Unbearable low mood and HRT doesn’t suit

[Wjdbxb]

The dreaded perimenopause low mood has been creeping up on me for a couple of years now (I’m 47) but in the past few months it’s felt all consuming. I’m so so low all the time, I can’t see the point in anything, nothing bring me joy, and I feel like I’ve lost myself entirely.

I tried HRT a few months ago (estrogen and progesterone patches) and they made me feel terrible - really unbearable side effects. The estrogen ones weren’t too bad apart from stomach cramps, a bit of bloating and low level nausea, but the progesterone ones were unbearable and I couldn’t continue with them after spending two weeks of each cycle feeling suicidal, enormously bloated, weight piling on, headaches, plus the worst PMT symptoms ever for the entire 2 weeks. I spoke to a gynaecologist and she felt that I should stop the patches and only use estrogel but only for the 2 weeks before my period (no progesterone at all as my own progesterone was too dominant). This seems to have lessened my PMT symptoms, which is great, but it’s obviously doing nothing for actual perimenopause.

is there anything I can do? Not massively keen on SSRIs as I spent 8 years feeling flat on those when I took them for post natal depression. Progesterone clearly kicks my arse so I can’t take that. What now? Is there a natural alternative?

Have you asked chat GTP? I found that it was so good with my menopause symptoms and recommendations.

I just asked it for you “what are the alternatives to HRT if I can’t tolerate prefesterone” so advise start with that.

It asks specific questions for you to answer so you can put in specific symptoms and if it doesn’t give the right answer just ask again in different way.

You can think about phyto oestrogens supplements soy isoflavones, black cohosh and red clover but also some decent vitamins such as d+k2 turmeric and magnesium b vitamins

black cohosh looks good for mood

I'd not say HRT 'doesn't suit' yet. You've only tried one type and there are many variations.

Not quite sure what you were using? What patches? If the 2nd half of each cycle were ones containing Norethisterone, that's a progestogen that many women find gives side effects. You could try micronised progsterone, the Mirena coil or tablets (Femoston) with a different type of progesterone.

You say your consultant said use just Oestrogel- how many pumps did you use?
Legally, a dr cannot prescribe estrogen only if you have a womb - you have to use a type of progesterone even in peri, with cycles of your own. What they can do is tailor the dose of progesterone off-licence, for example using it only every other month.

Low mood is usually eased by estrogen but you have to get the dose right and stick with it for up to 3 months. That's standard advice.
You can go up to 4 pumps a day.
How much were you using?

This seems to have lessened my PMT symptoms, which is great, but it’s obviously doing nothing for actual perimenopause.

Which symptoms are you having?

@fatgirlswims x-d post. OP has only tried one sort of progestogen. There are at least 4 types.
Black cohosh is dodgy- too much causes liver damage.

ChatGPT can be good but it's not perfect and there are disclaimers on it re. medical advice.

oh no ! My GP recommends black cohosh! However it was the one that wouldn’t prescribe me HRT and I actually thing she did not know what she was doing.

Anyway your point is completey correct.
CHAT GTP it does act a stimulus for gathering and refining information but it is only as good as a the person asking the questions and being able to rationalise the information which in hadn't appreciated not everyone would do. you need to use it as a starting point.

OP the menopause support net work on Facebook is a good source of information too.

I have struggled with accessing appropriate care from my GP.

just to add have you spoke to a menopause specialist nurse, gp or consultant? Not all consultants are trained in HRT.

I didn’t even think of Chat GPT. thank you.

The patches were Evorel Sequi (50 and Conti). I was just about ok on the 50, although did have side effects at that I struggled with, but absolutely could not tolerate the Conti. There was no chance of pushing through it for a few more months, I felt suicidal and the physical side effects were horrible.

The gynaecologist I spoke to was very knowledgeable about hormones and menopause. I described how I had been before I started HRT and the side effects at that started after it and she said that my progesterone was too dominant so needed to be balanced for the second half of the cycle with extra estrogen, hence the gel for 2 weeks of my cycle. I’ve struggled with terrible PMS symptoms for years - I get breast pain from about day 19 of my cycle (from day 15 when I was taking HRT) - not just a bit sore, like can’t even brush past them, feel like I’ve been kicked under both armpits, “period flu” the week before my period with sore throat and body aches, migraine the 2 days before my period starts, cramps, low mood. It was bad enough anyway but these symptoms went through the roof with me using Conti patches with the addition of severe nausea (like in pregnancy), rapid weight gain, and suicidal thoughts. I asked about a different sort of progesterone but she said as my usual symptoms are so bad in the 10 days before my period that it suggests progesterone dominance and adding to it was making it worse. PMDD was the term she used.

