Side effects after starting cyclical body-identical HRT and possible dose changes

[LogicAndLavender]

Looking for some advice or shared experiences!
I am on cyclical body-identical HRT 6 weeks ago:
Evorel 50 patches (continuous)
Utrogestan 200mg (oral, 2 weeks on / 2 weeks off)
Since starting HRT, I’m experiencing side effects I didn't have before

1. Unrested sleep (waking up unrefreshed on progesterone-free days)
2. Noticeable hair shedding
3. Breast tenderness & soreness
4. Involuntary muscle twitching

My guess is that because my ovaries are still working, adding Evorel 50 might be overshooting on estrogen, and the oral Utrogestan cycles might be messing with my sleep architecture. A few questions for anyone who has been here: Did you start on a lower dose (like Evorel 25) to avoid stacking on your natural estrogen? Did switching Utrogestan to vaginal administration help with sleep grogginess or side effects? Did initial sleep deprivation, hair shedding and breast soreness, muscle twitching settle down after 2–3 months? Would love to hear how you tweaked your regimen with your GP! Thank you!

I added the gel to my mirena coil.
I got breast tenderness but it went after a short time.
Are you taking magnesium glycinate for sleep? You might want to think about a coil as it’s continuous low dose.
Muscle twitching can be helped by magnesium.
I was losing hair before I started HRT so it’s no different for me.

@PersephoneParlormaid i am not taking Magnesium Glycinate, but my calcium tablet had magnesium in it. The calcium and magnesium combination taken at bed time was giving me stomach cramps and hence I stopped. Another symptom I started to feel now (since HRT starting) is jaw restlessness (inability to find a comfortable resting position for my jaw at night).

I second guessing if I should continue HRT.

Hi there @LogicAndLavender

I've been on gel and Utrogestan for years (around 18).

I think it's possibly too soon to link some of your side effects to HRT.
Many of the things you describe are menopause symptoms and your HRT won't be sorting those yet- too soon for some.

Hair shedding doesn't happen in 6 weeks. The hair cycle is many months and it's more likely that your hair was going to shed anyway due to low estrogen.
Reason I'm saying this is I've had a lot of hair shedding lately and it's coincided with reducing my estrogen for the past 6 months ( as an experiment) from what would be a 50mcg patch to a 25mcg patch (so I'm now going back up to 2 pumps =50mcg patch.)

The sleep- again, a typical menopause symptom.
Utrogestan is sedative so you will sleep better on it (usually) and notice a difference on the 2 weeks off.

Breasts- very common when starting HRT. It is usually linked to estrogen dose, so dropping to a 25mcg patch might help. Whichever, it often settles by 3 months.

Muscle twitching- no idea but it's not linked to HRT (no evidence of this) and more likely a peri symptom. Jaw- is this teeth grinding? It can be stress.

The medical guidance is to give HRT 3 months before changing doses.

@JinglingSpringbells thanks. 18 years on HRT gives you great perspective. The main reason I’ve been looking closely at the timing is I was feeling completely fine beforehand (before starting HRT). Particularly noticing these symptoms during the 14 days off Utrogestan.
Hair shedding could be initial hormonal shift/shock . It's really interesting that reducing your dose triggered shedding for you. thanks for the reminder about the 3-month guideline. I’m going to stick with it a bit longer, focus on bedtime magnesium for now (no calcium to avoid stomach cramps).

I personally don’ t think HRT is a cure all, I take steps and supplements to help some symptoms.

I've seen a private gynaecologist, one of the best in the UK, for all that time which adds up to a lot of hours picking their brains, with appts 2 or 3 times a year.

Hair loss doesn't happen in 6 weeks unless it's some terrible trauma when it can happen.

Look up 'hair cycle'. The cycle is around a year from growing to shedding.

TBH I'd not add magnesium yet. You won't be able to judge if it's the HRT or magnesium or even magnesium as a placebo.
There has been something in the media lately about magnesium and it's shown to be mainly placebo with no real evidence is works.

@PersephoneParlormaid thanks for your reply. what specific issues you found HRT caused, and what supplements or steps ended up making the biggest difference for you.
I only started HRT as a treatment to protect my spine after a DXA scan. I felt great before starting HRT no symptoms, my goal now is just to make sure the HRT regimen itself isn't introducing unnecessary side effects and long term issues.

Do you have low bone density and is the HRT a treatment (for osteoporosis) or severe osteopenia?

How old are you?

It changes the picture quite a bit to know you had no menopause symptoms but were recommended to use HRT.

Supplements will not address bone density by the way.

A DXA scan done as a measure of precaution showed low bone density in my early 40s.

How low is it?
Is there a reason / risk factors why you had the scan?
What's the bigger picture? Did you have an early menopause or are you still having periods?

I don't mean to bombard you with questions but am happy to help if possible.
I've had DEXA scans for 20 years - one every 2 years - and that is partly why I've stayed on HRT, as well as ongoing meno symptoms.

I have had advice and input from my gynaecologist and also a consultant rheumatologist(who he referred me to) who reviews the dexa scans.

