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[jasper]

Hello - I haven't posted on here in a very long time but I am hoping that some of you can provide some clarification and advice for me? Apologies in advance for the long essay!  I am 47 but not in menopause and still have regular periods.  I have however been prescribed HRT to try and see if this will reduce my chronic daily headache and hormonal migraines (very severe) and other symptoms - I have chronic lyme disease which has further upset hormones and when tested I have always had low in range estradiol, low progesterone and non existent testosterone. Over the years I have seen the Gluck clinic - wasn't impressed and progesterone cream just made me worse, Nick Panay - prescribed testosterone but this just moved my migraines a bit and otherwise didn't help, and most recently Prof Anne Macgregor who advised trying to stop ovulation via the Evorel patch and (ideally) mirena coil.  I am already pretty unwell and expressed concern about trying the mirena as I know it can go either way so it was agreed that I could at least start with just the Evorel patch to see how I reacted (even though prog would be needed obviously within a few months if no bleeding).

I have been using Evorel 50 and in the first month this reduced my most severe migraines from about 9 days to 4 days and so I was very hopeful.  I also had some improvement in muscle and joint pains and energy. However in months 2+3 I found that the migraines started to revert back to how they were.  I have had a normal period throughout this trial period and am aware that Studd for example says you need at least 100mcg to suppress ovulation.  Anne Macgregor's letter to my GP said I could go up to 100 so this is what I am now trying to do (have just moved up to 75). Ideally I would like to suppress ovulation in the hope that this reduces the migraines again (I am now getting them on day 4-9 and days 16-17 of my cycle instead of during) but I am worried about a couple of things..
a) my gp who is being supportive says that that even higher dose Evorel eg 100 has less hormone  than the contraceptive pill (which I can't take due to the migraines and occasionally dodgy BP)? However when I looked up the one that I was on in my 20s (Cilest) it says it has 35 mcg ethinyl estradiol, so I am confused? I am obviously worried about the risks of taking HRT full stop even though I know the patch is safer than non bio forms.
b) Is GP right in saying that I don't need progesterone for time being if I am still having periods and therefore shedding lining? If I am better on a higher Evorel dose then I have suggested to the GP that I try Utrogestan (she wasn't familiar with it) as per studd's articles instead of Mirena.  I think I have read that quite a few people on here are doing that? I am reluctant to speak to Anne Macgregor again until I know what is working and what isn't as I know she will suggest Mirena again and it is a pricey appointment.
c) I am thoroughly confused by the difference in attitudes towards progesterone between the mainstream and naturopathic/alternative practitioners. The former seem to see progesterone as a necessary evil to stop the lining of the womb building up, whereas the latter group talk a lot about estrogen dominance and the importance of having estrogen and progesterone balanced? I know mine must be well out of 'balance' now given that I am taking estrogen and my progesterone was already on the low side (increasing my progesterone levels via bioidentical cream a couple of years ago had no beneficial effect though). Can anyone explain this?

Thanks a million for any help that you can give me - I have been suffering severely from all of this for 3.5years now and really want to get a least some of my life back.

[Mary G]

I'm really sorry to hear about your migraines, they are horrible aren't they?  I only started having migraines in the lead up to the menopause and mine are caused by a combination of low oestrogen levels and synthetic/micronised progesterone in high doses.  I have what are known as 'silent migraines' which consist of 30 minutes of migraine aura but without the ensuing headache.  They leave me feeling very spaced out afterwards.

It took me a very long time to find the trigger but after much trial and error, I finally found an HRT regime that seems to keep them at bay, fingers crossed.

I had the first silent migraine in June 2004 just after my 43rd birthday and at the time, I had a Mirena coil for contraception purposes.  By that time, my oestrogen levels were getting very low and I always had an attack just before a period when oestrogen levels are at their lowest.  Once my periods stopped completely, they were more random.  Once I had the Mirena coil removed and I was on cyclical HRT, I only had migraines while on the progesterone phase - I have never had a migraine while on oestrogen only.

