ambrosia of middle age, and that a massive does of oestrogen and the testosterone mitigate the unpleasant side effects I had when I used a mirena 10 years ago.

@RuthGalloway i tried upping the dose when the nausea started - I spent two days hugging the toilet bowl - that was what started me thinking my nausea is from having too much estrogen rather than too little.

What reason has your HCP given for allowing you to take just oestrogen? You need the progesterone to ensure the womb lining stays thin and I don't think it's a case of giving yourself months to tweak your oestrogen dose first

You need progesterone now.

I am still ovulating, meaning the dominant follicule, after releasing egg, changes to corpus luteum which is what produces progesterone. So my tiny bit of extra estrogen is not completely unopposed. My progesterone levels are within normal range.
Also, this has always been only short term plan. I am extremely sensitive to any new medications, supplements, etc - so we decided to take it one a time so if I feel unwell we know what needs tweaking.

I think you need a second opinion as taking oestrogen without progesterone is really odd.

thank you all for your concerns about progesterone. I know it's perhaps not the orthodox approach but there are reasons and logic behind this short term plan.

Would anybody like to help me with my original questions please?

Oestrogen can make women feel sick and rubbish even after a positive initial few weeks but things may improve again.

You've 2 choices, stick with one spray and power through, the nausea may well settle down, or stop completely. Or, maybe ask for oestrogel? Easier to titrate doses as it's a gel so start with one pump then go to 2. Must be tricky trying to do this with sprays.

As others have said you should be taking progesterone even if you are still ovulating. Fine for the initial few weeks but not after that.

@Janiie why do you think my only options are to power through or stop completely?
I actually found relatively easy way to titrate Lenzetto - just bit of math and some plastic with holes. obviously, not 100% but considering Lenzetto dosage does not seem to be consistant depending on how long you used the canister, it's relative accurate.

Sorry of course there'd other options, trying other types etc.

My point was many women suffer fluctuating nausea in the first few months despite initial improvements so it may be worth persevering. It isn't an exact science.

Keep to a smaller spray and see how you go.

@Sidge Just dropping by to explain....the 3-month regime is in the NICE guidance, as being suitable for all women, in peri or post menopause.
There is also a tablet form of HRT called Tridestra, that is 10 weeks estrogen-only then 14 days of estrogen+progestogen.

I was started on exactly the same regime as @Kat2106 Not the spray, but gel. I was on a 3-monthly cycle from a specialist for years.

NICE
Regimen
The hormone replacement therapy (HRT) regimen used depends on whether the woman is perimenopausal, postmenopausal, the route of administration, and the woman's wishes.

Combined HRT can be prescribed as a:
Monthly cyclical regimen — oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days, depending on the type of progestogen. The suggested dose of progestogen given in a continuous combined HRT regimen is a minimum of 0.5 mg/day of norethisterone or 2.5 mg/day of medroxyprogesterone acetate.

Three-monthly cyclical regimen — oestrogen is taken daily and progestogen is given for 14 days every 13 weeks.

Continuous combined regimen — oestrogen and progestogen are taken daily.

For perimenopausal women, monthly or 3-monthly cyclical regimens may be used.

A 3-monthly regimen may be more suitable for women with infrequent periods or who are intolerant to progestogens. See the section on adverse effects for more information.

A monthly regimen produces monthly bleeding whilst a 3-monthly regimen produces a bleed every 3 months.

A continuous combined regimen is not suitable for use in the perimenopause or within 12 months of the last menstrual period.

For postmenopausal women, monthly or 3-monthly cyclical regimens, or a continuous combined regimen may be used.

Many specialist consultants will suggest estrogen-only for a while to get the dose right.

This is completely logical as adding progsetogen makes it unclear which hormone is causing side effects.

No one is going to develop hyperplasia in 3 months. Most women are going that length of time or much longer in peri with only a period now and then- hence the flooding and so on.

The stats- if 100 women use estrogen-only for a year, hyperplasia will develop in 20. Of those 20, most hyperplasia will be 'simple' and a very small number may develop a pre-cancerous lining or cancer.

@JinglingSpringbells thank you very much for the reminder about the 3 month cycle regimen. I was getting a bit panicky about not taking progesterone after all the posts here.
I'm going to try half a lenzetto spray and just pray the current anxiety will subside at least to bearable level and then i'll introduce progesterone.
I feel sooooo bloody aweful right now....... and still years of this to come

'thank you very much for the reminder about the 3 month cycle regimen. I was getting a bit panicky about not taking progesterone after all the posts here.'

I think posters were just concerned as you said you were just at the the 3month point and didn't seem to he suggesting incorporating progesterone anytime soon but as long as you're fully informed then fine. Good luck, hope the nausea settles.

@JinglingSpringbells I know but the OP seems to think she doesn’t need progesterone at all due to her still ovulating, which isn’t the case at all, and makes no mention of it being in the pipeline.

I wouldn’t want other women reading this thread to think that’s an option.

@Sidge I think you misread my post completely.
I only said that because I'm ovulating and thus producing my own progesterone, I can 'afford' the short term plan of being on estrogen only

@Kat2106 you didn’t exactly say that but it’s become apparent now.

Anyway I hope you feel better soon.

I think she just explained it badly and in the wrong order.

It's possible her consultant said that to her- that in peri, she's still producing her own progesterone, so it's ok to not take any for a few weeks and get the estrogen dose right.

Because Tridestra is not prescribed very often, (and it's been around for a long time), most women aren't aware of the 3-monthly option it gives, which can be replicated by 2 different items (estrogen + any progestogen) but most GPs aren't experienced or trained enough to start offering that kind of regime.