Continuous HRT and ongoing light bleeding, wondering about next steps

[PhoebeBuffay1234]

I was previously on cyclical progesterone but due to messing up timings, I was having annoying periods. My HRT nurse advised me to swap to continuous even though I was still getting regular, irregular periods. I’ve been on continuous since the end of April and I’m still getting light periods that seem to take ages to get going and then ages to stop. I’m on 2 pumps of Oestrogel daily, which I was started on in January. I’m loving being on it and it’s made a massive difference to me.

I’m going to go back to the nurse but I don’t know what the next steps would be. I’ve read that the Mirena often eliminates all of these issues but I worry about the effect on my mood as I have a history of anxiety, depression and OCD and I am currently stable with all of these and I really don’t want to upset it all again!

I’m also wondering if I’ve been moved to continuous too early? And I’ve read when I do go back to the nurse, I’ll likely be sent for a scan or something.

Can anyone offer any advice or info please? Thank you.

I have no advice but I’m going through the same thing so I am placemarking. I’ve also been considering switching to the Mirena but I’m afraid of possible mental health side effects as my anxiety and depression are very sensitive to hormones.

You're bleeding all the time as you've swapped to continuous too soon BUT it can also take 6 months to settle. You won't need a scan because you are a) not post menopausal and likely on the wrong sort of hrt and b) it takes 6 months for continuous HRT to settle even for women post meno.

How old are you?

I was previously on cyclical progesterone but due to messing up timings, I was having annoying periods.

What was happening? How did you mess up the timings?
On sequential/cyclical you follow the same pattern each month.

The easiest way is to start the 12 or 14 days of progesterone on the SAME DATE every month which creates an HRT cycle, with a regular withdrawal bleed around about Day 30 of the cycle. So for example, choose the 1st of the month for your progesterone and stick to the 1st every month.

(This is the same as packs of pill or patches where there are 28 days in a cycle, with progestins for 14 days.)

•Started oestrogel 26th Jan (just when I picked it up)
•Period started 2nd Feb - normal for pre HRT cycle
•Progesterone 9th Feb - 20th Feb inclusive (2 weeks after starting oestrogel as I thought that was the right time to take it).

Then I continued taking the prog on the 9th - 20th of the month for March and April up until 27th when I saw the nurse who suggested changing to continuous.

So I, incorrectly I believe, created my own HRT cycle by initially taking the prog 14 days after I started the Oestrogel instead of day 14 of my actual menstrual cycle.

I am on continuous progesterone because I have endometriosis so it is recommended for me as unopposed oestrogen would feed any endo deposits and could worsen my symptoms. I still had regular periods when I was put on it and have not had any breakthrough bleeding. I have been on it since March.

However, I did look into the whole continuous progesterone and still having periods thing before I went to the GP and a consultant gynaecologist said in a podcast with Louise Newsam that anecdotally women with endo said the breakthrough bleeding settled down after six months. I would consider giving it 6 months. I just bought a load of period knickers to wear daily should I bleed but luckily I haven't. I have used them for my periods.

I was offered the mirena but I didn't want it, they said it would help to prevent breakthrough bleeding which is likely for continuous progesterone. The main worry about the bleeding is that it can be written off as breakthrough bleeding when it could be something else.

Just seen your update, I was initially prescribed cyclical and was asked when my last period was to see when I could start taking it. As I was never going to take it cyclically I just didn't pick the prescription up until I talked to the GP again about continuous.

When I started Elleste Duet, I bled for exactly 3 months and two weeks.

When I went onto Elleste Continuous, I bled for exactly 3 months and two weeks.

It was weird, both times it stopped like turning off a tap.

You didn't do anything wrong.

Look at it this way- when many women start HRT they have not had a period for maybe 6 weeks or 6 months. They can't wait for a period to arrive and take progesterone on Day 14. It doesn't work like that.

The actual guidance is start whenever you like! Usually giving it a couple of weeks on estrogen then adding the progesterone.

IF you are someone who has very regular periods, starting progesterone mid-cycle is great- but it doesn't always work out that way.

I started HRT almost at post meno. My consultant put me on long cycle HRT (suitable for late peri) which was 10 weeks of only estrogen then 2 weeks of progesterone. There is actually a tablet form of HRT that is exactly that.

I'm not sure why you changed to cyclical. I don't know why the nurse suggested it more to the point!

Something is missing here- you said you had 'annoying periods'- meaning what? At the wrong time? Outside of the monthly HRT cycle?

That can happen but you need to give it time to settle. You hardly had any time on it at all before she told you to change.

