How much are we supposed to handle?

[ChristmasLightsLover]

I am perimenopausal. 48. Don’t want to drip feed so here’s where I am at: Mirena coil + 4 pumps estrogen + 2 progesterone every day all month round. Migraine supported by sumatriptan. Taking all the supplements inc magnesium at night. Using GLP1 successfully for 2 years and lost 7 stone a
to date. History of awful periods and adenymosis. Diagnosed ADHD in October and meds are working well for that - perimenopause meant that came to the fore quite quickly!

I have been spotting since the 23rd December. Pain. Period symptoms. Doubting myself. Struggling with decision making. Teary. Struggling to cope.

I work FT in leadership role. DS1 at uni. DS2 taking A levels. Husband. Dog. Ageing mother.

How do I figure out as to how much / how long / how intensely I am supposed to cope with life and all it throws at us?

Do I google “what does a breakdown look like”? I just can’t work out if I’m supposed to crack on with this? Or do I go for the hysterectomy which is my only other route? Or do I need anti depressants? I already do therapy once a week. What am I missing?

I'm sorry you're feeling so low.
Is there a back story here?

You're on a very unusual combo and presumably seeing a consultant?

By that I mean the Mirena + micronised progesterone 200 mgs every day.
That in itself could send anyone over the edge with all that progesterone- different types.

What's been happening for that to be prescribed?
Is the Mirena for bleeding even though you're on 200mgs progesterone or for birth control?

Can't you use sequential HRT in peri which is the guidelines?

@ChristmasLightsLover
Sound terrible.
Do you have a good menopause doctor - it maybe that you need to fiddle with doses, and/or consider different formulations. Try bio-identical, etc.

Separately - I don’t know which estrogen pump you have - but if its Estrogel - 4 pumps is a MASSIVE dose. Normal starting dose is 2. Have you always been on such high dose?
Too much estrogen can also cause problems.

Hope you can find a doctor who can help you tailor your meds, and certainly look into spotting for a month.

I agree with pp about doses. My progesterone is 2 weeks on, 2 weeks off, no mirena, and 3 pumps estradiol. Obviously we're all different, but your doses don't seem very balanced

Thank you for the replies.

Yes. With a consultant. This HRT combo is all to try and keep the bleeding at bay as it was truly awful. Spoken to consultant and they said they can’t see any route now other than hysterectomy and I don’t know if I am ready for that.

Not much of a back story. Just the usual. Wombled along with life and without an ADHD diagnosis until three years ago. SSRI after having two under two but that was 16 years ago. Then peri kicked in and changed everything. Having the bleeding managed means I can do more - swimming and getting into running now I’ve lost some weight.

I will google sequential HRT and what too much progesterone looks like.

I went with Louise Newson’s clinic at first. My NHS GP went postal over their dosing. Went with private consultant locally. Have had exploratory surgery as they were worried about cancer. That was 14 months ago and had my coil replaced then.

I just can’t figure it out. Are we supposed to cope with feeling this hormonal? It’s wildly fluctuating for me over the last month. I’m tying it to the spotting and am worried I’ve missed something or simply should be coping better…

There is an interaction between progesterone, oestrogen and ADHD. https://www.menopausespecialists.com/post/adhd-during-the-perimenopause-menopause

I'm very new into exploring it myself as I have AuDHD and cyclical HRT sent me over the edge on first try so I am now on sequential. My understanding is that it is a very individual reaction. I don't want to give you any incorrect information as I am really still working it out for myself. I think you need someone very knowledgeable in ND and perimenopause - I have heard anecdotal mixed feedback on this regarding the Newson Clinic.

I'm not sure if it is helpful, but my GP (menopause specialist) cautioned against throwing an SSRI into the mix too. I have also been on them previously.

I have a very busy leadership role and I have considered stepping back to maintain my sanity, but not got there yet.

Thank you, @Egglio- will go and do some reading. I didn’t want to look at SSRI because I feel so medicalised these days. I have resorted to putting supplements into pill dispensing pots! I will think about someone experienced in ND and menopause. Who have you gone with?

I do feel that the magnesium helps me sleep and helps with migraine prevention.

My employer is very supportive. I have a role with high visibility so they want to be seen to do the right thing ;) But they are good humans too, so I don’t feel it’s lip service.

So far I have been lucky to have a very supportive and knowledgeable GP. I only started my HRT in November and the first cycle caused obsessive suicidality, so I had a bit of a rough ride and that why I did so much research into the interactions. I also need sumitriptan for migraines and would never stop with my magnesium glycinate either so I understand that part too (highly recommend the new Boots Modern Chemistry Magnesium - the sleep I had!!). Plus I have the the DC at uni and the aging parents!

