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[Emzib0b]

Hello,

I’ve been experiencing symptoms of perimenopause (and my cycles started to go a bit haywire) since I was 38, I’m now 40. I saw a GP 2 years ago, had 2 FSH blood tests (which were both normal) and was sent on my way.

I saw another GP earlier this year as I was feeling even worse and was prescribed HRT (Evorel Patches and Utrogestan tablets). I had my FSH levels checked first (it was 56.5) but for some reason the GP never ordered the second blood test at 6 weeks.

I had my first 3 month HRT review recently, but with a different GP. She was very concerned that I’d been prescribed HRT based on a single FSH blood test and now wants me to have my FSH levels tested again - 2 tests, 6 weeks apart as per NICE guidelines.

I’m concerned that now I’m on HRT, it’s going to skew the results of the blood tests. I’m afraid if the results are both normal I’m going to lose my HRT and have to endure all the horrible symptoms again! The HRT has made a massive difference to my symptoms since I started it and I really don’t want to lose it 

Could anyone advise if it makes any difference?

[laszla]

HRT has made a big difference to my FSH: it went from 80-something to 45ish at last count and is likely to be lower still at my upcoming test next month (I'm post-meno and on a high dose of estrogel).
You should of course be allowed to take HRT even if fsh has gone down if you have symptoms

[Emzib0b]

Hi laszla,

Thanks for this, that’s really helpful to know! I have my blood test tomorrow morning, or should I later this morning, it’s 3am and I can’t sleep! My sleep’s been terrible since my Oestrogen dose was increased - I’m wondering if I’m getting too much?

I guess there’s always the possibility that my FSH could be normal anyway given that I’m peri and ups and downs are normal!

[Emzib0b]

Results are back:
FSH: 11.6
LH: 2.5
I’ve been cycling regularly again since July plus on HRT so this didn’t come as a surprise!

[joziel]

You should be prescribed HRT on symptoms alone and not on blood tests, although some doctors do do blood tests if you are under 45yo.

I've not heard of HRT affecting FSH although it might appear to, because your FSH can fluctuate anyway - which is why you have to do two, at least 6 weeks apart if you want to confirm. It's unlikely that the change is due to HRT, it's more likely that fluctuation would have happened anyway.

Just because you are not absolutely post-meno with two high FSH results, doesn't mean you are not peri-menopausal though! And if you are peri with fluctuating hormones, you would benefit from HRT and the stability it offers. In fact, the fluctuations are why peri is often worse than post-menopause state.

If I were you, I'd see another doctor or get a private meno consultation via video with an online menopause clinic and get some HRT

Oh, and you might just benefit from the progesterone at first by the way. I'm a big fan of Lara Briden, who recommends first trying the urogestan only (body identical progesterone) the last 2 weeks of your cycle. This is the same as the sequential regime on HRT, just without the estrogen. And then if you still have symptoms, adding in the estrogen. But the progesterone alone can help a lot in peri, because it's the progesterone we lose drastically when we stop ovulating regularly - progesterone is only produced if we ovulate, from the corpus luteum. Meanwhile estrogen continues to be around and to fluctuate wildly, sometimes very high, during peri.... this is why you might be finding it hard to sleep. Ideally, you'd try the progesterone by itself first...

But be advised that UK doctors don't 'get' women using only progesterone without estrogen, so you may need to accept the script for both and then just use the utrogestan....

[Hurdity]

Hi there

Just to clarify - it is not a question of "You should be prescribed HRT on symptoms alone and not on blood tests, although some doctors do do blood tests if you are under 45yo. ".

NICE Guidelines recommend that peri-menopausal status should be determined both by cyclical changes, and the two blood tests for women under 40 and sometimes for those between 40 and 45.

Here is what it says about menopausal diagnosis on this website:

"Home kits can be used to check for a raised FSH in a urine test, and you can have a blood test to measure the level, however the level depends on the phase of the cycle and can vary by a factor of 10-30 or more during the menstrual cycle. If having a blood level measured, the blood sample should be taken on the 3rd to 5th day of a period. A normal level does not exclude early menopausal transition and a raised level does not exclude continuing ovarian function. One raised level should therefore not be relied upon as a reason to stop using contraception since egg release can still occur late in the menopausal transition. "

https://www.menopausematters.co.uk/diagnose.php

The reason for the two tests I believe, is partly because for some women, the first test may be low even though they have cyclical changes - and FSH varies hugely throughout the cycle.

Also to confirm the answer to your question that yes oestrogen suppresses FSH and that includes HRT, which is why it is meaningless to perform the test now that you have started HRT.

When you say your cycles started to go haywire - what was happening to cycle length - did it vary between cycles, and what sort of symptoms did you experience?

If you are heading for premature menopause, then it is absolutely crucial that you maintain adequate oestrogen levels for your future health, never mind symptoms so your doctor would be remiss in stopping the HRT.

