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[Penguin]

Hi

I'm trying for the second time to come off of hrt or at least drastically reduce it. To recap, I'm 49, still in peri, been on sequential estrogel / utrogestan for a year. This last month has been horrendous with awful estrogen surges and really painful, hard breasts since day 15 and crazy anxiety,  so  I think there's a lot going on for me with my own cycle underneath the hrt cycle and the 2 pumps of estrogel I'd worked myself up to seems to have made it all worse.

So, my question is, I've reduced over the last few days down to half a pump of estrogel. I've just finished my 12 days of utrogestan so am waiting for my bleed. Ideally I'd like to do a whole month on half a pump of estrogel and see if that controls symptoms sufficiently. However, what do I do about the utrogestan? There's no way I need the full dose of 200mg x 12 days but what could I lower it to safely given such a low dose of estrogen?

And does anyone have any suggestions to manage any hot flushes that wake me at night without upping the estrogen again?

[joziel]

Have you tried just using the oestrogel during the first and last week of your cycle (at the 2 pumps), when your own estrogen is lowest? And then not using it at all around ovulation in the middle, when your own will surge? I did that for a while...

As long as you tolerate the utrogestan okay, it's fine to continue that at the usual dose and will probably help with sleep - and there is also research to suggest that it helps with hot flushes as well.

[Penguin]

Thanks. No I haven't tried that. So, with a 28 day cycle (which is what I use to manage the utrogestan dosing on days 15-26), I'd take the estrogel days 1-7, and 21-28 and then nothing in-between, is that what you mean?

My estrogen surges happened around days 20/21 though and inly stopped when I reduced the estrogel down to less than one pump and also lowered the utrogestan for the last two days so I think it may be quite erratic. My symptoms seem to be worse in lead up to ovulation and then from about days 20 onwards which doesn't make sense to me.

I suppose what I'm really asking is if I use half a pump every day throughout whole cycle, would that be enough to build the lining up enough to justify using the full 200mg of progesterone? I'd much prefer to do a lower amount of progrsterone if possible because it makes me feel so awful and unhinged after the first week.

[sheila99]

You need enough to ensure you have a decent bleed. For me that's 200mg but some people use 100. Obviously this is off licence so I can't say it's safe.

[DottyD68]

Hi Penguin,

I totally understand your logic and it is what I think makes sense i e less oestrogen requires less opposing progesterone. However several of the GPs  I have spoken to have the same stock response ...200mg  of utrogestan14 days out of 28 or 100mg daily. Catagorically. They cite lack of endometrial protection if this doseage is not taken. However it has never been explained to me why the doseage can not be reduced with minimal / reduced oestrogen.

The other thing I wrongly assumed was that having a bleed indicated the lining was shedding as a result of the progesterone being absorbed properly. However, I have read on this forum that a breakthrough bleed could indicate tha the progesterone is not being absorbed properly hence causing a bleed of the lining. I find it all so confusing. This makes me think (maybe wrongly) that the only way you can be 100% sure that the oestrogen isn't causing a build up of the lining is regular scans.

I suspect my GPs are following guidelines to the book regarding progesterone but they have made me paranoid about getting sufficient progesterone absorbed whilst on any form of oestrogen HRT.

I hope you are able to find the right balance and get the right level of protection.

[Penguin]

You need enough to ensure you have a decent bleed. For me that's 200mg but some people use 100. Obviously this is off licence so I can't say it's safe.

My bleed is good on the full dose of utrogestan and 2 pumps, but not much difference a few months ago when I reduced the progrsterone for the last few days and stopped a day early,  I also had a good bleed. Any idea how long I could do a reduced dose, say 100mg for 6 days and 200mg for the the 6 days, before needing a scan? Assuming I was only on half a pump of gel.... I have no idea over what time period womb lining builds up before it can turn nasty...

[Penguin]

Hi Penguin,

I totally understand your logic and it is what I think makes sense i e less oestrogen requires less opposing progesterone. However several of the GPs  I have spoken to have the same stock response ...200mg  of utrogestan14 days out of 28 or 100mg daily. Catagorically. They cite lack of endometrial protection if this doseage is not taken. However it has never been explained to me why the doseage can not be reduced with minimal / reduced oestrogen.

The other thing I wrongly assumed was that having a bleed indicated the lining was shedding as a result of the progesterone being absorbed properly. However, I have read on this forum that a breakthrough bleed could indicate tha the progesterone is not being absorbed properly hence causing a bleed of the lining. I find it all so confusing. This makes me think (maybe wrongly) that the only way you can be 100% sure that the oestrogen isn't causing a build up of the lining is regular scans.

I suspect my GPs are following guidelines to the book regarding progesterone but they have made me paranoid about getting sufficient progesterone absorbed whilst on any form of oestrogen HRT.

I hope you are able to find the right balance and get the right level of protection.

