How to get right dose of HRT

[Hrtquery]

Age 45. Have been on HRT about 2 years. A few months ago I switched from oetrogel/cyclogest combo to evorel 50 patches. This meant reducing my dose a bit (was on 3 pumps a day of oestrogel, so equivalent of evorel 75).

Was ok at first but the last six weeks have been horrendous (extreme PMT all month, night sweats, terrible sleep). And now today I appear to be getting my period 10 days early. I have an appt to speak with the pharmacist next week but just wanted to get some other opinions.

First, does this mean my dose is too low?

And second, should I now start a new cycle? I applied my third (of four) conti patches last night. Should I go back to the sequi ones now and start again? I don't really want to get another period in ten days!

My opinion on what might be happening is your natural hormones are surging at and so you’re experiencing symptoms plus your adding in additional hormones with the HRT. I only say this as I was similar in that my oestrogen was off the scale recently and I felt awful. I have private HRT and private hormone testing so I could see how out of range I was. My oestrogen dose was dropped right down as a consequence. I’m currently still not feeling good. Waiting for things to settle down. That’s the difficulty with the peri menopause I think. The hormonal fluctuations. In terms of how you best deal with it I’m not sure. My private GP’s message seems to be that the overall aim of treatment is to balance the hormones and I’m clearly not there.

I'm confused.

And second, should I now start a new cycle? I applied my third (of four) conti patches last night. Should I go back to the sequi ones now and start again?

Conti patches are oestrogen and progestogen.

Sequi is a regime with 2 weeks of estrogen only then 2 weeks of estrogen + progestogen.

Can you explain?

Oh dear, yes sorry I am very sleep deprived and mixing up my terminology.

I am on the sequi regime - four evorel 50 patches and four conti patches per month. Wanting to know if I should ask to switch up to evorel 75 (as part of a sequi regime) in the future, and also if I should take off my conti patch today and apply an estrogen only one instead so that I can start a new cycle (as opposed to waiting for 10 days to start new cycle).

Thank you that's really helpful. I totally assumed that this was due to a reduction in oestrogen, it didn't even occur to me that my oestrogen might be too high. I wonder if the amount of progesterone in the conti patches is the same as with cyclogest, maybe that's also an issue. So confusing!

If it turns out that your oestrogen is too low, you can top up the patches with a pump of oestrogel.

It's such a nightmare trying to work out the right dose. I'm on the Evorel Sequi regime and I top up with gel. I think I'd like to cut out the gel and see how I feel on just the patches but I'm scared to tinker with it.

Thank you, I'd thought about doing this but I was concerned that then maybe there wouldn't be enough progesterone to oppose the amount of oestrogen?

The BMS guidance is that using more than 100mcg patch means you may need to use more progestogen.

Had your periods stopped at 43 or were you having peri symptoms?

I wouldn't over think the progestogen side of it just yet. If you are using the correct patches in the right order, the early bleed is more likely to be your own cycle breaking through ( because you are still very young!)

You can easily go up to a 75mcg patch.

Why did you swap from gel/ cyclogest?

You should follow the regime as normal and not swap to estrogen only just yet. The HRT sets a cycle and it's better to try to follow that even if you have a blip.

I was actually prescribed initially as an attempt to fend off PND (by a private Dr). Now 2.5 years postpartum and having peri symptoms so just carried on with it.

Thanks very much for the guidance. I'll stick with current regime and ask if I can go up to 75. It does feel a bit like my "natural" cycle is out of sync with the HRT induced one at the moment. Do you think that going up to 75 will help to sync them up?

Also, as an aside, is there a reason why I couldn't use progesterone throughout the month? I think that I may feel better during the weeks when I'm using the combined patches versus when on the oestrogen only ones. I'm aware that the conti regime is usually recommended only for post meno, but not sure why.

Do you think that going up to 75 will help to sync them up?

No. The only benefit of a higher dose is an improvement in your symptoms. The downside is you may bleed more heavily.

Also, as an aside, is there a reason why I couldn't use progesterone throughout the month?

You could try this BUT the downside is that even in women post meno it can take 6 months to get the lining thin (balanced by the 2 hormones) and they often get spotting during that time.

The downside for women your age is that your own periods might break through at odd times.

But you could always give it a whirl.

@JinglingSpringbells
You are a fount of knowledge. Thank you so much!

@JinglingSpringbells i wonder if you you or anybody can help/advise. I take sequential Hrt, changed from 75 patches to gel recently as I seem to absorb this better, however, within 3 days of taking the utrogestan the insomnia is horrendous!! I feel like a walking zombie. Could this be too much oestrogen? I’ve read lots of previous threads suggesting to take the utrogestan vaginally for 12 days & 100 mg. Alternatively as I’m 52 & have been on sequential for 3 years would you suggest I move over to continuous Hrt for more balance? Thank you

@MiaFl I think I'm going to post the BMS guidance on this as a new post because it's the 2nd time today this has come up.

Utrogestan is a known sedative. It can take a while to get used to it and that's why drs say give it a few weeks.

To avoid this, you can use it vaginally but it has to be at the same dose as orally.

(There was a dr a while ago who was advocating half the dose when used vaginally but this isn't correct and the BMS has issued guidance to this effect.)

If you want to swap to combined continuous, you could try it but you would still need 100mgs a day. You should expect some spotting in the first 6 months is using any combined continuous hrt, and if you aren't actually post menopause your own periods might break through.

Being 53 isn't a guide to being post meno- some women aren't till they are 54/55.