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[buffy26]

Hi all,

Based on the Nice guidelines recently released, as I am on 4 gel pumps of Estrogel I increased to two tablets of Utrogestan a day. The positive effects have been a reduction of cognition issues and fogginess and deeper sleep. The negatives (if related) are a racing heart, anxiety and raised blood pressure. I am literally losing my cool at the slightest challenge, snapping and flapping all the time. This is all of a sudden so I can only assume it is connected to the increased dose. I am wondering if the dose is too much as I am likely not absorbing the whole four pumps of gel adequately, with my estrogen dropping to 273 on last blood test. We cant win can we!!   I am enjoying being more alert and sharp but at what cost and is it worth it

[CLKD]

I know nowt about HRT regimes but would it be prudent to either knock of 1 of the Utrogestan : perhaps the sudden hike in dose is too much?  MayB every 3rd night. initially?

[bombsh3ll]

You could try taking either one or both vaginally, sometimes this makes it easier to tolerate.

The evidence for increasing the dose of progesterone for a given dose of estrogen isn't strong, particularly when you understand that two women on the same dose can be absorbing very different amounts.

Another option would be to stick with your existing dose and get a scan every year or so to ensure your lining is not becoming too thick. This isn't offered on the NHS but may be worth paying for in order to keep a treatment that you are happy with.

[Hurdity]

Hi buffy

Has your specialist or GP recommended this increase?

Yes women absorb differently but as a general rule of thumb the amount (dose and duration) of progesterone needed to progect the endometrium is dose dependent on the oestrogen. ie more oestrogen requires more progesterone - though it is not possible to determine this precisely. The standard licensed doses are arrived at through trials and of course err on the safe side so may be too much for some women, but equally insufficient for others.

The British Menopause Society:

"The dose of the progestogen should be proportionate to the dose of estrogen. Women who require
high dose estrogen intake should consider having their progestogen dose increased to ensure
adequate endometrial protection."

If you are not absorbing the oestrogen then you may not need to increase the dose and if your specialist has recommended this in the absence of symptoms (ie unscheduled bleeding or spotting) then I would request a scan - because it is the thickness of the endometrium rather than oestrogen levels which is the crucial factor in determining whether your HRT regime is working (though levels are obviously important as well - but only as a proxy measurement for what could be your endometrium thickness).

I wasn't aware of progesterone causing racing heart and increased blood pressure....you are post-menopause?

Hurdity x

[buffy26]

I know nowt about HRT regimes but would it be prudent to either knock of 1 of the Utrogestan : perhaps the sudden hike in dose is too much?  MayB every 3rd night. initially?

You could be right on the sudden hike, I am not sure of the irregularity of two nights one tablet and 3rd night two. Maybe someone here has some experience of doing this. Thank you for the suggestion, and idea to suggest when I message the doc

[buffy26]

I know nowt about HRT regimes but would it be prudent to either knock of 1 of the Utrogestan : perhaps the sudden hike in dose is too much?  MayB every 3rd night. initially?

You could be right on the sudden hike, I am not sure of the irregularity of two nights one tablet and 3rd night two. Maybe someone here has some experience of doing this. Thank you for the suggestion, and idea to suggest when I message the doc

Hi buffy

Has your specialist or GP recommended this increase?

Yes women absorb differently but as a general rule of thumb the amount (dose and duration) of progesterone needed to progect the endometrium is dose dependent on the oestrogen. ie more oestrogen requires more progesterone - though it is not possible to determine this precisely. The standard licensed doses are arrived at through trials and of course err on the safe side so may be too much for some women, but equally insufficient for others.

The British Menopause Society:

"The dose of the progestogen should be proportionate to the dose of estrogen. Women who require
high dose estrogen intake should consider having their progestogen dose increased to ensure
adequate endometrial protection."

If you are not absorbing the oestrogen then you may not need to increase the dose and if your specialist has recommended this in the absence of symptoms (ie unscheduled bleeding or spotting) then I would request a scan - because it is the thickness of the endometrium rather than oestrogen levels which is the crucial factor in determining whether your HRT regime is working (though levels are obviously important as well - but only as a proxy measurement for what could be your endometrium thickness).

I wasn't aware of progesterone causing racing heart and increased blood pressure....you are post-menopause?

Hurdity x

Hi Hurdity,

Thank you for your thoughts.

My GP said it was advisable to increase the dose as I was on 4 pumps quoting the new guidelines.  I am post menopause and have the endometriosis history which was another reason for the increase. I was scanned in the beginning of HRT as i had bleeding, the endometrium had thickened to 7mm then. I was referred for a Hysteroscopy, no sample was taken though. All seemed ok and no further bleeding occurred even with incremental gel dosage increasing to 4 pumps. I am really feeling the benefits of less brain fog, which was quite bad, as mentioned in my post. I may try adding a further estrogel dose up to 5 as my skin is so dry and a poor absorber just to make sure there is a better balance. The GP did mention she would refer me for another scan, however I think she may have not done this as the high blood pressure and chest pain was her primary concern.so I will follow up on that.  The pharmacist did say he doesnt think high blood pressure and racing heart was a side effect but I did wonder if this anxiety thats gradually creeping in is an effect. Perhaps its just a case of the body getting used to it all. I am also yawning a lot in the day!!

[buffy26]

You could try taking either one or both vaginally, sometimes this makes it easier to tolerate.

The evidence for increasing the dose of progesterone for a given dose of estrogen isn't strong, particularly when you understand that two women on the same dose can be absorbing very different amounts.

