Taking both patches and oestrogen gel together

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So I've been on HRT for about a year. I'm 45, early menopause caused by chemo, periods had stopped for 6 months but have now come back, very irregular and generally light. I've had an ultrasound recently, all fine.

i started out on oral progesterone and oestrogen gel - starting on one 1mg sachet, then over the year gradually increasing to 1.5 then 2 sachets. The reason for increasing was that my hot flushes came back. They were/are my only menopause symptom, but they're unbearable.

all was well with this regimen, I hate the two weeks on progesterone as I feel quite down/flat, and also had some dizziness on the first couple of days each month, but they help me sleep so all fine.

in September I started on Mounjaro. I was advised that this can affect the absorption of oral progesterone so I had a GP appointment to discuss options.

I absolutely won't get a coil. I had a very bad experience during cancer treatment and I'm not putting any more man made objects into my body.

I agreed with the GP I would switch to patches (Evorel sequi). The catch is, the highest dose they come in (for sequential HRT) is Evorel 50, which is the equivalent of the 1mg gel. So, half the dose I was on before. I understand that it is possible to get Evorel 100, but only if you're on continuous HRT or have another source of progesterone (eg the coil).

I decided to give the patches a try, thinking maybe my symptoms have settled and I'd be fine on the lower dose of oestrogen. I managed about 2 weeks and the hot flushes came back and I really couldn't cope with them.

I had asked for a referral to the menopause clinic and, hoping that would come through soon, I decided that in the meantime I would just apply one sachet of gel daily as well as using the patches.

My logic was that surely this is exactly the same dose as I've been receiving for the last year? Half of the oestrogen from the patch, half from the gel, and the progesterone in the patch is the equivalent of the 200mg I was taking orally? Which did make me think that as I increased my dose of the gel from 1mg to 2mg, shouldn't the progesterone have also been increased?

I've just had the menopause clinic appointment come through and it's not until January, which means I'll have to decide whether to carry on as I am or discuss another option with the GP. When I had my initial appointment, her suggestion was 'maybe you can just stick two patches? I don't see why not? Seems logical?'. My issue with that is that if I use two of the Evorel conti patches, I'll be doubling both the oestrogen and progesterone - won't that give me double the negative progesterone symptoms?

I had an earlier thread on this and other suggestions were to use the progesterone vaginally, or to increase the dose of the oral progesterone when I go up a dose of Mounjaro. Honestly I'm not keen on using the progesterone vaginally, and the GP won't officially prescribe it, and I really don't want a higher dose of progesterone as it does make me feel crap. I'm getting on much better with the patches and if I could get the right dose I'd prefer to stick with them.

I feel uncomfortable using both the gel and the patch as it's something that wouldn't be prescribed, but it's working perfectly and I can't really see why what I'm doing should be an issue? Can anyone advise otherwise?

Are you using evorel sequi or conti, you refer to both in your OP? If the former have you tried the joint patch progesterone weeks yet? In my expereince the side effects were much worse on the sequi patches than with utrogestan as it is a synthetic progesterone, although I appreciate not all women respond the same.

The synthetic progsterone in Evorel sequi also has higher risks for breast cancer than utrogestan. I would be inclined to try utrogestan vaginally first.

I understand that it is possible to get Evorel 100, but only if you're on continuous HRT or have another source of progesterone (eg the coil).

Evorel 100 is not just for use post menopause/ You can use micronised progesterone with any form of estrogen, at any dose, and it can be used sequentially.

However, you're saying you can't use micronised progesterone orally while using WLJs.

If I'm understanding what you're saying, it's that you need a high dose of estrogen and the appropriate dose of progestogen.

There are options which you can discuss.
There is the synthetic progestogen Norethisterone which is quite strong and can be prescribed as a tablet (it's the same drug that's in combined patches.)

You could also stop using Sandrena (in a sachet) and change to Oestrogel which can be used up to 3mgs ( 4 pumps a day) and is the same as 100mcgs patch.

The guidance around increasing micronised progesterone is just that- guidance- not mandatory. The higher doses are there if needed. (eg spotting or irregular bleeding between cycles, or spotting for a long time if used continuously.)

As you are in peri and have some natural cycles anyway, you may be ok with the usual dose of 200mgs x 14 days or 100mgs daily if used continuously.

You may also be fine with gel + an estrogen only 50mcg patch and a combined 50mgs patch (for half the month.)

Because you've had some issues before this (your other treatment) your GP could consider referring you for an annual scan to check your womb lining (if you use a high estrogen dose and the 'normal' amount of progesterone.

Evorel Sequi, which has two types of patches in it - Evorel conti and Evorel 50. I actually started with the conti (which has progesterone) for the first 2 weeks and it's been ok, no worse than the oral progesterone

So the weight loss injections can affect absorption of all oral medication, which I assume means norethisterone tablets would have the same issue as the oral progesterone.

I don't think switching between sachet or pump for the oestrogen will make any difference, as it's the progesterone that's the issue.

I had a scan recently and my womb lining was fine, so are you saying that I could stick to my old regimen (oestrogen gel plus oral progesterone, 200mg for two weeks) and just not worry if the progesterone isn't being absorbed? I do have irregular bleeding but it doesn't particularly bother me.

Hi ive been perimenopausal for about 5 years im 46 I started hrt gel n tablets three years ago im on 16mg of test n have been for over two years end of March I started peeing blood protein n leukocytes in urine too had ct scan n camera in bladder all clear still awaiting urology appointment to come through constantly getting uti s around same time I begin bleeding which I know is connected but everytime I ask any of my doctors if it the menopause I keep getting told no but Google says it is has anyone experienced this? Thanks

I think you should start a new thread @Allychaz

It might be a good idea to read this (page 3 , half way down) on the increasing of progesterone. It uses the words 'consider' not 'should' and also says there are no absolute doses established for high estrogen doses.

thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

I'm not saying you should or shouldn't do something but you should talk to your GP about it. If you can't get an appt at the NHS meno clinic till January, and you can't wait, going privately to an HRT specialist is an option if you can afford it.

Thank you @JinglingSpringbells , really useful document. So much about HRT is so vague/poorly researched. It's also shocking how badly informed GPs are. I had no idea I was on a 'high' dose of oestrogen, I was told very casually to take one or two sachets of gel and never really thought much of increasing the dose.

I'll definitely make another GP apppintment to discuss options and yes, maybe going private is an option. I can't afford it, but maybe I can't afford to ignore the problem either!