Thanks, that is exactly the position I am in, my GP won't even discuss a reduction but then he also doesn't think I should reduce my hrt anyway so I'm a bit stuck. The clinic I spoke to no longer support lower doses / durations either. I was really really hoping to taper off the hrt slowly but I can't see how I can do that if I have to continue with such a high dose of progesterone as it impacts me so much. My breasts getting so sore absolutely terrifies me and I have no idea whether that is the estrogen or the progrsterone, except that I am 100% sure I have had estrogen surges this luteal stage as my libido made a brief but intense return for two days after being MIA these past couple of years 🙈

[DottyD68]

For me it was the oestrogel causing severely large, swollen, sore boobs when I was on 4 pumps. Once I got down to 2 pumps (on the same amount of progesterone) they reduced in size and felt more normal.

In hindsight I don't really understand how HRT can be successfully managed during perimenopause especially when your own hormones fluctuate so wildly and uncontrollably. Hw do you know how much you need on any given day? I think mine were having their last big hurrah early last year which is why I was all over the place and the HRT just exacerbated the highs. I am hoping things have levelled out now and the HRT now helps rather than makes things even more uncontrollable.

[Penguin]

For me it was the oestrogel causing severely large, swollen, sore boobs when I was on 4 pumps. Once I got down to 2 pumps (on the same amount of progesterone) they reduced in size and felt more normal.

In hindsight I don't really understand how HRT can be successfully managed during perimenopause especially when your own hormones fluctuate so wildly and uncontrollably. Hw do you know how much you need on any given day? I think mine were having their last big hurrah early last year which is why I was all over the place and the HRT just exacerbated the highs. I am hoping things have levelled out now and the HRT now helps rather than makes things even more uncontrollable.

Ahh so maybe that is the case with me. My estrogen was clearly high during this luteal phase and its the first month I'd been doing 2 pumps. They went large, sore and hard in places which can't just be from the progrsterone as that has never happened before. How long did they take to settle when you reduced? I reduced 3 days ago and the stabbing paid have gone, they are not hard anymore, but still big and a bit tender on and off. Is 3 days too soon for it to completely go?

I also think mine are probably having their last big hurrah now so the last thing I need to be doing is adding more estrogen in 🙈

[DottyD68]

Probably a week or two rather than days before they were noticably smaller and less painful.

When I was reducing down I think 1- 2 pumps (or 50 mg patches) is my "sweet spot" at the moment. I haven't seen any noticeable increase in my boob size since I have re-started HRT (patches) 2 weeks ago so fingers crossed.

[Penguin]

Probably a week or two rather than days before they were noticably smaller and less painful.

When I was reducing down I think 1- 2 pumps (or 50 mg patches) is my "sweet spot" at the moment. I haven't seen any noticeable increase in my boob size since I have re-started HRT (patches) 2 weeks ago so fingers crossed.

Thanks thats good to know, I need to be more patient then! Left boob sore as I poked and prodded it so much trying to find horrible reasons for the hardness that I ended up making it even more sore 🙈. Been wearing a crop top in bed the last couple of nights to keep my hands to myself! 2 pumps was defo too much for me, they literally doubled in size!! Given how small they were to start with it was easily noticeable!

I'm glad you haven't had the increase and soreness come back. Tbh I'd gone up to 2 pumps on about day 12 and they got bigger straight away but it wasn't until a few days after adding in the progrsterone that they started to hurt x

[Hurdity]

Hi Penguin

Have you any idea where in peri-menopause you are ie early or late? How often your natural cycles are?

Very early and early peri-menopause can be more difficult to treat with HRT because that's when, as you say the hormones are fluctuating dramatically - huge surges in oestrogen and dramatic falls, leading to sore boobs when oestrogen is high, and flushes and low mood tearfulness etc when it falls. Overall though oestrogen levels on average may not have fallen by much ( and if periods still more or less regular, then perhaps not at all)

At this stage a low or medium dose HRT can help to cushion the falls but as you say you may well not need two pumps of gel during the surges and especially around ovulation when oestrogen will be at its highest.

In terms of the fluctuations, suppressing ovulation could work and this can be achieved eg through the contraceptive pill (ie QLAIRA or ZOELY) that contain estradiol, or through VERY high oestrogen doses ( as per the Studd regime used to treat reproductive depression).

In terms of flushes/sweats - you really want to have the minimum dose of oestrogen that stops these as that is usually the first/main symptom that drives women to want to try HRT....but I get what you're saying about sore boobs....

Yes progesterone also causes sore/achey boobs. When I'm on the prog part of the cycle my boobs enlarge and can be achey (and that really is annoying at my age ).

In terms of prog dose - yes it is dose dependent but there have not been studies looking into lower doses of prog along with lower doses of oestrogen (lower than 50 mcg) and of course one size doesn't fit all as there are so many other factors to take into consideration, though licensed doses can't be individually tailored to that extent unless doc is willing to do regular scans.