One solution could be to take one of the combined contraceptive pills desiged for peri-menopause which replace oestrogen in bioidentical form (as estradiol), provide contraception, and suppress the cycle hence preventing the dramatic hormonal fluctuations of peri-menopause.  They are QLAIRA  and ZOELY.  One thing I don't know is whether they maintain adequate oestrogen levels for much younger women but certainly they would be a vast improvement on the POP one of which (Cerazette) actually depresses oestrogen levels.

However if you are happy with Evorel sequi then there is no reason why you should not continue to take it, though if your cycle is still strong, you may get bleeding etc at the "wrong" time. Taking HRT itself should cause a regular withdrawal bleed anyway irrespective of whatever cycle you may have.

Do let us know the outcome and please resist being taken off HRT against your wishes - though stopping HRT for a few months is the only way you can return to whatever natural cycle you have and determine true FSH levels.

Hurdity x

[CLKD]

Morning.  U could also look at the Daisy website, specially for 'early' menopause.

Let us know how you get on.

[Emzib0b]

Hi Hurdity, joziel and CLKD,

Thank you for your replies, and sorry it’s taken a while to respond.

Hurdity - you have confirmed my big concern regarding these blood tests. I am really surprised and quite concerned that both the GP and the consultant she sought advice from are not aware of this, or are choosing to disregard it.

I have seriously considered seeing a private Menopause specialist as I’m rapidly losing confidence in the decisions the GPs I have seen so far have made. For example, I’ve received conflicting opinions on the Oestrogen dose required to offer protection against Osteoporosis.

The GP who initially prescribed my HRT back in March wanted to start me off on Evorel 50. I asked if I could try 25mcg first to see how I got on with it, with a view to increasing further down the line. She expressed concerns that I needed a higher dose for bone protection. When I asked the GP who did my HRT review about this, she told me there was no minimum dose of Oestrogen required for bone protection, but agreed to nudge my dose up to 37.5mcg to see if my brain fog and mood would improve.

My cycles have been getting gradually more  irregular over the last 2 years. I’m having quite a few short cycles of 19-21 days, the occasional normal length cycle and some long/missed cycles. The long cycles are getting longer and happening more frequently as time goes on.

I’m not 100% sure what my own cycles are doing now I’m using HRT. I’ve only had one bleed that was timed with the end of a Utrogestan course, all the others happen when they happen! I suspect I’d had a missed cycle the one time I had the withdrawal bleed and all the others have been my own cycles?

The symptoms I’ve been experiencing are hot flushes, waking up multiple times in the night overheating and then struggling to get back to sleep, mood swings, low mood, anxiety surges, upwelling of emotions that leave me sobbing for no reason, generally just not feeling like myself - like a part of me was missing, memory problems, struggling to find the right words when talking to people, overactive bladder, pelvic floor weakness which has resulted in a mild urethrocele, zero libido (although I haven’t really had one for years - it was rare, but now it’s nonexistent), fatigue…I’ve only experienced vasomotor symptoms when I have a long/skipped cycle. The mood swings/low mood and crying spells are worse during those times, too. When I sought help earlier this year I was having about 20 hot flushes a day and only getting 4-5hrs sleep a night. Since starting HRT I haven’t had a single hot flush!

When I had my HRT review I was still struggling  with my moods and noticed a significant improvement after moving up to 37.5mcg.

Unfortunately I can’t take the combined pill as I get migraines with aura. I feel safer using transdermal Oestrogen and I’m pleased to say I’m having no issues with Utrogestan at all compared to the misery I had with synthetic progestins in the past!

[Emzib0b]

My second blood test was delayed by 3 weeks as I had Covid…

FSH: 28.9
LH: 10.6

I suspect my FSH would have been over 30 had I not been on HRT! I had a feeling it was going to be raised this time. I’m on day 19 of my cycle and haven’t ovulated. After thinking I’d found my sweet spot on 37.5mcg of Evorel the horrible low moods and anxiety have returned in the last couple of weeks. No hot flushes though. Do you think I need to ride this out as an Oestrogen dip or is it time for a dose increase?

I’m off to book a follow up appointment!

[Emzib0b]

Do let us know the outcome and please resist being taken off HRT against your wishes - though stopping HRT for a few months is the only way you can return to whatever natural cycle you have and determine true FSH levels.

I had my HRT review today with a GP I used to see regarding contraception and reproductive health a number of years ago. She was amazing! So knowledgeable and sympathetic! She was happy for me to continue HRT and to increase my patch to 50mcg based on the return of my mood struggles in the last month and ongoing brain fog, and has put my patches back on repeat prescription (the last GP had taken them off). She recognised that HRT has lowered my FSH levels and said that although my most recent result was borderline at 28.9, it was still high and demonstrates I need a higher dose of Oestrogen.

I’m so relieved at how well the appointment went, and so glad I’ve found a good GP! My partner had a bit of a word with me afterwards about all the worrying I did for nothing!

A big thank you to you all for your support and advice during this time!