Print

Please login or register.
1 Hour 1 Day 1 Week 1 Month Forever
Login with username, password and session length

[Hurdity]

I am just posting this as a separate thread because there was a discussion on another thread about how continuouis combined HRT works re the effect of progesterone compared to taken cyclically.

I did post elsewhere on another thread a few years ago but reposting.

To understand how it works it helps to understand how oestrogen and progesterone work generally in relation to the endometrium (womb lining).

Oestrogen makes the womb lining grow in a dose dependent manner ie higher doses will make it grow thicker than low doses. This all happens at cellular/tissue level – you can google endometrium menstrual cycle images or something similar and you will see what it looks like.  While it is growing it is called “proliferative”.

When progesterone is added, the structure of the endometrium changes to prepare it for the fertilised egg and pregnancy. If you look at the images you have googled these are shown – actually structural changes take place and this is also dose dependent – the more progesterone the more the endometrial layer  is changed  - and while this is going on it is called the“secretory” stage. During the menstrual cycle I imagine it is usually pretty well balanced for most women.

In the menstrual cycle after ovulation the empty egg sac (corpus luteum) produces progesterone to start the process of converting the lining to secretory.  If there is no fertilised egg  the egg sac runs out of progesterone, dies away and the level of progesterone falls. Once this happens the feedback mechanisms trigger the bleed of menstruation

With cyclical HRT you are trying to mimic this – firstly giving enough oestrogen to eliminate symptoms and then to give enough progestogen to convert the endometrium from proliferative to secretory. The actual amounts needed to do this are not fixed and vary from woman to woman and also depend on how much of each hormones is absorbed from the various HRT dose and delivery method used.  With cyclical HRT the bleed  is known as a progesterone withdrawal bleed – the same as happens in the menstrual cycle.

Any other type of bleeding is to some extent abnormal: oestrogen withdrawal bleeding – some women develop some spotting just after ovulation when the oestrogen level falls dramatically, and the same happens with some women on HRT if they reduce their oestrogen level suddenly.

The most common type of abnormal bleeding I think is oestrogen breakthrough bleeding – which is when the endometrium gets too thick for whatever reason and starts to come away sporadically and spontaneously – this is not a proper period and wouldn't happen on a regular basis. This is the sort of bleeding that needs checking out and can happen with continuous combined HRT where there is too much oestrogen relative to progesterone. If peri-menopausal it isn't always possible to tell whether the bleed is from a normal period or spontaneous shedding although if a proper period after ovulation many women have the usual pre-period signs and body changes beforehand.

When you take continuous combined HRT the progesterone acts to interfere with the oestrogen receptors so that they don't allow proliferation. If you imagine the endometrium and the lining – it won't be entirely uniform and from what I have read the effect of progesterone (on preventing the lining growing) doesn't happen all at once. However this can be an imperfect process as it is also dose and time dependent so takes a while for the endometrium to respond  and for any spotting/bleeding to cease.  Here is some information:

“Continuous combined HRT and the endometrium

Studies have shown that continuous combined HRT induces an atrophic endometrium and eliminates bleeding in most postmenopausal women within six to 12 months.16, 29–32 It is known that the continuous presence of progestogen in a regimen of continuous combined HRT causes downregulation of oestrogen and progestogen receptors, which in turn decreases sensitivity to hormonal stimulation.33 In addition, progestogen induces 17-β dehydrogenase, which converts oestradiol to the less active oestrone, thereby reducing the oestrogenic stimulus.34 It is not known which of these mechanisms predominates in producing endometrial atrophy in postmenopausal women on continuous combined HRT.”

https://jcp.bmj.com/content/54/6/435

If the balance between oestrogen and progesterone veers too much in favour of progesterone then the lining can get over thin and cause ulceration and spotting or bleeding as a result of endometrial atrophy. Not sure about the type of bleeding here but I imagine it is not bright red and profuse as would be the case with lining being shed?

Only proper investigation will determine the cause of an individual's bleeding and even then not always!  There are guidelines for when this should be carried out.

Therefore if anyone experiences bleeding while on HRT it could be several things eg a change in progestogen type or dose, fall in progestogen, change in oestrogen or insufficient progesterone in relation to oestrogen.

Here is some more info:

https://www.uptodate.com/contents/abnormal-uterine-bleeding-beyond-the-basics

Hope this helps

Hurdity x

[Dotty]

👍🏻👍🏻👍🏻 Thanks Hurdity xx

[Shannonplussed]

I have had this post bookmarked for a while, as I've found it very helpful. Sorry to bump this, but I think it's full of useful info and deserves more views!

I'm on continuous HRT (post meno, don't ovulate) and have some very very light spotting for several days about every two weeks for the last little while. Much like when I first had a Mirena in my late 30s, very light brown spotting for weeks. So either this is the process of the endometrium becoming atrophic, or the balance veering in favour of progesterone. Based on the italicized portion of the original post (downregulation of estrogen receptors) and my symptoms, I'm inferring that an increase in estrogen is called for. Indeed, I've been having low grade hormonal headaches for a month (not migranes) and occasional night sweats. Had some days of PMS-like flat mood. The headaches coincide with me finally releasing some of the weight that piled on before I was able to start HRT. I've increased Estrogel by a pump (from 2 to 3) and so far not much has changed, although my mood is better. Last year, when I increased to 3 pumps, I was tearful and generally emotionally unstable and dropped back to two pumps (maybe that was while the progesterone portion was "settling").

Anywho, I wanted to see if others have the same interpretation that estrogen may need to be increased after some period of time on continuous...and if anyone else saw previously stubborn weight begin to release at the same time?

Finally, while I understand the "lowest dose for shortest time" principle, at what point is it clear that estrogen is too high? Because I wonder, if I'm on the right track, how far I can increase it. My breasts aren't sore, I don't bleed red blood, and I'm as emotionally stable as I can expect of myself  But I have to be honest, losing 15 of the 45 pounds that I gained in the months while I was off hormones and waiting for diagnosis has me hopeful to regain my old figure, and I wonder if more estrogen is the ticket. I'm 43, so maybe I well need more?