Another option would be to stick with your existing dose and get a scan every year or so to ensure your lining is not becoming too thick. This isn't offered on the NHS but may be worth paying for in order to keep a treatment that you are happy with.

Thanks bomsh3ll, it seems you and Hurdity have more or less said the same. I am fortunate that my GP has suggested the scan, when I mentioned it to another one a previous appointment, she laughed and said that wont happen! This was when I said I was nervous about being on HRT as a person who had endometriosis. It would be good if ladies who suffered with this conditon all their lives could be monitored, as it was such a battle to get anyone to understand or refer back then and we had to endure a lot. I feel we deserve to be monitored more closely

[joziel]

If it helps when I first started HRT I had anxiety increased BP episodes and weird stuff. But it all settled down…

It does sound more like E symptoms than P. 273 is a low E level really, you probably need higher… but let the body adjust for 3 months between each dose.

I also think sometimes estrogen kicks cortisol up which can make you feel anxious. Try taking cortisol lowering supplements before times of anxiety. These are zinc, ashwaganda, & Alpha GPC or PS-100 (choline).

[buffy26]

Thank you Joziel
 Good to know it settled down. I am going to up my dose to 5 pumps and see if this does anything, but as you say Estrogen can also up the anxiety.  Those supplements are interesting and I will take a look. I am on a good quality Zinc as I was discovered to be significantly low in that.

[Hurdity]

Hi again buffy

The level of 273 pmol/l is not a particularly low level for post-menopause per se - but of course symptoms are key and that is probably on the low side for 4 pumps of oestrogen. I'm not sure that the symptoms you describe are due to inadequate oestrogen though? One off blood tests don't give a full picture. Also if you have increased progesterone on the advice of your specialist, then maybe not wise to also increase oestrogen if you have endometriosis. Not sure dry skin is necessarily a symptom of oestrogen being too low? But definitely ensure you are scanned regularly given your circumstances.

Hurdity x

[buffy26]

Hi again buffy

The level of 273 pmol/l is not a particularly low level for post-menopause per se - but of course symptoms are key and that is probably on the low side for 4 pumps of oestrogen. I'm not sure that the symptoms you describe are due to inadequate oestrogen though? One off blood tests don't give a full picture. Also if you have increased progesterone on the advice of your specialist, then maybe not wise to also increase oestrogen if you have endometriosis. Not sure dry skin is necessarily a symptom of oestrogen being too low? But definitely ensure you are scanned regularly given your circumstances.

Hurdity x

  Hi Hurdity, thanks for your thoughts
Good point, I suddenly also had a hesitancy about upping the dose without more consideration so I'm still on 4.
My skin is kind of rough on the upper arms, despite exfoliation so I'm wondering if the gel may not be able to sink into the skin as easily. It would be good to know if I could apply it to the bum cheeks instead to see if there is a difference. I may speak to the manufacturers, they would have trials I  expect on various locations tested.
Ideally with Ostepenia too I would like to be feeling more of an improvement and know there's scope to be reaching far better optimal levels. My bloods have been tested about 3/4 times along the way,the highest was 320
The specialist I saw who assessed it all said she wanted me to be at least @500
with HRT, an ongoing project! I have regrets waiting until 58 to decide to go for it really. I'm hoping and expecting the next ultrasound shows little change on the thickening of the endometrium as I have no signs of bleeding.

[joziel]

buffy, really you need to experiment and see if you feel better. Being afraid to try things will just leave you where you are...

By the way, on 6 pumps of gel my estradiol was at 334pmol. On TWELVE pumps of gel (double the dosage), my estradiol was at 328pmol. That's right, I wasn't absorbing any more of it. That's with a pump on my butt cheek and 5 pumps on my thigh (all around it and not overlapping) on each side.

Like you, my doctor wants to get me higher, around 500-650pmol at least, to see if that helps improve symptoms. I am having a phone consult on Monday with my Newson doctor to switch - probably to Sandrena. If that doesn't work, we will have to use oral. Many women need higher levels to have their symptoms controlled. Most HRT is designed to bring women just over the minimal amount to give some protection to bones and other body parts - which often doesn't hit the spot for a lot of us.

If I'd been afraid to try increasing (by the way, I also have a history of endometriosis and had a lap for it in 2013) I just wouldn't be making fast enough progress. I'd be fannying around on 6.5 pumps or 7 pumps or something. Of course you shouldn't change a dose more rapidly than every 4-6 weeks but if you are not optimal, you do need to have the courage to try things out...

[buffy26]

I know Joziel, I'm a chicken! I think reading clinical journals over the years has caused me to be Ms Cautious. I think I've been so relieved to have no bleeding that its made me jittery about rocking the boat. I've heard lots of good things about Sandrena. Will be really interested to how things go with your appointment, did you ever consider the Lanzetto spray as its on one spot only? I think Lisa Snowdon rates it. Did you bleed at any stage in your journey of increasing dosages, what a performance, 12 pumps 😱 I admire your persistence and courage!

[joziel]

I'm only 46yo and still in peri, so I do still bleed. Except these last few months I've been on such a high P dose compared to E, I think that's why I haven't bled. That, or my 23 day cycle has now gone long and the other direction... But I do often bleed about a week or two after increasing E, which is very normal - you should overlook any bleeding that happens within 12 months of increasing dose.

The Lenzetto is supposed to be quite weak and people often need many sprays of it anyway, so given my transdermal absorbing problems and that I need to get my E up quite a bit, I don't think it's a good option.