starting HRT & migraines?

[Leafbuds]

I'm thinking about going to my GP and asking about starting HRT. I'm 53 and used to have migraines at the start of my periods (and occasionally other times) but haven't for about fifteen years, until a few last year as my periods were winding down. The thought of the cyclical HRT and the sudden changes in progesterone levels have made me slightly wary about starting HRT, as has the idea of having to have a bleed again, so I was kind of waiting until I'd been a year period-free so that I'd be more likely to start on the continual regime. But I know there are some in-between schedules that might be suitable, so was thinking maybe I should go and speak to the GP sooner. I'm not sure whether she is much of an expert in the area or not - I've not been in since before covid and it'll probably be a phone call anyway.

I've had lots of hot flushes, though maybe slightly fewer now, and also worried about osteoporosis (had a dexa scan after a fracture recently, and I'm OK for now - slightly low but not bad for my age - but it's on my mind) and dementia (massive family history). Not sure whether to explain all of those things or really just say it's for the hot flushes and leave it at that. I don't think I have many other symptoms, but of course it's a bit hard to know as some of them are fairly subtle. Things like itching, plantar fasciitis, weight gain, have so many other causes but could possibly be related. On the whole though, I don't seem to be having the problems some women have, so then I'm questioning whether it is worth the risks?!

I had a couple of periods last summer, so 7 or so months ago, and before those two, nothing for the previous 6 months, and then sporadically the year before that. And no signs at all of ovulation any more, when I used to be able to tell fairly clearly when it was happening. Is that likely to be infrequent enough that I'd be given the continuous version?

I think I want patches for the oestrogen rather than gel - is one brand better/more preferred than another? My GP will almost certainly go for whatever is cheaper and/or meant to be given as a first line option, as she is very keen on following protocol, so if I want something specific, I might have to push for it.

I want to reduce the risks of things like breast cancer, etc as much as possible, as well as reduce the likelihood of migraines coming back more seriously, so I guess the best option for progesterone would be the tablets, because they are body-identical, is that right? I'm certainly not having a coil, and I don't know enough about the risks of the type used in the combined patch, but I thought I read they were higher - though I have to admit that a combined patch sounds quite convenient!

I have medicated high blood pressure.

Any words of advice on what to ask for? Push for continuous (or a version of this) schedule to hopefully reduce chance of migraines, or is that too risky if it's only been 7-8 months since the last period, even though it was quite a long gap before then? Go for tablets and patch combination as the least risky? What type/brand of patch best to start with? Is it something to build up the dose in order to reduce risk of migraines coming back?

Most women now use transdermal and this is especially so if you have migraine.
Patch, gel, spray.

You can use Utrogestan as the progesterone, or a combined patch which has a transdermal version of Norethisterone (another progestogen.)

TBH I'd not overthink it.
I have had migraine all my life and used to get a pre-period migraine, but once I started on HRT I dont have them (not linked to hormonal cycles, anyway.)

It's best to start on sequential. This way you are testing the dose of estrogen before the progestogen kicks in (for half the month.)

I was early 50s when I went onto HRT. (I see a consultant gynae.)
I was started on long cycle HRT which was 10 weeks of only estrogen, then 12 days of progestogen.

This is acceptable (it's in the NICE prescribing guide.)
It's for women who are intolerant to progestogen but it's also suitable for other reasons.

There isn't a huge choice of patches (ie brands.)
Women say they like Estradot as it's small, but there are often supply issues.

If you can afford it, it's worth considering going to a private meno specialist where you can discuss all the things you've said here. You'll get 45 minutes and expert advice (if you choose someone good!)

thanks, interesting thought about starting on a cyclical regime to get used to the oestrogen dosage. Really not keen on starting bleeds again though, so hope I don't have to - the 10 weeks + 12 days sounds more reasonable, so she might suggest that if it's in the guidelines.

I think my migraines were caused by the sudden change in hormone levels, so that's why I'm less keen on the cyclical version.

I don't think the transdermal progesterone is supposed to be as low-risk as the tablet form, so while I'd rather the patch in some ways, I'm not sure whether the risks are worth it, if it's not body-identical. Maybe it's not so bad though in those doses. I'm much keener on trying patches than gel or spray for the oestrogen certainly; wasn't sure whether to push for a certain brand or not - smaller sounds better, but not sure I will be able to choose to start with, but we'll see. Also I expect I'll have to start with the tablet progesterone, as the combined patch only seems to be for higher doses of oestrogen, and I presume they'll start me on the lowest dose to see how I respond.

