Missed gel dose - bleeding issues when post-menopausal

[funnelfan]

Hi,

I'm post-menopausal (no periods for about 4 years) and started on Evorel Conti patches last year, and topping up with Oestrogel (3 pumps a day). All fine, symptoms managed ok.

Last week I had a couple of crazy days and realised I'd not applied my gel one day. Resumed the next day, I started spotting and that turned into a full bleed. I'm now on the 7th day of what I would characterise as a moderately heavy period. The blood is still bright red and fresh and the flow is not slowing down at all. My periods used to last 5 days max.

The gel label says missed doses can lead to withdrawal bleeds, so I am not panicking, but the length of time and the amount of blood is starting to worry me. Is this effectively 4 years worth of uterine lining that is being shed? Or could something else be going on - how long do I leave it before asking my GP? I had a polyp on my cervix a few years ago, and I used to get a bit of spotting with it before it was removed and the bleeding was nothing like this.

Ironically I cleared out a cupboard and got rid of a load of old san-pro a couple of weeks ago thinking I was done with all of this and I wouldn't want to use 5 year old Tampax anyway. Hahaha.

Can you explain why you are using Evorel conti and 3 pumps of gel? is this from your GP ?

The most likely reason for the bleed is you are using more estrogen than the amount of progestogen needed to offset that.

There has been a report by the British Menopause Society recently where they stated that women on 3 pumps of gel (classed as a high dose) may need more progesterone (200mgs a day on the conti regime) .

You are actually using a high dose of gel PLUS more estrogen in the patch.

The bleed is most likely because the uterine lining has build up and is not being controlled by the Everol because you're also using a high dose of gel (against licensing dose.)

Thanks.

The Evorel Conti didn't manage all my symptoms on its own, and I was told that I could increase the amount of oestrogen by using the Oestrogel on top. Started at one pump a day and have gradually worked up to 3 pumps a day to manage symptoms. I worked out that the daily dose of oestrogen from the patch is slightly less than one pump of the gel (50 ug vs 75 ug), so the amount of oestrogen I'm on is not outside typical prescribed levels.

I specifically asked whether the amount of progesterone in the patch would be enough to balance the oestrogen in the gel if I upped the dose and was told I could take up to 4 pumps a day of the Oestrogel while on the Evorel Conti patch. This was from the menopause specialist/practice nurse at my GP surgery, and the prescriptions have all been signed off by the GP.

Of course, we're all different and it could well be that I do need a higher dose of progesterone to prevent uterine lining buildup. I did think though that it was progesterone withdrawal that triggered a bleed, not oestrogen, so I don't really understand the mechanism of why a missed dose of gel caused this bleed.

Crikey, you are on a huge dose of oestrogen compared to the amount of progesterone you are getting. Urs no wonder you are bleeding.

The conti patch contains sufficient progesterone for the oestrogen in that patch only. Not for 3 pumps of gel aswell.

I worked out that the daily dose of oestrogen from the patch is slightly less than one pump of the gel (50 ug vs 75 ug), so the amount of oestrogen I'm on is not outside typical prescribed levels.

Whoops no!
The dose of gel is mgs and each pump is 0.75mgs (so 2 pumps = 1.5gms)

The dose of the patch is in micrograms . FAR lower.

The patch is a medium dose, so adding in 3 pumps of gel you're on a high dose, not being controlled by the amount of Norethisterone.

Looks like the nurse doesn't understand the difference.

It's nothing to do with missing a dose.
It's the lining shedding spontaneously as it's too thick.

You really need an appt with your GP for a scan because you might need a course of just Norethisterone to control the bleeding and reduce the lining.

1.5gms= 1.5 mgs (typo)

For reference here are the doses of tablets, patches and gel.

https://www.menopausematters.co.uk/postmeno.php

1 pump of oestrodiol is 750micrograms of oestrogen, 10% of which is absorbed through the skin so the actual dose received is 75 micrograms.

"5.2 Pharmacokinetic propertiesAbsorption
Pharmacokinetic studies indicate that, when applied topically to a large area of skin in a volatile solvent, approximately 10% of the oestradiol is percutaneously absorbed into the vascular system, regardless of the age of the patient."

https://www.medicines.org.uk/emc/product/353/smpc

One gram of gel contains 0.6 mg of the active ingredient, Estradiol (0.06% w/w).
Each pump actuation delivers 1.25 g of gel which contains 0.75 mg of Estradiol.
For the full list of excipients, see section 6.1

From the link you left.

