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[Tribbins]

Hi Mary

What progesterone do you use? I have migraines with aura mainly, glittery lights/lots of yawning/neck pain. I think they have been caused by fluctuating/dropping oestrogen. I had to stop work for two years when they were at their worst, during late peri. Up until I started HRT (8 years post-meno) they were a bit more manageable - one 48 hour migraine a week, with several headaches in between, but no more vomiting or vertigo. I feel like I lost 10 years of my life though. I read somewhere that if migraine improves with pregnancy then it usually improves post-meno. If it gets worse in pregnancy then it is worse post-meno. Mine were worse from second trimester, and also the start of ocular migraine which is apparently caused by high oestrogen/spikes.

I read your posts, where you advocate for a low and consistent dose of HRT to manage migraine. Mine definitely improved when I got to 37mcg Evorel, but unfortunately I was on unopposed oestrogen for over 3 months so had to start with some progesterone. I tried Utrogestan but that was just awful, urgh! So Cyclogest is just about bearable but I feel sedated, a bit less today so hopefully I will be able to tolerate it.  xx

[WishIdknownsooner]

Hi Tribbins, I hope you’re continuing to manage.

In answer to your question, I was worried I was going to be put on utrogestan once it came back in stock.  Happily, newsons have kept me on cyclogest as I am having few side effects compared to what I’ve had in the past.  She said utrogestan often gives more side effects than cyclogest.

She also recommended a trial of testosterone to clear any residual brain fog, which is definitely present for me when I’m on my cyclogest part of my cycle.  I know you’re post meno and need to take progesterone daily.

Hurdity - I’m not medical by any means, but by working with nurses constantly, I’ve picked up bits of info (a little knowledge can be a dangerous thing though I admit lol). Medications taken rectally and vaginally enter the bloodstream very quickly. Hence buccal midazolam given rectally for seizures.  To my mind, the vaginal wall would be similar to the rectal wall, so that’s why I’m comfortable to risk it.  So if it gets absorbed into the blood stream, rather than being metabolised by the liver, more would reach the uterus than utrogestan taken orally. I’d love your take on it.  I think I’m trying to say that whatever the route, oral, vaginal or rectal, the progesterone works systemically, not locally, but by bypassing the stomach and liver, it reaches the blood faster. Sorry for the waffle lol. I’d love some proper evidence though.

[Mary G]

Tribbins, it sounds like you suffer with similar migraines as me and unfortunately, unlike menstrual migraines, they do not improve post menopause and can be difficult to treat.  Mine are silent migraines which consist of 30 minutes visual disturbance but no headache.

Once post menopause, you need to aim for a steady, continuous combined HRT regime but at the same time, it's very important to (a) maintain a reasonable base level of oestrogen (in my case that is 300 pmol) and (b) not overdose on progesterone.  Testosterone increases serotonin levels so it's worth adding that to your regime if you can.

For perimenopause women with migraine aura, continuous HRT is not possible so a higher dose of oestrogen and progesterone is needed on a cyclical basis.

I used to use 50mg progesterone lozenges which were excellent but because of Brexit, the pharmacy can no longer post to Spain so now I use 50mg transdermal progesterone gel which I buy in Spain.  I also use just over one pump of Oestrogel and testosterone every day. 

More recently, I found that hormone manipulation was not quite enough to keep the migraines at bay so now I have added a low dose of amitriptyline (an AD) which is a migraine preventative at a low dose and it also increases much needed serotonin levels. 

Migraine auras are caused by cortical spreading depression which is caused by low serotonin which in turn is caused by low oestrogen.  Obviously this means that I'm on HRT for life otherwise I would be plagued with migraine auras forever.

[Hurdity]

Hurdity - I’m not medical by any means, but by working with nurses constantly, I’ve picked up bits of info (a little knowledge can be a dangerous thing though I admit lol). Medications taken rectally and vaginally enter the bloodstream very quickly. Hence buccal midazolam given rectally for seizures.  To my mind, the vaginal wall would be similar to the rectal wall, so that’s why I’m comfortable to risk it.  So if it gets absorbed into the blood stream, rather than being metabolised by the liver, more would reach the uterus than utrogestan taken orally. I’d love your take on it.  I think I’m trying to say that whatever the route, oral, vaginal or rectal, the progesterone works systemically, not locally, but by bypassing the stomach and liver, it reaches the blood faster. Sorry for the waffle lol. I’d love some proper evidence though.