I'd also advise not to compare Utrogestan with women on patches/ Mirena as they contain a far stronger, synthetic progestin which tends to work better than micronised progesterone.

Thanks so much. They were just at the wrong time and outside of the HRT cycle, so I thought I was doing it wrong. Then in April, I had a period that lasted for quite a while (something that had also happened previously every now and then)❤️. I think I was just all confused and being honest, the nurse didn’t try and explain or help me be not confused, just told me to try the continuous. I’ve added pictures of my period calendar since the beginning of the year in case it helps. The greeny coloured circles are my period on the Balance app journal. I was taking the oestrogen since 26th Jan and then the red lines are when I was initially taking the progesterone. Then from the 27th April, that’s been continuous.

Don't overthink it.

The nurse was wrong IMO to suggest a change so soon. All HRT takes time to settle and it's pretty normal for periods to be all over the place for a while.

If you're under 50 and having regular periods the guidance is stick with sequential for a year at least .

There will always be examples on here from women saying they took continuous from the start and didn't bleed. That's unusual and the guidance is there because most women do bleed on it if taken too soon.

Thanks again! Do you think I should continue as I am for a while then? And if so, how long should I give it before I mention it to the nurse again?

I've missed how old you are.

If you're under 50 you should in theory be on sequential hrt unless your periods stopped a year or more ago.

I appreciate there is a recent trend to move women onto continuous, sometimes after 12 months on sequential, which didn't apply when I started HRT (over 15 years ago.) The guidance (which is still on some medical sites) is aged over 54 , or no natural periods for 12 months.

The downside is that for every woman who finds continuous works, others are like you, end up having bleeding and sometimes having unnecessary investigations.

You've moved from one to the other far too quickly and the nurse is in the wrong.

Daily progesterone is rarely enough to control bleeds in women who still have a strong ovarian function. So ideally you ought to go back to sequential and give it time to settle into an hrt cycle.

For context, I'm still on sequential in my late 60s- with guidance from one of the best menopause gynaecolgists in the country- as daily progesterone doesn't agree with me.

I was 50 in January. One of my birthday presents to me was getting my HRT! 😂 As I say, I was still having ‘regular, irregular’ periods. In the sense that mostly they came every 24 ish days, but occasionally they’d be 6 weeks apart. And on those ones that were 6 weeks between, they lasted longer. In my mind that was because there’d been longer for the lining to build up. Not sure if that is correct. They’ve never been heavy for a while. Usually spotting, light, medium for a couple of days, light again, spotting again. On the longer ones it’s just pretty much spotting then light all the time.

Do you think I should just try the sequential again or is it best speaking to the nurse? I don’t want to be sent for investigations if this is expected.

It would take away a lot of the indecision if the nurse followed guidance. The experience and training of nurses can vary. I assume she thought she was doing the right thing to help, but it doesn't tie-in with guidance. So it would be better to follow the guidance.

This is from the BMS (British Menopause Society)
Women taking a sequential preparation (sHRT) over the age of 45 should be offered, after five years of use or by age 54 (whichever comes first), a change to continuous combined (ccHRT).

This is from Menopause Matters (written by a consultant gynaecologist associated with the BMS.)
https://www.menopausematters.co.uk/postmeno.php

POST MENOPAUSAL -
Continuous combined therapies.

"Period free" or continuous combined therapy can be used by women who are 54 + yrs, or more than one year since last period at any age. The criteria should be fulfilled in order to offer such treatment to women who no longer have a continuing ovarian cycle, so that steady levels of both estrogen and progestogen can be achieved. When there are steady levels of estrogen and progestogen from daily administration of both, the womb lining stays thin. Although some bleeding in the first 6 months of therapy is common, there should not be bleeding after that and the lining does not go through the stages of stimulation and then shedding as it does during a normal cycle and with sequential therapy. Start with low dose

Thanks again so much. I still don’t know whether to change to cyclical again and then see how it goes, maybe checking in with the nurse in a few months. Or whether I should see her first before making any changes.

Given the nurse is not following any guidance (and maybe doesn't know what she's doing!) is there any point?

Following the guidance, linked above, you should be on cyclical.

Very true! I’ll revert back and give it until my yearly review in Feb or something then. Any tips on when to take the cyclical given where I am at the minute would be gratefully received too. Or will it not matter? Shall I just do it from tonight as it’s day 14 of my actual menstrual cycle? I really appreciate you taking your time to help.

Good timing @PhoebeBuffay1234 ! You may as well start now- a day later (15) makes no difference. In fact the patient leaflet says days 15-26.