Hi Sfifties
Thanks for your pm which I was just about to reply to but seen you have posted a similar question on the open forum so I will answer on here for the benefit of anyone else who might be interested as well.
First thing is - FSH levels are no indication of menopausal status. The fact that you had gone 10-11 months without a period does not necessarily mean you are post-menopausal. You might have been, but equally might not have been.
Bleeding is to be expected within the first 6 months of continuous combined HRT even if you are post-menopausal but if your cycle is also coming into play this could also lead to bleeding.
Some of the time during those 10-11 months without a period - your lining will have been thickening as eggs start to develop and produce oestrogen but as your ovarian function was declining, ovulation did not occur - this could mean the lining had built up during this time, so once you added more oestrogen in the form of HRT and then a progestogen - the bleeding could be the shedding of this lining.
So answering your Qs put to the GP
Question 1 - she is answering like an automaton - "computer says no"...if she thought about your situation and read the BMS guidelines she would realise that increasing progesterone is and always has been one method to deal with unscheduled bleeding on HRT. Here is the relevant excerpt from the BMS guidelines:
BMS Tools for Clinicians
https://thebms.org.uk/publications/tools-for-clinicians/Scroll down to Progestogens and endometrial protection
"
Unscheduled bleeding on HRT Women who continue to have unscheduled bleeding beyond 4-6 months despite modifying their progestogen intake or where there is a concern about the clinical presentation or bleeding amount/ pattern should have a transvaginal ultrasound scan assessment of the endometrial cavity and an endometrial biopsy where appropriate. Consideration should also be given to assessment of the endometrial cavity by hysteroscopy where clinically indicated or in cases with persistent bleeding and an endometrial biopsy obtained to assess for and exclude endometrial pathology..."
"
Progestogen intake could be modified as follows: For cyclical HRT regimens, the dose of progestogen could be increased (e.g. micronised progesterone 300 mg for 12 days a month instead of 200 mg, or switch to a different progestogen) or increase duration of progestogen intake (can take progestogen for 14 days a month or for 21 days out of a 28- day HRT intake cycle).
For continuous combined HRT regimens, the dose of progestogen could be increased (e.g. increase micronised progesterone daily dose from 100 mg to 200 mg daily on continuous basis, or switch to a different progestogen), particularly when combined with higher dose estrogenic regimens"
There it is in black and white - yes you can increase the dose to 200 mg per day and see if this sorts out the bleeding (though she might want to check the health of your lining too?)
Q2 If Provera were dangerous it would not be able to be prescribed. It is the only tablet progestogen (aside from Utrogestan capsules) licensed for HRT. There may be small increased risk of breast cancer with some forms of hRT but the link is not proven and the absolute risk is very small. You may also be at increased risk of breast cancer if you are overweight and drink more than the recommended amount of alcohol. The data from different studies are often not comparable due to different timescales and combining together result from studes where women took different formulations of HRT. Unless you have an increased breast cancer risk either through past history, family or genetic risk, then she cannot refuse to prescribe this licensed drug on personal grounds, if this is what you would like to try.
Q3 - Fair enough - this is an option (her recommendation to conti with conti for a few months) - though I think in your position I would be tempted to try sequi for a few months to ensure any lining which had built up would be shed predictably rather than continue to come away sporadically over the next few months.
She is also wrong about counting the cycle. The default cycle is 28 days. Full stop. Can be varied yes. However she is proposing shortening this. Who knows why. If you are post-menopausal (or very late peri) then you just start counting Day 1 on any particular day. From Days 15-26 you take the utro (licensed dose of 200 mg per day). count Day 27 Day 28 then back to Day 1 and start counting again. The bleed will come when it comes. Some women adjust their Utro each month so they can start counting again day 1 when the bleed starts. Some specialists suggest taking the utrogestan monthly starting 1st of the month because it is easier to remember - which means each cycle will be a slightly different length and gives 12 cycles per year rather than 13 with a 28 day cycle. It may not work for women who are very early peri....
She is proposing a 26 day cycle which is shorter. It may work fine but most women would prefer to take progesterone as little as possible so would not welcome a cycle like this!
Hope this helps and all the best - keep us posted!
Hurdity x