Feeling somewhat desperate, I made an appointment with Professor John Studd in London and that changed everything.  I was immediately prescribed Oestrogel, 100mg Utrogestan (used vaginally) for 7 days each month and a small bead of testosterone everyday and so far, so good.  I had a few migraines to begin with but I also discovered that I was magnesium and vitamin B12 deficient (known to be a problem for people with migraines) but as soon as I started taking the supplements, the migraines disappeared.  On the advice of my gynaecologist, I now take 10mg DHEA everyday - I was taking 25mg but she suggested I now reduce the dose to 10mg because I have started to produced my own oestrogen again. 

I also consulted Professor McGregor who was very helpful and she suggested I take 300mg of aspirin while on the Utrogestan phase and I use 75mg daily aspirin for the rest of the time. 

I have had to tweak my HRT regime several times but now I use Utrogestan every 5 weeks and have reduced to 2 pumps of Oestrogel everyday because of heavy periods which are now much lighter but it does seem to be working well so far. 

It has been a nightmare and it has taken a long time to find something that works.  Everyone is different with different migraine triggers but it might be worth seeking the advice of Professor Studd because he has a lot of patients who suffer with migraines who have been helped by his low dose progesterone regime.  He may well say that you don't need any extra progesterone because of your age and I think he would recommend you use Oestrogel instead of patches like he did with me.  I didn't get anything like enough oestrogen from the patches to keep my migraines at bay but the gel got my levels up immediately and it is very easy to adjust the dose - I actually managed to abort a migraine once by immediately applying the gel.

I hope that helps. 

[jasper]

Thanks Mary and glad to hear you have had success with your silent migraines. It is tempting to go see Studd but as I've already been round the houses and GP is on board re supplying evorel and potentially utrogestan I am going to see if I can make some progress myself first (as I have read most of Studd's articles).  I am interested to know if Prof Studd generally starts on 100mcg + in terms of dosage (what is a pump in mcg?)? I feel very nervous of trying to go so high, when still not even in obvious perimenopause, but everything of his that I read says 100+ of oestrogel or patch. Glad that the magnesium and B12 helped you too - sadly I tried that a few years ago and no change - I have a constant headache and it's relentless. 

I am struggling at the moment trying to take 75mcg patch as I have loads of neck pain and general muscle pain (which I suffer from anyway). In hindsight though I had this for the first month starting on Evorel and then it went so I am trying to stick it out, but wondering if I would be better going straight to 100 patch and only having to go through it once!?

Can anyone else answer my questions re 100mcg suppressing ovulation and use of progesterone?
big thanks

[Mary G]

jasper, in theory, 1 pump of gel is roughly the equivalent of a 25mcg patch but in my case, the reality is a different matter.  It all depends on the individual and how well you absorb the different products but generally speaking, the gel seems to absorb more easily and it is very easy to quickly up the dose if you need to.  I certainly achieve far higher blood levels of oestrogen from the gel, for example, my oestrogen blood levels from the 100mcg patch were much, much lower than 3 pumps of Oestrogel which is supposedly the equivalent of a 75mcg patch.  Unfortunately, it is not an exact science.

Others on MM are far more knowledgeable than me when it comes to peri menopause, PMS and suppressing ovulation but I think Professor Studd often prescribes 4 pumps of Oestrogel everyday for those women but again, much would depend on your particular case and hormone levels - I think.  I am pretty sure that if you are still producing adequate progesterone, you would not need to take Utrogestan. 

What a pity the magnesium and B12 supplements didn't work.  It is very frustrating but keep persevering, it might take time but you will get there in the end, it is just a matter of finding a regime that works for you.

