Is low oestrogen a cause of bleeding?

[sunshinechaser]

Hope someone can help. I’m 50 and have been on HRT since I was 43. I was doing great with Oestrogel (4 pumps) and Utrogestan (100mcg every night) for years but really felt awful within about a week of the packaging change. I had insomnia, palpitations and weird numb patches on my legs after changing. So I asked my GP if I could switch to patches. I switched to Oestrodot 100mcg patches and at the same time my GP realised I should have been on a higher dose of Utrogestan so she upped me to 200mcg at night. The higher Utrogestan dose zapped me orally so I switched to vaginal and it’s a bit better.
Anyway about 3 months after starting the patches I bled so went to my GP, got referred for a scan but all was normal. The gyn said if it continues I could try a Mirena coil.
The bleeding has come back this week-very light bleeding, not enough to need a pad or anything. I really don’t want the coil as I had one years ago and didn’t love it.
I have also not felt as good on the patches as I did with the original gel and I just wonder if the bleeding and feeling rubbish means I’m not absorbing the patch well.
Thanks if you’ve got this far! Any ideas what I could do? I’m not hugely concerned about the bleeding, it’s more feeling flat, not sleeping that well and I feel I have zero energy on the patches.

Can I check - 200 Utrogestan every night with no break? Usually it’s 100 every night or 200 for two weeks/12 days. I take mine on the 1st -12th of every month.

If you have a break, did you bleed during the break?

Yes I take continuous HRT so never get a 'period'. I started off taking Utrogestan the way you described then after about 5 years the GP switched me to continuous.

Hmm, seems high to me. Per NHS:

The usual dose of Utrogestan is 2 capsules (200mg) taken once a day, on days 15 to 26 of your 28-day HRT cycle.

You'll usually have vaginal bleeding for a few days each cycle after you stop taking Utrogestan. This is normal.

If you have not had a period for 6 to 12 months or more, your doctor may recommend that you take 1 capsule (100mg) once a day, on days 1 to 25 of your 28-day HRT cycle.

I just wonder if you are having too much progesterone vs oestrogen and that’s why you’re not feeling as good?

@EmotionalSupportBiscuit there's two ways of taking HRT-cyclically or continuously. I'm on the continuous regime. A quick Google will explain this to you. Thanks anyway.

And the BMS guidelines have been updated to recommend a higher progesterone dose if you are on a high dose of oestrogen.

Yes yes I know you can take it continuously, I just thought it was 100 if continuous. I did Google to check my understanding. Wow.

The guidance now is that if on higher doses of oestrogen then women need higher doses of progesterone.

@sunshinechaser I would really consider the Mirena, and go back to gel. You’ll get much better bleeding control. It is possible that using the progesterone vaginally isn’t as effective for you either.

Thanks @Sidge. The bleeding has only happened two times in about a year so it's not too much of an issue. My DH said he felt the end of the coil during sex which is a bit of a turn off. Plus I just feel it's a bit permanent but maybe I need to think about it.
Do you think the side effects of Utrogestan are higher than the Mirena?

Hi @sunshinechaser so your DH can't feel the actual coil as it's at the top of the uterus, but they can sometimes feel the strings. They can be trimmed, or just tuck them up the side of the cervix!

Yes women are much more likely to have progestogenic side effects from utrogestan than the coil; with a Mirena it's supposed to be the equivalent of taking one mini pill (progesterone only pill) every 5 days, so much less than even micronised progesterone.

Might be worth going back to your doctor to discuss if there's anything else going on. You're on a fair whack of oestrogen, if you switch back to gel and you're no better it might not be hormonal.

Thanks @Sidge. The first time it happened I got an internal scan which was reviewed by a gynaecologist I think and it was normal. Ugh! It's just a hassle even getting to speak to a GP at my practice. It will be about 6 weeks before I could get an appointment but I guess I need to go back and get it checked out again.