Magnesium glycinate definitely helps me sleep, no matter what the ‘experts’ say. I gave up alcohol years ago as that gave me agitated sleep. I also go to bed at the same time every night, and read a book, as I think a good sleep routine helps too.
HRT did nothing for my joints, I found the biggest difference from taking a good omega 3.
I power walk a couple of times a week, plus use weights, for my muscles and bones, and take D3 with K2.

Thanks for your reply.
I’ve also noticed over the last 3 days that my jaw really hurts when I wake up in the morning. I’m only getting about 4–5 hours of sleep a night and am really struggling to get back to sleep once I wake up. The jaw ache and tiredness just carry on through the morning as well.
Has anyone else found that the sleep disruption, morning jaw pain, and tiredness settled down after the 3-month mark, or did you need to tweak your dose? Would love to know.

Generally 3 months is a good time to allow a fair assessment, so yes, more time needed.

Keep a symptom diary - hugely useful as it’s hard to remember things.

Have you had any blood tests to check things like iron (ferritin is the important number), b12, vit d, magnesium? I recently had an iron infusion as mines been low for years - game changer!!

I personally had side effects from oral Utrogestan, namely acid reflux. I now use it rectally (vaginal irritated my bladder).

Jaw ache - bone aches should improve on estrogen, but takes time.

Are you warm enough now nights are cooling - being cold wakes me up. I swear by wool socks!

It’s all so personal - keep that diary and keep trying to figure things out for you…but I definitely recommend sticking with the HRT. In time you can tweak it, but I’d say don’t stop it

@AutumnDuck @PersephoneParlormaid @JinglingSpringbells thanks all for your reply.

On the jaw ache, mine is actually continuing into the daytime now too. I've got a feeling it might be related to the HRT. I read that higher estrogen levels can loosen the jaw joint? Apparently these joints are packed with estrogen receptors and can be sensitive to shifting hormone levels.
Definitely taking on board the 3-month mark. I've started a symptom diary this week to keep track of everything. And wool socks are coming out tonight.
Thanks again.

I had the same issues when starting HRT, especially the jaw issues which were because I was clenching my teeth - for some reason the added oestrogen sparked off this and a bout if TMJ.

I was 50 when I started HRT and I was having regular periods- I couldn’t tolerate the oestrogen properly for ages and after a few days of just one pump daily the jitters, wrecked sleep and anxiety / jaw pain would kick in. I used to take utrogestan and be fine - in the early days I don’t think I needed too much oestrogen

Im now 53 and at my last review a few months ago my GP offered to prescribe Slynd mini pill to take continuously to stop my never ending regular periods. It has stopped them and has also allowed me to get up to two pumps of gel daily without too many side effects. In fact, I put the two pumps on in the morning and by the following morning now I wake with the usual jitters and anxiety and I don’t feel great UNTIL I’ve reapplied the gel.

So I think the symptoms of high and low oestrogen are very much the same.

I’m on my 3rd cycle of sequential HRT - 1 pump Oestrogel every evening and 200mg generic micronised progesterone for days 15 to 26.

I’m not sure if the Oestrogel is working. I still get hot flushes although maybe not as bad as before (hard to tell as it was a really hot summer before I started HRT). Still wake up with joint pain in my hip which a physio previously diagnosed as GTPS. Haven’t noticed any improvement in the brain fog / forgetting words either. I also think it sometimes takes me longer to get to sleep when I’m on the oestrogen only days than it did when I wasn’t taking HRT.
The oral progesterone definitely does do something but not what it’s supposed to! I haven’t had a withdrawal bleed yet after 2 complete cycles. The first cycle it gave me weird anxiety-ridden dreams and night sweats / racing heartbeat about 6-7 hours after taking it. That improved with the second cycle but I was still getting hot flushes on waking up, triggered by just the slightest movement eg turning over in bed or lifting my arm to look at my watch. Weird stuff.
I need to book a review soon. I don’t know whether the synthetic progesterone via a patch would work better for me than the micronised oral form but mostly I’ve heard the opposite. Why am I not having a withdrawal bleed? Nothing at all.

@usedcars11 Thanks so much. It really feels like such a Goldilocks situation trying to get the dose just right!
@Fakeplasticchimneyswhy It can be so worrying when new, strange sensations crop up, so I really hope things settle down soon.

I mainly started HRT for my bone density, so I’m really hoping it does its job there without introducing any extra grief. It really feels like we have to do all our own research, take other women experiences, and fight our own corner to get our doctors understand what’s going on so as to get what we want. For now I will try to ride out the 3-month window.

An update for the thread: the jaw ache has settled down and I’ve had two consecutive nights of 7 hours' sleep, it’s genuinely a rare luxury for me.

@JinglingSpringbells you’re right regarding the hair growth cycle. Looking back, the sudden hair loss maybe the styling gel I was using rather than HRT.
I don't want to cause any unnecessary alarm here.
I think I’ve been hyper-vigilant because my GP was initially hesitant, and I had to push for the HRT prescription based on my own research, that gave a sense of personal responsibility. So left me overthinking about every minor change.
I’m keen not to project my anxieties onto other women here. In truth, I need to back my own judgment and stop drowning in endless research (but still leaning on the real-life experiences of women here).I just need to relax a little and give my body time to adjust.