[jasper]

thanks Mary, it's all such a nightmare, so many problems and no idea if I need more estrogen or if it just isn't going to work for me. I certainly feel worse when I vary the dose either way so I must be pretty sensitive - I tried to come off it a while back having reduced to 25 first and I had 7 days of all over body pain and migraines within 24hrs. Likewise, 2 days into increasing to 75 and literally everything hurts! Trying to balance with existing variations within cycle seems impossible.

As per my original email, what confuses me is this issue about 'estrogen dominance' and balancing hormones that alternative practitioners talk about vs. the idea that progesterone is only needed in order to offer protection if you have a uterus? My progesterone levels are on low side but I felt no better when I got levels up using an OTC cream.

thanks again

[jasper]

Can anyone help me re. my questions on stopping ovulation, progesterone and dealing with hormone variation in early perimenopause? I realise I have probably asked about too many things and it's all rather complicated, but I would really appreciate some more help.  Bit worried about trying to dose so high when I still have a cycle? thanks a million

[Hurdity]

Hi jasper - sorry your latest post with questions seems to have got missed.

Not sure what specifically you are asking. I do know that some gynaes seem to prescribe additional oestrogen without progesterone for women who still have regular cycles - but if it were me I would want to be reassured that my lining was shedding sufficiently each month.

Yes as you have said Studd (and others) prescribe high doses of oestrogen to suppress ovulation and it has to be sufficiently high to reduce FSH. If it is not high enough then you are assing to your own oestrogen - which maybe could get too high (I'm not familiar with this) at the ovulatory peak, but it would prevent the crashes that lead to the mood dip at the end of the cycle because you are taking a constant background amount. Theoretically this should help with mood swings even if ovulation is not suppressed.

Re the oestrogen dominance thing - this is promoted by the alternative lobby to sell progesterone cream!!! Incidentally if your regular doctor says that your progesterone is low then it may not be sufficient to oppose the extra oestrogen so I am confused here  . Progesterone varies throughout the menstrual cycle, and is usually only measured to check if ovulation is taking place, and also to see if fertility treatment is needed.

During peri-menopause some cycles are anovulatory ( no ovulation) so a period is skipped and the next one is heavy - so in this sense oestrogen in dominant in these cycles, so additional progesterone can prevent thickening of the endometrium and reduce bleeding.

There is an article here which explains it: http://www.menopausematters.co.uk/article-perils-of-the-perimenopause.php

Re the CCP - there is one now called Qlaira which contains estradiol - the same oestrogen in HRT - and nothing like the strong synthetic oestrogens in the traditional CCPs. This might be a possibilty although you might be sensitive to the synthetic progestogen. if you tolerated it, this might help with the hormonal migraines because it suppresses the cycle and also there are only 2 tablet free days - unlike the 7 day break of normal Pills.

I'm not sure if any of this is helpful but hopefully a little!

Hurdity x

[jasper]

Thank you so much Hurdity and sorry about the multitude of questions. It sounds from what you are saying that currently I am just adding to my own estrogen peaks and troughs.  My best time of the month used to be around ovulation, now I have quite bad muscle/joint pain and I think that might be because my levels are too high at this point.  Last month I had the best few days just before my period which does imply my estrogen levels are staying up! I had gone up to 75 Evorel from 50 but have had to drop back at ovulation because of the leg pain. It sounds like I need to get higher to get to the point where my own levels are suppressed?

So with progesterone there is really no benefit apart from shedding lining? No other issues with balance that are important? My progesterone levels have been low / bottom of range for 2 years so it seems surprising that I am still having regular and apparently normal periods despite adding in the Evorel patches? And I know that I am absorbing the estrogen as I get the most hideous migraine if I take the patch off!

I feel like I am stuck between a rock and a hard place at the moment as the estrogen clearly helps to reduce my severe migraines but I am getting increased body pains instead :-( I don't think anyone will prescribe me the ccp given family history and tendancy towards high bp etc.  Have you heard about anyone getting muscle / joint pains  (which I have normally but these are worse).

massive thanks again for replying