Urgent question please: do I need to stop HRT? (spotting)

[YolandaYolanda]

Please could anyone give me advice about whether or not it's necessary for me to stop HRT and Cerazette in these circumstances?

Background: I'm 51. I started Cerazette (progesterone-only contraceptive pill) about 5 years ago, at which point my periods stopped. No idea whether or not I would still be having periods if I wasn't on Cerazette. I started non-cyclical HRT 18 months ago.

I had some spotting last week after not bleeding for about 5 years. The GP said I needed to stop both HRT and Cerazette for 6 weeks. Not entirely sure why (I got a bit confused), but something to do with checking whether or not I was post-menopausal (because it would be possible to see whether or not I had a period in that 6 weeks), and because there was concern over whether the HRT was thickening my uterus lining.

I asked whether it was OK to continue for a week before stopping the HRT and Cerazette, because I had a busy week coming up and it would be hard to cope if I was feeling crap. The GP said that would be OK. The week is now up.

In the meantime I've had a scan done of my uterus and all looks very normal, no thickening.

I plan to try to get an appointment tomorrow with the GP to ask whether I really need to stop HRT and Cerazette cold turkey, in the light of the scan results. Does anyone know whether that's a viable course of action, please? What questions should I be asking, or what points could I be making?

If we need to know whether or not I'm post-menopausal, then maybe I could go to the menopause clinic and have blood tests to determine that question? Or maybe I could move to the Mirena coil and oestrogen patches, which I think are OK even if you're not post-menopausal, instead of taking non-cyclical Utrogestan and oestrogen patches?

Sorry for the wall of text. I REALLY, REALLY don't want to come off my current regime, which suits me very well. Hoping that somebody wiser than me may have more info than I've got...

Bump

If you've been given the 'all clear' after your scan then it's unlikely you need to stop HRT.

The 'stop hrt' for 6 weeks is a new-ish directive for GPs and it's supposed to reduce the number of referrals for scans- to see if the spotting stops when HRT stops. This is because most bleeding on HRT is due to mis-absorption or an 'HRT hiccup'.

You can't have a blood test at your age for showing post menopause- not accurate.

There's no real benefit from moving to the Mirena coil unless you prefer that and want to avoid possible spotting.

From what you have said, you could still be ovulating occasionally and the mini pill has masked that (as it does) but not always.

I'm not a dr, but I've used HRT for many years, under a consultant, had a hysteroscopy once, but was never told then to stop HRT.

I am guessing the person who did your scan wasn't qualified to give you advice on your HRT? Some scans are done by consultants and they can advise there and then.

I had similar and was allowed back in my regime. But I'm just really surprised at the timeline here. You were spotting last week and have since seen the GP, been referred for a scan, had the scan, had the report back all in a week over the Easter weekend? And expect another GP appointment tomorrow? It took me 2 months to have that done in Dec/Jan. 😕 Can I move where you live?!

@JinglingSpringbells Thanks so much - this is really helpful insight.

No, afaik the scan wasn't done by a consultant. It was done in a small local hospital by somebody who I think only does scans and then sends the pictures off to be interpreted by someone else. The scan report is visible in my NHS app type thing, basically saying that everything looks normal and the uterus layers are normal thickness etc.

@clarryloveHaha, yes, I can't believe the timeline myself!! Saw the GP on Thursday. Then was phoned later the same day by the hospital to ask whether I could attend for a scan on Tuesday morning (maybe a cancellation? At the time I was just panicking that the GP might have told them, "this looks sinister, fit her in!"). Was told the scan results would take 5 days, but they are visible already. Literally no idea how all this has happened in the time. It's very far from typical of the NHS in our area!

Also I'm not sure whether or not I'll actually manage to get a GP appointment tomorrow. They are like hen's teeth and everyone has to scramble at 8am and hope they answer your phone call... Bonus points for it being in the middle of my school run time, so I get to discuss my uterus in front of an audience.

As I said, this 'stop HRT' is a new directive which wasn't happening before. I think the wording is actually 'consider stopping' - it's all online as GP guidance (which is where I read it.)

It's partly to give breathing space to see if it's HRT related (although I don't really see the logic there because even if it were something sinister, the bleeding can be stop-start.)

TBH (and bear in mind I'm not medical just relating my own experience) going back onto HRT for a few days till your GP has seen the results is neither here nor there. It takes months or years for endo cancer to appear/ grow and you've already been told that it all looks normal.

@JinglingSpringbells Thank you - that's very good information to have. I'm beginning to realise how much I don't know about this stuff!

I have a telephone call later this morning with the GP (hopefully).

I'm concerned that one reason they may want me to stop HRT and the pill is to see whether I get a period and check whether or not I'm actually post-menopausal (and hence whether I should be on cyclical HRT or continuous HRT). As you were saying in your earlier post, a blood test for this may not be accurate.

At the moment I'm on continuous HRT, although I suspect I'm not fully post-menopausal. (I have a history of menstrual migraines and was keen to avoid hormonal variations as much as possible.) While this isn't standard, I'm not sure what the actual disadvantages are. It's been working out well for me. And if I really need to know whether I still get periods, then perhaps I could stop the Cerazette and switch to cyclical HRT for a while, instead of continuous?

The whole thing seems a bit odd to me, because presumably if I'm perimenopausal then my periods might be irregular anyway and I might miss a few. So 6 weeks unmedicated with no period wouldn't necessarily mean that I was post-menopausal anyway.