You are confusing micrograms and milligrams.

jeez that’s a lot of oestrogen!

have you upped the dosage yourself or is it prescribed ?

I'm really not. 1 milligram = 1000 micrograms.

So 1 pump delivers 0.75 milligrams of estradiol. 0.75 milligrams = 750 micrograms. 10% of that is absorbed through the skin, therefore you receive 10 % of 750 micrograms, ie 75 micrograms.

As @Runaround50 also said, the Norethisterone dose in the patch is the ratio for that amount of estrogen. It's not enough for another 2.25mgs gel.

You can't compare patches and gel in the way you are trying to.
Please see your GP.

The nurse who said you could do this is wrong.

This is why you have bleeding and you should be referred for a scan.

Jingling is 100% correct. You are taking a very high dose and need to see your GP to discuss

Agree with @JinglingSpringbells
You are using way too much oestrogen to progesterone.

Be very careful.
You need to review this with a knowledgeable medic.

You absolutely can compare patches and gels as they are both transdermal routes of administration, and the product leaflets give all the information on the actual doses of drug that the body receives. Transdermal administration is actually a very inefficient method of drug delivery but it is popular as it avoids so many of the side effects of oral administration.

For example, Evorel Conti contains 3.2 milligrams (ie 3200 micrograms) of estradiol per patch, but we only absorb 50 micrograms per 24 hours. "EVOREL CONTI has a surface area of 16 sq cm and contains 3.2 mg of estradiol corresponding to a nominal release of 50 micrograms of estradiol per 24 hours and 11.2 mg of norethisterone acetate corresponding to a nominal release of 170 micrograms of norethisterone acetate per 24 hours" https://www.medicines.org.uk/emc/product/10929/smpc

So 1 pump of oestrogel is of the same order of magnitude as the amount of oestrogen in 1 patch. I am receiving 275 micrograms of estrodiol per day, (50 from the patch, 225 from 3 pumps of the gel) which is within the standard medium-high range published by the BMS https://thebms.org.uk/wp-content/uploads/2022/12/03-BMS-TfC-HRT-Practical-Prescribing-NOV2022-A.pdf

I agree that I need to revisit whether the amount of noethistrone is enough for me and whether actually 1.5 or 2 patches would be better. But you are massively overestimating the doses the transdermal products give you.

You still haven’t told us if you are self prescribing or the doctor has told you to do this.

I did in my second post - this was all done under the supervision/agreement of the menopause nurse at my GP surgery, and the prescriptions signed off by the GP.

On the link I left to menopause matters, on HRT for post meno, you can see this:

POST MENOPAUSAL -
Continuous combined therapies.
"Period free" or continuous combined therapy can be used by women who are 54 + yrs, or more than one year since last period at any age. The criteria should be fulfilled in order to offer such treatment to women who no longer have a continuing ovarian cycle, so that steady levels of both estrogen and progestogen can be achieved. When there are steady levels of estrogen and progestogen from daily administration of both, the womb lining stays thin. Although some bleeding in the first 6 months of therapy is common, there should not be bleeding after that and the lining does not go through the stages of stimulation and then shedding as it does during a normal cycle and with sequential therapy. Start with low dose preparations and increase as necessary for symptom control.

Seriously, it's not just about finding the right dose of progestogen, you need a scan to see if the lining is ok now after the bleed or if it's not (and is hyperplasia.) If it's still thick they may suggest a biopsy. The treatment can be several weeks of daily Norethisterone or the Mirena coil.

Good luck with it all and hope you get on ok.

that’s what I need to know thanks, whether I’m justified in being concerned about why I’m bleeding so heavily and whether there anything else going on. Ive only been on 3 pumps for about six weeks so hopefully no long term issues have developed and this bleed has cleared it all out.

To assure you, it’s not like I’ve decided this myself, I went in the patches first, they were fab but after 3 months some symptoms came back and the menopause nurse cheerfully said, oh you can just top up with the gel. So I started on one pump of that in addition to the patch. I remember the conversation on whether the progesterone equivalent in the patch was enough to balance the oestrogen and she said, oh yes you can take up to 4 pumps of the gel, it’s all fine and the patch can cope with that. At my 6 month review we agreed I should go up to 2 pumps of gel, and she said if I needed more in the future I was clear to go up to 4 without further review if I felt my symptoms warranted it.

im going to go back armed with the report you mentioned that says patients on 3 pumps may need more progesterone and see what she says. I think long term two patches instead of one would be better.