Don't think I can really afford any private consultations, but then it's weeks to get to have a call with the GP, so I might end up that way. Or I'll just keep waiting as I guess there's not any real need to take it, if I'm coping with the hot flushes.

anyone else with experience with migraines, and whether the cyclical pattern and sudden changes in progesterone dose have caused any problems ,or indeed been advised of any risks given migraine and blood pressure history?

Mirena coil and oestrogen patch is gold standard for migraine sufferers, as more stable hormone levels

I really don't want a coil though, and no need for contraception either, though I can understand how the stability might be useful. I am not at all keen on the idea though!

Fair enough, although potentially less likely to get systemic progesterone side effects from mirena. I’d expect they would suggest patch plus micronised progesterone then. At 8m post last period I’d be happy to start continuous, if you get erratic bleeding could easily switch to cyclical. If you have a look on the balance menopause website they have lots of helpful info and a menopause and migraine fact sheet.

Your options are

Estrogen as a patch, gel, spray (not a tablet.)

Progesterone as Utrogestan (micronised progesterone and body-identical), Norethisterone (tablets or in all combined patches -used in the 2nd half of a month for cyclical), the Mirena coil.

Yes, I know. I was not considering tablets for oestrogen (nor gel nor spray, if I can get on with patches, which are my preferred option I think).

I'm weighing up whether I would want to consider the synthetic progesterone for the combined patches, or whether I would only want the body-identical version of the tablets. I think I would find the combined patches more convenient, but I am not sure I'd want the higher risk of the synthetic progesterone in them. I also am not sure I'd be started on them anyway, as they have a higher oestrogen dose than the minimum available in separate patches, and I expect I would be started on the lowest dose unless there is an obvious reason.

I'm not really considering the coil unless I have to as a last resort.

Thanks, yes I think that sounds like the most likely combination.

I really don't want a coil, but if I did start to get migraines again, then perhaps I would have to consider it. I think I'd find it all a bit traumatic, and as I have no need for it for contraception reasons, it seems more trouble that it's worth, but I will keep an open mind.

Continuous sounds good from the point of view of less bleeding; I"m not really having any natural cycles at all now, and no ovulation, so I'd hope there would be no erratic bleeding. So I hope they agree that it would be a good option - though I know it is a bit higher risk for cancers etc, so I guess I should discuss it - not sure what else they can say though, it's a risk I have to decide on.

I don’t think continuous is higher cancer risk. It’s the same dose overall (100mg daily rather than 200mg for 2 weeks on/off) and continuous gives better endometrial protection over time, so in theory should reduce endometrial cancer risk. Hope you can get sorted with the GP appointment :)

I've suffered with migraine with aura since I was 13 and have hrt - patches and utrogestan pills. My migraines have stopped again (they reappeared after 15 years with peri-menopause). There are quite a few options available to you. Have a read of NICE guidelines and search for specific conditions that you're worried about so you know what you should hear. I was given mis-information and challenged it. Got sent to the gynae clinic at the hospital, as my GP refused to reconsider. They said it was fine, and my GP will follow their advice, but I had to push.

Thank you! Glad to know you were able to find a successful combination. What dose did you settle on? Did you find the continual regime better in terms of hormonal stability? Did you start on quite low dose oestrogen?

In terms of longer term conditions, it's dementia I'm most worried about, but I know that the research on that is incredibly mixed and nobody really has an answer. I'd like to protect against osteoporosis, which I think there is decent evidence for. I have high blood pressure, along with the migraines, which worries me slightly in terms of stroke risk, but I think the transdermal type seems OK for that. Cancer risk doesn't seem too high, but it's always still a vague concern, part of weighing up whether the protective factors of HRT are stronger than the concerns about cancer or stroke or whatever.

Or I could just not take anything, as I'm dealing with the hot flushes - not pleasant but not absolutely awful any more. But I do think the benefits for bone health might be good, if the other risks are mitigated as much as possible. It is harder to work out what dose is the best, though, if I'm taking it more for protective factors than to eliminate certain symptoms.