Hi yes - both rectally and vaginally anything taken this way avoids what is known as the "liver first pass effect" and goes (and is absorbed) straight into the bloodstream without the body having to deal with large quantities of the metabolic by products, some of which cause even more negative side effects.

However taken vaginally in addition to absorption into the bloodstream , the progesterone is transported through the cervix directly to the uterus - known as the "uterus first pass effect" or something similar - so it does work locally on the uterus (as well as systemically). Some limited research has shown that therefore a lower dose of progesterone when used vaginally can be used by comparison with oral intake. However this research has been translated by some specialists to mean that half the vaginal dose can always be used, irrespective of the oestrogen dose when in reality the mounr of progesterone needed is broadly dependent on the oestrogen dose ie more oestrogen used = more progesterone needed to protect the womb. The BMS has advised that this should not be universally prescribed and that when used vaginally the same dose as oral intake should be prescribed. This does not alter the fact that more gets to the uterus though, so under medical supervision, for women who are sensitive to the effects of systemic absorption can be prescribed a lower dose when used vaginally.

This is a long-winded way of saying for progesterone intolerant women, vaginal use may be preferable because lower doses can potentially be used, but only under medical supervision with regular scans.

Does this help or is it more confusing?

Hurdity x

[WishIdknownsooner]

Thanks Hurdity.  It does make sense and it’s interesting stuff.  God help me if they want to universally up the progesterone dose as I’m on day 8 of cyclogest and am already counting down the days until this month’s cycle is over with! Tears everywhere… (Although I still prefer it to any other synthetic progesterone I’ve had in my life!)

I’m only on one pump of oestrogel, so I’ll continue to risk the back passage for a while, but will bear your comments in mind if I have to increase the dose x

[Furyan]

Is anyone using Cyclogest? Does it get any better? I started last night, on a small amount just to try it out. I felt really anxious after the Utrogestan experience. I used about an eighth of a 200 mcg pessary. Struggled to sleep, woke about 3am with a weird vibrating feeling, unsettled. Went back to sleep and woke again at 9am! Now can't shake the fuzzy, woozy head off. Thankfully I don't have to drive anywhere today, as I wouldn't be able to do so safely.

I hope this is just 'start-up' side-effects - I had to stop Utrogestan after a few days as it absolutely floored me. I think half a Cyclogest will leave me unconscious! Like a lot of others on here, I feel like throwing in the HRT towel.

Hi Tribbins - that dose of Cyclogest is extremely low even for a low dose of oestrogen. I hope the initial experience you had started to ease a little since first posting?
I moved from Utrogestan to Cyclogest some weeks ago and I cut the tablets to give me approximately 75 - 80mg daily via rectal route. These pessaries are designed to be taken vaginally OR rectally and both routes are of equal effectiveness. Any spaced out feeling I got from taking them daily eased within a week and from lowering the dose, as I am only taking the equivalent of 2 pumps oestrogen atm. Hope you are settling on them - as with all regimes, it’s worth sticking it out in the interim to give your body time to adjust x

[Tribbins]

Hi Furyan

I was taking 50mcg daily, now on 100mcg on alternate days. Last night was the first night where I didn't have any freaky dreams, still a little bit tired during the day but seems to be working out fine so far, fingers crossed. Managed a 5 mile fell walk today and felt good. I felt pretty scared to start off with having had such a crappy experience with Utrogestan, hence the low and anxious start! x

[Furyan]

Hi Furyan

I was taking 50mcg daily, now on 100mcg on alternate days. Last night was the first night where I didn't have any freaky dreams, still a little bit tired during the day but seems to be working out fine so far, fingers crossed. Managed a 5 mile fell walk today and felt good. I felt pretty scared to start off with having had such a crappy experience with Utrogestan, hence the low and anxious start! x

Tribbins, thanks for the update which is sounding VERY hopeful (5 miles? Dammmmmm..!). So glad you waded it out and long may it continue x

[pepperminty]

Tribbins, it sounds like you suffer with similar migraines as me and unfortunately, unlike menstrual migraines, they do not improve post menopause and can be difficult to treat.  Mine are silent migraines which consist of 30 minutes visual disturbance but no headache.

Once post menopause, you need to aim for a steady, continuous combined HRT regime but at the same time, it's very important to (a) maintain a reasonable base level of oestrogen (in my case that is 300 pmol) and (b) not overdose on progesterone.  Testosterone increases serotonin levels so it's worth adding that to your regime if you can.