Depending what the GP says (she seems to be efficient and up to date, touch wood), I might try staying on the HRT for at least another week and trying to book a private menopause clinic appointment in the meantime to chat it through.

Thank you again for all your insight.

You've hit the nail on the head!
No one knows if they are post meno if they are a) on the mini pill and b)on HRT.

There's little point in experimenting because you could go 11 months with no period then have one! And until you've gone 12 months you're considered per meno.

It's usually best to start HRT on sequential as the guidance anyway is this is the right one for women aged under 54, or who are in peri.

By 54, 80% of women are post meno.

The risks of starting continuous too soon are odd bleeding- your own cycle breaking through- which then needs investigating.

TBH if you can, I'd suggest you go onto sequential for at least a year and see how that goes.

The mini pill Noriday can be used as part of HRT in 3 x the dose (3 tablets a day.) Some other mini pills can also be used in 2 x the dose (your GP would need to check this- it's all online.) They were an option when there was a shortage of Utrogestan a couple of years ago.

If you need it for contraception, that could be one solution. No need for Utrogestan as well.

Or you could drop the mini pill (odds of being pregnant and carrying full term at 51 are almost zero) and try sequential Utrogestan.

Thanks so much!

If I used a mini pill x2 or x3 as part of HRT, would I be able to do this as part of cyclical HRT? Would I need to stop taking it (or reduce the dose) for 2 weeks out of every 4?

Sorry for all the questions... obviously I will ask my GP about this later. But I suspect you may be better informed than her.

TBH I'm not sure because if you missed it for 2 weeks a month it wouldn't work as contraception.
It's use as part of HRT is off-licence so needs GP approval.

It's all in here.

https://thebms.org.uk/wp-content/uploads/2024/02/15-BMS-TfC-HRT-preparations-and-equivalent-alternatives-JAN2024-B.pdf

You need to scroll through the pages to find the part where it refers to Noriday as an option. Pages 6 and 7.

This has all been so helpful to me.

I spoke to the GP and she OK'd me to stay on HRT and just monitor the situation, on the basis that I had a normal ultrasound scan and no big risk factors. In order for her to refer me to a menopause clinic, then I would need either an abnormal scan result, or else to have stopped HRT for 6 weeks so that they could look at my unmedicated hormonal profile. At the moment I don't think the value of this would outweigh the disadvantages.

She says she has to assume I'm post-menopausal, on the basis that I haven't had periods for years (since starting Cerazette) and Cerazette doesn't stop periods in most users. However, I still think I may well not be post-menopausal. I looked it up, and Cerazette does stop periods in about one third of users, and my periods were regular right up to starting Cerazette at the age of 47, whereupon they just stopped. I think there's a good case for thinking that Cerazette is suppressing my periods.

So the GP doesn't think I need to switch to cyclical HRT, but I have my doubts. I'm planning to look for a menopause clinic privately and discuss the situation with them, just to try to work out what's best at the moment.

Thanks again for all your help. It has really been invaluable. ❤

Thanks for your update @YolandaYolanda

This may be relevant or not, but cyclical or continuous is actually a choice. It's not mandatory to use continuous.

I've been on HRT for over 15 years and am still on cyclical (and I'm much older than you.) I tried continuous for around a month and felt awful on it.
I'm doing cyclical with the agreement of my consultant. (This is privately.)
It's all monitored and I have scans to check everything.

I think it's worth mentioning that for long term use of HRT there is slightly less risk of breast cancer with cyclical (it's about 1% less) although all these figures are based on the older types of HRT as micronised progesterone wasn't included in most of the research.

I have a whole history of all this @YolandaYolanda !! I was on mini-pill for years with virtually no bleeding. I came off it around 46/47 to see where I was, as I was starting to get bad meno symptoms. No bleed for 3 -4 months, then I had a can’t-leave-the house flooding level period. Back on minipill!

I then started sequential HRT but I Stayed on the minipill. After 1.5 years of this and not bleeding at all, I started bleeding and got back ache, so I stopped the minipill and started bleeding all the time. Every day for weeks with terrible back ache.

I went for a scan - 11mm after all the bleeding which they say is thick if post-meno, but not so much if still peri. They’ve never known where I am, as bloods checked before starting HRT had v high FSH.
Anyway,. I felt certain myself that it was taking all these hormones, but never having a proper bleed due to minipill that caused my problems but I just don’t know. None the wiser after referral to gynae for more scans (they just kept giving me same ultrasound scan).
I stopped the Minipill and i am again trying to see if I need HRT or not by changing it up. It’s all a minefield! I’m now 50. I definitely blamed the HRT/mp combo but now I wonder if it was just my nearing the end of reproductive life and having dreadful periods breaking through!

Thanks, @JinglingSpringbells - I haven't tried cyclical at all yet. But it does sound like it might be the more appropriate choice for me, for several reasons which I hadn't appreciated before this thread!

It's also really good to hear that HRT (cyclical or otherwise) can be successfully continued for 15+ years. I fully intend to continue it as long as may be advisable!

I've had hysteroscopys 3 times to check out bleeding. Never been told to stop taking Hrt whilst waiting for appointment /results. For the most recent one I had to wait around 2 months for the appointment.

I'm on continuous Hrt (I'm 55). Have been told the bleeding is most likely happening due to fluctuating natural hormone levels. I have contemplated coming off Hrt to see if I'm period free and if so, decide which is preferable.