Bleeding on HRT for 9 months.

[Carsong]

I’ve been bleeding on HRT for a while now. Had the investigations, 2 polyps removed. Changed to Evorel Conti 50 in June but still bleeding. My doctor has advised to increase the dose to 75 mcg and says it’s fine to cut the patches in half to make 75 mcg. She says that increasing the oestrogen dose should help with the menopausal symptoms I still have and that the increase in progesterone should stop the bleeding.
Thinking about it though, I’m worried that the increased oestrogen will cause the bleeding to continue. I’m not convinced that the increase in Progesterone will stop the bleeding since I’m upping the oestrogen dose too.
I’m worried that the increased oestrogen could stimulate more polyps.
My Doctor is advising this after doing further training in Menopause and HRT.
I’d like to be able to read the evidence for this myself but I can’t find anything on how to manage post menopausal bleeding once it’s been investigated.
What is the HRT solution for women who have wombs that like to bleed? 50 mcg Oestrogen is as high as I’d rather go on HRT.
I think I need more progesterone.
I’d rather avoid a Mirena coil.
Apparently, bleeding on Utrogestan is common, but is that because the dose needs increasing, needs to go vaginally?
Does anyone know what Louise Newson or other menopause specialists would advise?

There seem to be some 'flaws' in your dr's assumptions about doses.
The ratio of estrogen and progesterone in the patches (if you use 1 and a half) will still be the same. You won't be getting more progesterone.

The main point is why are you now using combined continuous HRT?
Are you at least 12 months post menopause,(no period for 12 months) or age 54?

Were you bleeding irregularly on sequential HRT?

Changing to combined continuous usually always results in erratic bleeding for up to 6 months (so you're not quite there yet!)

If you aren't over 54 or post meno, you should stick with sequential HRT.
That will give you a predictable monthly withdrawal bleed.

If you really want to use combined continuous, you may have to change products.

You could use an estrogen-only patch, and a separate type of progestogen.
This could be Norethisterone tablets (that's what' s in the patches but the dose might be changed) or Utrogestan (and the dose would be individualised to manage the bleeding.)

These are the type of options you'd get privately, rather than just a box of patches or tablets.

Tried to edit- bleeding on Utrogestan isn't 'more common' (who told you that?)
It's used vaginally to avoid some side effects, like feeling sedated , but used in the right amount it is effective.
Unlike patches or pills, the dose can be increased in women who are on higher doses of estrogen (75 or 100 patches) if they find they are bleeding.

Because I was on 4 pumps of Oestradiol my Utrogestan was increased to 200mg every day (continuous HRT) from Xmas.
Still bleeding so finally decided to try the Mirena last week - no problems so far and no bleeding yet, fingers crossed.
I’m just praying the Mirena has finally sorted it.

I’m late 50’s so post menopausal. I was on Evorel 50 and Utrogestan 100 orally at night when the bleeding started. Changed to Evorel Conti in March (I think) asking for 50’s but too scared to use the full dose whilst waiting for investigations so cut in half.
I’ve never taken sequential HRT, I only started using it more than a year after stopping my periods.
The doctor told me bleeding is common on Utrogestan.
Went back up to Evorel Conti 50’s in June after reassurance from consultant after 1st hysteroscopy.
To me it would make sense to try a double Utrogestan dose and Evorel 50’s, possibly sleeping better with this dose.
I wonder if the timing of the polyps and the higher Evorel dose might have caused the polyps or possibly could be avoided with more utrogestan.
I will have a read about Norethisterone tablets too.
It does say to stop eating 2 hours before taking utrogestan, something I never managed to do, so possibly my fault it didn’t work. I’d be willing to try harder though to get this fixed.
I don’t think a mirena coil would be an option as the consultant who did the first hysteroscopy had difficulty opening my cervix. What if it’s difficult to remove? I’d be willing to try it if I could have reassurance that it wouldn’t be a problem.
There’s plenty of information on HRT but there doesn’t seem to be any for patients on management of bleeding. Very difficult to make an informed choice on the safest most effective way forward. It seems like we’re all at the start of learning about this together, including the GP’s.

It's not entirely correct that bleeding always happens more with Utrogestan. It can happen sometimes, but that's because the synthetic types like Norethisterone, MPA and Provera are more powerful- but they also come with side effects.