I have migraine and am on HRT. I was advised to do continuous as hormonal fluctuations were already a major migraine trigger for me. Peri had also triggered migraines as every time I had a hot flush, I had a migraine.

To some extent the decision was made for me as I was already on the progesterone only pill to stop the menstrual migraines so staying continuous was obvious.

Options were: Mirena coil or Utrogestan + patches or gel. As you aren't having any cycles these would be your options. You could have combined patches but I absolutely did not want Northisterone as it is associated with the risk of breast cancer.

I opted for the Utrogestan as really didn't want a Mirena (but my best mate swears by hers!) + patches as didn't want to be applying gel.

It's been great for me, stopped the hot flushes and associated migraines. Bearing in mind I already have very tricky migraine so it can definitely be done.

Thanks, that sounds like the combination I will try to go for I think, patches plus the utrogestan. The risks of the synthetic progesterone in the combined patch do worry me a bit, so tablets seem better and though less convenient, I take enough other tablets daily so it'll just be one more, especially if I can get the continuous ones.

What dosage of oestrogen patches did you go for? Did you experiment much with that? If I don't have hugely debilitating symptoms - just the hot flushes - and want to take it partly for protective reasons for future health, it will be somewhat harder to know what is the right dose, whether to go for the minimum that deals with the hot flushes and doesnt' cause other issues, or the bigger dose if I can tolerate it in order to get more protection.

Is it the utrogesten that there is a shortage of as well as the patches? I don't really want to start something and then not be able to continue it, which will cause more fluctuations!

It does @littlejellyfish It's in all the medical research stats.

It's not the dose it's the regimen.

The breasts supposedly are at a higher risk if two types of hormones are taken daily, without a break. The theory is that any irregular cells in breasts die off when they are given a break from progestogens. (This is a very simple way of describing it.)

Endo cancer is far easier to treat IF it occurs.

@Leafbuds I think you need to be willing for some trial and error.

Many women on HRT have migraine- some get better, some worse, some the same.

Patches: there is Estraderm, Evorel and Estrodot. I honestly find them quite interchangeable but definitely have a preference!

Estraderm - absolute shite. Massive and doesn't stick. OK if you cover it with a film dressing such as Opsite.

Evorel - personally my favourite. Mainly because it sticks but is easy to get the remnants of the glue off

Estradot - most people's favourite. Smallest, the stickiest. I got fed up of having rings of glue from old patches over my legs

Shortages seem better but that's why I've had all 3 types, just swapping to whatever I can get at the time. Utrogestan shortages also better.

Dose wise you start small and work up. I started at 25, immediately felt better but then the flushes were back. Am now at 100 and no flushes. I don't think there is evidence that higher doses = more bone protection.

Finally have you thought about vaginal oestrogen? It was really important to me not to end up like my mum with endless UTIs.

I don't think there is evidence that higher doses = more bone protection.

The dose is directly related to bone density/protection.

If you look at the HRT types on Menopause Matters, it gives the amount needed for bone protection or treatment. There is an * beside the HRT that is licensed for bones.

eg 2 pumps of gel is suggested.

I started very low - 12.5mg patches and went up to 25 after a month, then 37.5 and to 50 etc.. I'm now on the NHS max. of 100, but some symptoms have not totally disappeared (insomnia and hot flushes). They are much reduced, though, so overall I'm happy. I am aware that my weight is a much bigger breast cancer risk than my hrt, but didn't look too much into the other types. My consultant has said that she's happy for me to continue into my 60s and discharged me from the hospital clinic.

I've always had migraines linked to hormones, as I got nearer the menopause they became horrendous. I've been on HRT for a year now, but recently have had to change from patches to gel and tablets, my body wasn't absorbing correctly on the patches and I was becoming unwell.

I'm a month into the change over, I didn't want the gel initially as I thought it would be a faff, but I've slotted it into my morning routine fine.

thanks for the experiences/advice. It sounds like it will be worth a try, if I can get a GP appointment, and then a bit of experimenting if needed. I'll ask to start on patches and Utrogestan if I can and see how it goes. It looks like 50mcg is the typical amount, although the minimum useful amount seems to vary according to different sources. But hopefully I will either start on that or go up to it if I start lower.
I am also quite overweight, so I know that is a risk for cancer and other things as well - trying to deal with it but it's hard!