I have been diagnosed ND just before perimenopause. And that brought a lot of grief and adjustment into the mix. I have a neurodivergent/neurodivergent trained local therapist, which is amazing as I feel less like I need to mask with her.

I'm sorry I don't have more answers, I just wanted to offer solidarity.

Thank you @Egglio- I really appreciate you replying here. I’m now looking for someone on Bupa who is gynae and ND experienced…

If anyone sees this and has suggestions I am open to them. And even if not on Bupa, because I need to figure something out.

what I don’t get though, is how I would know when to take HRT sequentially as my cycles were historically so all over the place. Ten days on, ten days off, six week break, then weeks of full bleeding needing iron tablets… So I can’t see how I’d make that aspect work for the bleeding or the interaction with ADHD meds…

what I don’t get though, is how I would know when to take HRT sequentially as my cycles were historically so all over the place. Ten days on, ten days off, six week break, then weeks of full bleeding needing iron tablets… So I can’t see how I’d make that aspect work for the bleeding or the interaction with ADHD meds…

HRT sets a cycle like the Pill.
You don't follow your own cycle at all.

Many consultants say start micronised progesterone on the 1st of each month for 14 days. Repeat each month.
This should give a regular withdrawal bleed often 2-3 days after the 14th tablet.

I've looked at the link a poster left. The drs there are GPs, not consultants, and it's very much hit and miss with anyone.

I've had excellent private meno care for many years (consultant gynaecologist surgeon, with menopause and hormone expertise) and know all the 'good names' . I think you might need to think if the ADHD is really that important to prescribing. (I do know about ADHD, professionally.)

Whereabouts in the country are you if you're looking for another dr?

What's the relevance of BUPA- does your private cover not include consultants on their approved list?

Also why are you on 4 pumps of gel?
Have lower doses not helped?

Thank you @JinglingSpringbells - that’s a lightbulb moment for me re HRT setting the cycle! After the bleed do you take progesterone again? Or wait to restart on 1st of the next month?

ADHD meds have been transformative. I use Xaggitin, usually at 54mg. If I knew my cycle and could work with it, I could add an additional 24mg on if it was being dampened at a particular part of my cycle.

I'm open to trying it out. Nervous about the bleeding, hormonal migraines, flooding and pain. But if it was 48 hrs might be do able…

re Estrogen gel. Anything less than two pumps AM and another two PM means all sorts of bleeding. The same with 100 of microgeniaed Progesterone rather than 200…

My healthcare policy to access private services is through Bupa. It doesn’t have to be someone on the Bupa list but if there is someone there would be useful. I’m based in the South East - Norfolk. Suffolk. Cambs. Herts. would work…

Why do you have mireba plus progesterone? That’s unusual

that’s a lightbulb moment for me re HRT setting the cycle! After the bleed do you take progesterone again? Or wait to restart on 1st of the next month?

You take it for 12 or 14 days once a month. So the 1st of each month.
(The leaflet is based around a 28 day cycle but many consultants suggest making it a 30/31 day cycle and using it for 12 or 14 days.) 14 days is better for women who need a little bit more to help keep the lining thin.
For some women on 4 pumps of gel they may need 3 tablets (300mgs) for 14 days. But as you have the Mirena you shouldn't in theory need anything else!

re Estrogen gel. Anything less than two pumps AM and another two PM means all sorts of bleeding

That's counter intuitive because more estrogen = more bleeding. It has a direct effect on the endometrium making it grow. The usual practice with bleeding that's break through is to reduce estrogen and / or increase progesterone.

Presumably you've had scans to rule out fibroids, endo, adenomyosis etc?

If you could possibly bear to experiment, it might be a good idea to try 3 pumps of gel and 200mgs x 14 days progesterone for a trial of 3 months. You've already got the Mirena which in theory means you don't need progesterone as well.

The link to the drs in the SE looks okay- the one who deals with ADHD- but I'd try a few options yourself because it's all trial and error.

Also, you need to check bupa would cover you- most don't cover menopause as it's ongoing, not an acute condition.

Sorry- I missed that you are diagnosed with adenomyosis.

How experienced is the consultant you're seeing?

It's a bit of an odd situation and I really feel for you .

The bottom line is you're on a dog's breakfast of drugs!
Normally it would be the mirena and 2 pumps of gel, perhaps going up to 3 if 2 didn't control sweats, flushes, low mood etc.

Most women don't need the Mirena and micronised progesterone - one reason is it's 'overload' and can cause low mood with 2 different types.

And the Mirena alone is the standard a treatment for a thick lining (hyperplasia.)

It might help to go right back to the beginning and use 2 pumps of gel and the Mirena, and nothing else and see how that feels. The Mirena is more effective/ stronger than micronised progesterone.