Taking Utrogestan WITH food doubles its effectiveness.
The reason the info says take on an empty stomach is to reduce side effects that may occur and would be 'enhanced' if taken with food. You can take it however you like.

There is quite a lot of info available from the BMS om bleeding and HRT.
https://www.menopausematters.co.uk/postmeno.php Some info at the bottom of the page.

https://thebms.org.uk/wp-content/uploads/2021/10/14-BMS-TfC-Progestogens-and-endometrial-protection-01H.pdf

This was written in 2021.
See page 6.

The guidance is to increase progesterone. So that would be 200mgs daily not 100mgs.

@JinglingSpringbells Thanks for sharing your knowledge and advice that makes complete sense to me. I’ll have a read.
I think I probably do need the 75 mcg dose of oestrogen. I’ve been out for a run today for the first time since upping the Evorel Conti patches to 75 mcg. For the first time since this bleeding started I’ve had no bladder leakage.

…interesting that the BMS says that continuous combined regimes can have micronised progesterone added to the regime as a solution to unscheduled bleeding.
Maybe that would be an option for me. I can’t see the current prescription working unless the progesterone part is changed to be relatively higher than the oestrogen part.

@Carsong you could then try 75patch and higher dose utrog, that way you can titrate the oestrogen and progesterone separately to manage symptoms and bleeding x

@JinglingSpringbells , can you please share the literature you have on synthetic progesterones being more powerful and that taking Utrogestan with food is doubly effective. I’d feel more confident about the way forward if I could read about it.

@Christine0708 , so swap out the Evorel Conti 75 with say Utrogestan 100 for Evorel 75 and Utrogestan 200 maybe?

Is there any evidence to say that Utrogestan PV is more effective, is the NHS offering this route yet, is the dose different?

Well I finally have different HRT to try… I have Oestrogel and I’m wondering if there’s a safer place to put it? The doctor said to spread each pump over a surface area the size of an A4 sheet of paper and the instructions say mid inner thighs. A4 sheet size would be too high up and round to the front and back of my legs.
Is it actually safe to put it on shoulders or outer arms? Isn’t it too close to breasts? The instructions say to alternate the application sites.

I also have Medroxyprogesterone 5mg tablets to take at night continuously. Does it need to be taken on an empty stomach? No leaflet enclosed so any advice/ experience of this prescription, especially to resolve bleeding on HRT would be great.

I know there are unqualified self proclaimed experts on this board but your latest questions are best answered by a medical professional I think? Part of your question is about risk of cancer I assume, I wouldn't be relying on the internet as your own medical history is a factor here. Have you thought about seeking out a private specialist if you don't feel you're getting the support and advice you need?

I feel for you, having been through similar earlier in the year it can be so hard to get the oestrogen/progesterone balance right. My bleeding was so bad I did end up having to increase progesterone only to suffer other side effects (the sort you'd usually get from lack of oestrogen) - it's such a delicate balancing act, good luck with it. Mine eventually stopped only after a D&C.

Thanks for your reply. I thought I’d ask here as there is no time to chat things through properly with GP’s these days and I understand that. They’d never get home from work.

I know you’re right. I could get all this solved with by paying a gynaecologist who could look at hormone levels too. I will have to figure out how to fund it though. In the meantime I’ll see what I can find out here.

With gel, you can use it on the back of your upper arms and your inner thighs.
This is on the leaflet in the pack. It's worth reading all the leaflet where it tells you how to use it and what not to do (eg body lotions etc.) You can do at the same time.

I don't know what dose you're on but if it's the equivalent of 50mcgs patch, that's 2 pumps of gel. 75mcgs patch is 3 pumps of gel.

These equivalents are online, written by medical professionals, but I don't have time to find all the links- google will be your friend!

You can split the gel application morning and evening (this is in the medical advice by the BMS.) So you can do 1 pump in the morning and 1 before bedtime. You can split 1 pump between 2 thighs or 2 arms.

MPA- ask a pharmacist .Usually with meds if there are special instructions for food/ no food, they will be on the label.

The other points that you started with in your original post are all covered in the link I left, from the BMS, about ratio of estrogen and progesterone. The link gives GPs and the public information because the BMS reports are written by consultants.

Thanks @JinglingSpringbells . I think splitting the Oestrogel into two doses would be better. I’m on Evorel Conti 50 mcg at the moment so will do one pump morning, one pump evening. Going to start on Monday.