For perimenopause women with migraine aura, continuous HRT is not possible so a higher dose of oestrogen and progesterone is needed on a cyclical basis.

I used to use 50mg progesterone lozenges which were excellent but because of Brexit, the pharmacy can no longer post to Spain so now I use 50mg transdermal progesterone gel which I buy in Spain.  I also use just over one pump of Oestrogel and testosterone every day. 

More recently, I found that hormone manipulation was not quite enough to keep the migraines at bay so now I have added a low dose of amitriptyline (an AD) which is a migraine preventative at a low dose and it also increases much needed serotonin levels. 

Migraine auras are caused by cortical spreading depression which is caused by low serotonin which in turn is caused by low oestrogen.  Obviously this means that I'm on HRT for life otherwise I would be plagued with migraine auras forever.

Hi MaryG ,

do they have transdermal progesterone in spain? I know that some countries have more progersterone options .

PMxx

[Mary G]

pepperminty, yes, branded progesterone gel (Darstin) is available in Spain but it's only really suitable for women on a lowish dose of oestrogen. I use it (about 50mg every day) with just over one pump of Oestrogel and it works very well.  To give you an idea on the ratio, my blood levels of oestrogen are about 300 pmol.

If you use a higher dose of oestrogen and you want to use a transdermal form of progesterone, you would need to get it from a compounding pharmacy like the Specialist Pharmacy in London. They are able to produce bespoke progesterone creams that are stronger than the gel that I buy off the shelf. 

[pepperminty]

pepperminty, yes, branded progesterone gel (Darstin) is available in Spain but it's only really suitable for women on a lowish dose of oestrogen. I use it (about 50mg every day) with just over one pump of Oestrogel and it works very well.  To give you an idea on the ratio, my blood levels of oestrogen are about 300 pmol.

If you use a higher dose of oestrogen and you want to use a transdermal form of progesterone, you would need to get it from a compounding pharmacy like the Specialist Pharmacy in London. They are able to produce bespoke progesterone creams that are stronger than the gel that I buy off the shelf.

Thanks for letting me know. I do wish instead of coming up with more types of estrogen they would provide a better selection of progesterones for us all in the uk. If there are ones out there already why dont they make them available here.

PMXX

[Mary G]

pepperminty, yes, branded progesterone gel (Darstin) is available in Spain but it's only really suitable for women on a lowish dose of oestrogen. I use it (about 50mg every day) with just over one pump of Oestrogel and it works very well.  To give you an idea on the ratio, my blood levels of oestrogen are about 300 pmol.

If you use a higher dose of oestrogen and you want to use a transdermal form of progesterone, you would need to get it from a compounding pharmacy like the Specialist Pharmacy in London. They are able to produce bespoke progesterone creams that are stronger than the gel that I buy off the shelf.

Thanks for letting me know. I do wish instead of coming up with more types of estrogen they would provide a better selection of progesterones for us all in the uk. If there are ones out there already why dont they make them available here.

PMXX

I agree pepperminty.  It seems the will is not there and the NHS really want women to stick to their strict progesterone guidelines because they don't want to (or can't afford to) give women routine uterine scans. This means that many women are overloaded with progesterone they don't need because the NHS have to cover themselves by working on worst case scenario plus some.  Even if you are not progesterone intolerant per se, the type of quantities you are expected to take are difficult to tolerate and have a drag effect on the uplifting benefits of oestrogen which is counterproductive.

Manufacturers should start by producing a 50mg dose of Utrogestan but there are other types of progesterone out there that are better tolerated like bespoke lozenges and creams that could be mass produced - I know they work well because I have used them, backed up with scans of course.  A stronger version of my progesterone gel would be good too.

[Hurdity]

Re Darstin progesterone gel:

I looked up and posted about this last year on this thread: https://www.menopausematters.co.uk/forum/index.php/topic,64085.msg887322.html#msg887322

Just to recap on and requote some of the points I made then:

It is a very weak gel and designed to be applied to the breasts only to treat breast tenderness. It was first manufactured in 1983 so has been around for a long time.

The data say that when applied to the breasts - 80% of the gel is metabolised by the breasts and 20 % is absorbed systemically.

As far as I can see there is no information nor research on its use in protecting the endometrium.