So I currently use 1 pump (or a little less) per day of estradiol 0.6 gel per day from day 14 of my cycle until my period starts, and nothing else.

I'm sorry you're having such a rough time.

Your specialist isn't prescribing HRT as a licensed drug.
It's against prescribing guidance. Is this privately or NHS? You say you spoke to them- have you had a face to face consultation?

If you are using only estrogen and no additional progesterone, she ought to be referring you for scans every few months to check the womb lining.

Have you been offered the Pill which would stop ovulation so you'd not have a cycle at all?

Has no one suggested evening primrose oil which is recommended for breast pain? This is one of alternative herbal products which is actually endorsed (using research) by specialists.

Hi OP, I had the same issue with not tolerating progesterone pills - they induced absolutely horrific migraines - so I came back off them. The GP I saw was really helpful and has suggested I get the Mirena coil and continue with the oestrogen. I’m booked in for this next week. The GP has the same herself, and said the coil releases a small and steady amount of progesterone.

I know we’re all different but thought it worth mentioning. I hadn’t come across it as an option, and therefore thought HRT was sadly not an option for me.

It was NHS and quite a long and thorough phone consultation.

Do come back and let me know how it goes for you. I’ve always stayed away from the Mirena coil as so many friends had a bad time with it and bled constantly - I’m worried about it making things worse.

It was NHS and quite a long and thorough phone consultation.

I wonder if the dr knows it's off-licence?

It's quite an important issue. There are variations on the use of progesterone off-licence (eg longer cycles of estrogen-only) but the consultant has to take personal responsibility for prescribing. And they should tell you it's off-licence.

You should be offered E Primrose Oil for breast pain. (You can buy it and use it yourself .)

Many women do get breast pain in peri , which becomes worse, and sometimes it's because of low progesterone, when cycles are incomplete (missing ovulation for example.)

Here is a link to use of progesterone in HRT.
https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

Maybe you could raise it with your dr?

Potentially, the issue is that the further into peri you are, you will miss cycles, but you'll still be using estrogen-only on those cycles. There are ways around progesterone intolerance, with lower doses and longer cycles, which you could also ask about.

All the best.

My GP is very on the ball and did question it when I saw her (for something unrelated) a couple of weeks later and I know she sent a message to the co sultana querying it and asking if it was safe - I’m going to assume that she got a response justifying it as nobody has called me about it.

The query may still be in the 'queue', the response could have been lost along the line, or the GP may not want to challenge the consultant further.

For your own reassurance, there needs to be a proper explanation, not just suspected PMDD. Using only estrogen is not sustainable because when you start missing cycles or having cycles without any ovulation you won't have any natural progesterone.

If you're unsure what to query, this is from the BMS guidance above.

Page 1

• Unopposed estrogen replacement is associated with a significant increase in the risk of endometrial hyperplasia that is both dose and duration dependent with exposure between one and three years

. • Non-hysterectomised women require progestogen administered for 12–14 days in a sequential regimen and daily in a continuous combined regimen to minimise the risk of endometrial hyperplasia and endometrial cancer associated with unopposed estrogen exposure.

Page 2

The rationale for progestogen administration is to oppose and provide endometrial protection in all situations where estrogens are naturally produced or administered. A progestogen is required for at least the same duration as that produced during the luteal phase of the monthly cycle.

Non-hysterectomised women require progestogen administered for 12–14 days in sequential HRT regimens and daily in continuous combined HRT regimens to minimise the risk of endometrial hyperplasia and endometrial cancer associated with unopposed estrogen exposure.

There are variations for women who are intolerant to progesterone and these are covered in other BMS guidance. It includes longer cycles, but with the proviso of scans every few months.

I've had an off-license variation on HRT for many years but it's carefully monitored (it still includes regular progesterone) which is where I'm coming from with your question!

All the best. Hope you find a solution.