If you are having regular periods ie ovulation each month more or less, then you will be producing progesterone after ovulation, so the dose of Utro taken externally may be less of an issue (though also heavy bleeding can occur in peri due to the high oestrogen surges) but at some point as ovulation becomes more sporadic this becomes more important and you probably won't know when this happens. Also knowing when to scan while peri-menopausal is tricky - ideally this should happen immediately following a bleed when the lining is at its thinnest - as it will be growing and shedding both due to the HRT and your natural cycle.

This is a bit of a ramble and a few thoughts and probably not very helpful though hopefully something useful in there!

Hurdity x

[Penguin]

Hi Penguin

Have you any idea where in peri-menopause you are ie early or late? How often your natural cycles are?

Very early and early peri-menopause can be more difficult to treat with HRT because that's when, as you say the hormones are fluctuating dramatically - huge surges in oestrogen and dramatic falls, leading to sore boobs when oestrogen is high, and flushes and low mood tearfulness etc when it falls. Overall though oestrogen levels on average may not have fallen by much ( and if periods still more or less regular, then perhaps not at all)

At this stage a low or medium dose HRT can help to cushion the falls but as you say you may well not need two pumps of gel during the surges and especially around ovulation when oestrogen will be at its highest.

In terms of the fluctuations, suppressing ovulation could work and this can be achieved eg through the contraceptive pill (ie QLAIRA or ZOELY) that contain estradiol, or through VERY high oestrogen doses ( as per the Studd regime used to treat reproductive depression).

In terms of flushes/sweats - you really want to have the minimum dose of oestrogen that stops these as that is usually the first/main symptom that drives women to want to try HRT....but I get what you're saying about sore boobs....

Yes progesterone also causes sore/achey boobs. When I'm on the prog part of the cycle my boobs enlarge and can be achey (and that really is annoying at my age ).

In terms of prog dose - yes it is dose dependent but there have not been studies looking into lower doses of prog along with lower doses of oestrogen (lower than 50 mcg) and of course one size doesn't fit all as there are so many other factors to take into consideration, though licensed doses can't be individually tailored to that extent unless doc is willing to do regular scans.

If you are having regular periods ie ovulation each month more or less, then you will be producing progesterone after ovulation, so the dose of Utro taken externally may be less of an issue (though also heavy bleeding can occur in peri due to the high oestrogen surges) but at some point as ovulation becomes more sporadic this becomes more important and you probably won't know when this happens. Also knowing when to scan while peri-menopausal is tricky - ideally this should happen immediately following a bleed when the lining is at its thinnest - as it will be growing and shedding both due to the HRT and your natural cycle.

This is a bit of a ramble and a few thoughts and probably not very helpful though hopefully something useful in there!

Hurdity x

Thanks so much. I don't 100% know where I am in terms of peri / meno. Just over a year ago (before I started hrt) my cycles had shortened to 25/26 days and were 2 days long and scanty, barely needed a liner. I had horrendous pmt symptoms from mid cycle sometimes startimg as early as day 8, still felt like I was ovulating as lots of cm around the right time but also was waking up each morning super early with hot flush and cortisol or adrenaline spikes which wpupd come and go throughout the morning. My anxiety was through the roof and I had sore finger joints, dry eyes and vagina and was on and off constipated. Due to mental health, doctor persuaded me to initially try an ssri (citalopram) and then hrt which I've been on since Jan 2023. My cycles still result in a predictable bleed when i stop the utrogestan which is now a bit heavier and longer since starting hrt. However in October 2023 when I stopped for 7 days at the start of the cycle, I ended up without a bleed that month which makes me think my own levels have further dropped. I didn't then bleed fprv60 days when I was due my withdrawal bleed at the end of the following month.

I do have a compromised gene pathway which means I produce more of the bad estrogens (4OH) so I am very worried about taking anything synthetic in case I can't detox it well enough (I also have a partially compromised detox pathway which I supplement for).

If I continue with half a pump of estrogen which really is the minimum i can measure out, do you think I could get away with 100mg of utrogestan for 12 days rather than 200mg, then maybe get a private scan after 3 months? I do understand the benefits of some estrogen and also progrstrone to keep it in check but am so scared of how my body and mental health would react to the full dose given how much the combo of utrogestan with clear estrogen surges has triggered my ocd this month.

Also the thing I used to find hardest before hrt was the waking at 4 or 5am with hot flush and cortisol. Is there anything non hrt related i could do about that that you kmow of?

I am paying to see a psychiatrist in mid April to see whether I need to come off citalopram (I feel its doing nothing amd have been on it for 18 months) or change to something else as my ocd (particularly the looping thoughts) is out of control. That's partly why I don't want to completely pull the plug on hrt in one go. I guess I'm just really scared and don't know what to do until April when I can get a psychiatric opinion.

Many thanks for you help x