The problem with any transdermal progesterone is that it needs to be absorbed systemically and then transported via the bloodstream to the uterus, with all the potential side effects that this involves, if sufficient is to be delivered to protect the endometrium. Contrast this with vaginal delivery where theoretically a lower dose of progesterone is needed compared with other methods, because it is delivered directly to the womb. Yes there is systemic absorption and why we desperately need more research into this - as there are plenty of progesterone products out there used for fertility. We just need the research into lower doses of these formulations.

There is already a gel –  Crinone gel which is delivered vaginally but is 8 x more concentrated ( 90 mg prog/1.125g gel) than Darstin,, but not licensed for endometrial protection though has been researched but comes in pre-measured doses delivered by applicator and therefore I imagine very difficult to apply lower doses vaginally in the way it is designed.


Hurdity x

[pepperminty]

Re Darstin progesterone gel:

I looked up and posted about this last year on this thread: https://www.menopausematters.co.uk/forum/index.php/topic,64085.msg887322.html#msg887322

Just to recap on and requote some of the points I made then:

It is a very weak gel and designed to be applied to the breasts only to treat breast tenderness. It was first manufactured in 1983 so has been around for a long time.

The data say that when applied to the breasts - 80% of the gel is metabolised by the breasts and 20 % is absorbed systemically.

As far as I can see there is no information nor research on its use in protecting the endometrium.

The problem with any transdermal progesterone is that it needs to be absorbed systemically and then transported via the bloodstream to the uterus, with all the potential side effects that this involves, if sufficient is to be delivered to protect the endometrium. Contrast this with vaginal delivery where theoretically a lower dose of progesterone is needed compared with other methods, because it is delivered directly to the womb. Yes there is systemic absorption and why we desperately need more research into this - as there are plenty of progesterone products out there used for fertility. We just need the research into lower doses of these formulations.

There is already a gel –  Crinone gel which is delivered vaginally but is 8 x more concentrated ( 90 mg prog/1.125g gel) than Darstin,, but not licensed for endometrial protection though has been researched but comes in pre-measured doses delivered by applicator and therefore I imagine very difficult to apply lower doses vaginally in the way it is designed.


Hurdity x

Yes more research and there are quite a few progesterones out there , including dygesterone , so why oh why don't they get thier act together and license them in the UK for HRT. 

PMxx

[Furyan]

pepperminty, yes, branded progesterone gel (Darstin) is available in Spain but it's only really suitable for women on a lowish dose of oestrogen. I use it (about 50mg every day) with just over one pump of Oestrogel and it works very well.  To give you an idea on the ratio, my blood levels of oestrogen are about 300 pmol.

If you use a higher dose of oestrogen and you want to use a transdermal form of progesterone, you would need to get it from a compounding pharmacy like the Specialist Pharmacy in London. They are able to produce bespoke progesterone creams that are stronger than the gel that I buy off the shelf.

Thanks for letting me know. I do wish instead of coming up with more types of estrogen they would provide a better selection of progesterones for us all in the uk. If there are ones out there already why dont they make them available here.

PMXX

I agree pepperminty.  It seems the will is not there and the NHS really want women to stick to their strict progesterone guidelines because they don't want to (or can't afford to) give women routine uterine scans. This means that many women are overloaded with progesterone they don't need because the NHS have to cover themselves by working on worst case scenario plus some.  Even if you are not progesterone intolerant per se, the type of quantities you are expected to take are difficult to tolerate and have a drag effect on the uplifting benefits of oestrogen which is counterproductive.

Manufacturers should start by producing a 50mg dose of Utrogestan but there are other types of progesterone out there that are better tolerated like bespoke lozenges and creams that could be mass produced - I know they work well because I have used them, backed up with scans of course.  A stronger version of my progesterone gel would be good too.

What a great summary of the issue that I have with the prescribed progesterone! I’m not progesterone intolerant at all yet I find the daily doses recommended for HRT intolerable: I simply cannot take 100mg daily let alone 200mg for the recommended periods.

Which begs the question (for me) whether this dose truly mimics what happened in nature as a menstruating woman. Clearly, whatever amount I made naturally back then was enough as I never had uterine or mood issues. Interestingly, a number of sources I’ve read suggest that (healthy) menstruating women naturally produce around 20 - 30mg of progesterone during the luteal phase, which seems a lot less than prescribed HRT (that’s off the top of my memory though, google it to clarify). If true, it might add weight to your view that the NHS pushes doses that are way over what many women can tolerate. There seems to be a pattern as to the side effects reported among women who feel they are taking these excessive amounts.