You might be able to use your private insurance for a scan because you need to see how thick the lining is - sometimes spotting happens when the lining is too thin. If you have a scan you also really need it done by an expert- not just a technician who sends measurements to your Dr, but a consultant who can see exactly what's going on - there is a huge difference in their expertise.

Do you have endometriosis? I had an endometrial ablation and it was life changing for the bleeding so I just wanted to suggest it as it could help reduce your medication load if bleeding is the issue. I was losing over a pint in a couple of hours and a hysterectomy was next on the list.

Came on to say progesterone sounds high.I had progesterone pill each night as my mirena had expired and was only in place to stop bleeding.
Progesterone can cause low mood.I tried to come off hrt last year at 58.It caused migraines though so I went back on it.
I think you are in the thick of it at the moment.It will settle even if it takes a while

One more thing- weight loss injections are known to impact on HRT.
It can affect the effectiveness of oral progesterone.

Well done on losing weight, but also if you are still overweight your body produces more estrogen and that may be adding to the issue.

I can understand why you think more estrogen (4 pumps) might be helping but in fact it may be making everything worse.

Thank you to everyone who has replied. Lots to think about and read up on.

Went into town today. Saw someone I’ve not seen in 10 years. She’s 56. I’m 48. She mentioned something menopause related, took one look at me, said it will get better, and I started sobbing.

She said this isn’t you, and told my Husband I should be in with a private GP for a holistic view on this, to demand help and not be fobbed off. She’s sending me her private GP details. She says she feels so much better post menopause. And I feel like this doesn’t have to be it, for me, forever.

I’m going get into this and just in case this is useful for anyone else, will report back with an update. Still open to other thoughts whilst I figure this out. Thank you.

TBH I don't think a GP, even privately, is going to cut this, unless they are a hormone expert.

A lot of the comments here are saying the same thing- you are possibly using far too much progesterone and even estrogen.

Whoever you see, if they know about HRT, will probably suggest you cut right back on both hormones and start again from a baseline.

Both the Mirena and micronised progesterone are known to affect mood in some women- so you've got a double whammy.

Being honest, 4 pumps is high dose (you may not need that) and with adenomyosis, you're possibly going to get bleeding because the estrogen is stimulating the womb lining.

Did you start on a low dose of gel and work upwards? Not sure what happened at the start.

I'm not a medic but I've used HRT for a long time with an excellent private consultant so I'm just sharing a bit (I also have adeno.)

My take on this is you should reduce the gel and also drop the Utrogestan. The Mirena ought to be enough to control the womb lining on 2 pumps of gel (it's actually prescribed as the treatment for hyperplasia.)

If you still want to see someone privately, your best choice is London where there are plenty of excellent consultants who could help.

It sounds such a cocktail of medication, I'm not surprised you don't know whether you are coming or going. I would cut down and stop the HRT personally (with medical advice) to see where you are with your own hormones and whether your periods have stopped and whether you need HRT at all at the moment.

Befire I started taking GLP-1 I stopped taking the pill at 49 as I wanted to know whether my periods had stopped before thinking about HRT. But having lost weight and no periods for over 12 months, I feel great and am still not on any HRT. I have endometriosis and PCOS but have had no symptoms.

What worked for me as a peri woman with ADHD was stopping HRT.
I suffered on the pill, tried every contraceptive available, all even worse than the pill, terrible PMDD etc and I reacted to HRT the same way, it's the progesterone. Very common in with women with ADHD we now know.
Plus it caused severe menorrhagia and bloating and eventually fuelled the growth of a uterine fibroid until it was the size of a small baby. Took a year of daily bleeding and pain to get that diagnosed and removed. Had to leave my job, it had a severe impact on my life.
Haven't bled a single day since and not had any womb pain. Pretty sure I am now post menopausal but HRT/fibroid kept me shedding and in what felt like constant PMT.
HRT is not always the answer for every woman, especially if you are one of the 1 in 10 with a progesterone intolerance.

Some great advice on here I’d also check with a scan that your coil is in the right place. I had awful year at 48 and my coil was stuck in a fibroid growing then add in the nhs wait list of 12mths by the time it was removed under general as too embedded for a local (they tried), interesting the adhd link as I’ve had a lifetime of flooding monthly, and other issues and I’m now supporting my two teen DDs one who has AuDhd & struggling even at 14 with heavy periods & egg pain every month. Geez our hormones really do rule our life. I hope you can get some good support I’m now mid 50s and clinging to my career as so beaten up my dealing with MP symptoms despite HRT for ten years.

Reading this as an outsider I’m left thinking “wouldn’t a hysterectomy sort all of that?” You wouldn’t need any progesterone, you might not need as much oestrogen. It could be a complete reset. I know the op needs careful planning to fit into a busy life, as recovery takes some time, but my bestie had one last year (for constant bleeding) and has never looked back. I think, in your shoes, I would seriously consider it.