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[HelloSaffy]

Hi all,

I could do with some advice on what to do as I can't get an appointment with my GP for two weeks and I need to make a decision about my HRT now.  Here are the facts (!):

1. I have had a pelvic scan that suggested that I have a thickened endometrium at 1.35cm.  I am still menstruating, and the scan was three weeks after my last proper period started - so I'm not sure that this is actually particularly thick all considered.

2. I have been having continual spotting pretty much every day of brown blood for a couple of months.

3. I have been on oestrogel and utrogestan 200mg for 14 days for over a year.  I'm not sure that I've ever got into any sort of pattern though, I think my withdrawal bleed is supposed to be towards the end of the utrogestan, but it doesn't fit with this, it happens at different times of the month.  Other than I missed a month last September, bleeds (my own cycle?) have been every three to four weeks, though sometimes closer together.

4. A private menopause nurse suggested that I upped the utrogestan to 300mg to clear the bleeding, but my GP wouldn't prescribe this, so I did it for a month with what I'd got left over and then went back to 200mg.

5. I wonder whether I have too much oestrogen, I've been getting really painful breasts the last few months.  I was on three pumps.

6. As a result I haven't taken any oestrogel over the past few days, my breasts feel a bit better today.

7. A proper bleed started yesterday, this is about four weeks since I last had one, but two weeks since I stopped the last round of utrogestan.

Does anyone have any idea what it might be best do to now with the HRT?  I have to go back for another scan because they didn't get one of my ovaries (I don't think anything is wrong with my ovaries!) and I'm keen to do what I can to not have a thickened endometrium if possible so I don't have to have a more invasive procedure.  I'm supposed to start the utrogestan tomorrow - whilst I'm wondering whether this has any effect at all as it doesn't seem to cause a bleed when it should - I'm wondering whether I should (a) start the utrogestan with maybe just one pump of oestrogel to have a different oestrogen to progesterone ratio, or (b) just do nothing and not introduce any more oestrogen that will build up the lining again, or 3. Can I take just the utrogestan?  I'm presuming that it might be suggested at some point that I have a Mirena, I've not been keen in the past, but everything's moving at snails pace anyway so won't help in the shorter term.

Thanks for getting to the end of this, and any ideas?!

[Hurdity]

Hi HelloSaffy

 

"I am still menstruating, and the scan was three weeks after my last proper period started - so I'm not sure that this is actually particularly thick all considered."

You're absolutely right - the endometrium grows during the first part of the cycle (natural or artifically induced from HRT), then when you add progesterone (or it is produced after ovulation) the lining changes structurally and often thickens to some exctent, reaching a maximum just before it is shed ( when you stop the progesterone).

That measurement is completely within range if you look at this paper:
https://www.healthline.com/health/womens-health/endometrial-stripe#normal-range-ofthickness

which says it varies from 1 to 16 mm in women of reproductive age depending on the phase of the cycle.

However the persistent bleeding is an indication that something needs investigation but also depends how old you are and where you are on menopause - ie what stage you were at before starting HRT a year ago?

If your cycle is still coming into play then this will have an impact on bleeding.

Your GP is out of order not to prescribe 300 mg as recommended by your private nurse. This is in fact recommended by the British Menopause society if the standard dose of 200 mg is insufficient to control bleeding. See this paper here (Tools for Clinicians - Progestogens and endometrial protection https://thebms.org.uk/publications/tools-for-clinicians/: ):

"The dose of the progestogen should be proportionate to the dose of estrogen. While no data is
currently available on the endometrial effects of high doses of estrogen and the optimal dose of
oral or vaginal progestogen in this context, women who require high dose estrogen intake should
consider having their progestogen dose increased to ensure adequate endometrial protection (e.g.
micronised progesterone 300 mg for 12 days a month instead of 200 mg in cyclical HRT regimens or
200 mg daily on a continuous basis instead of 100 mg in continuous combined HRT regimens)."

You could reduce the oestrogen but if you are happy on that dose then why should you? Can you go to another GP in the practice (or thre same one) armed with the above advice from the BMS?

It is important though that if an increased progestogen dose does not control the spotting then you should seek additional advice but you really need to have a scan at the right time which is immediately after your main bleed ( though if this is not in sync with your HRT this is difficult) - ideally a U/S then a transvaginal scan to check all is well. Only if your lining is thick at its thinnest point or abnormailities are detected, would you need a further investigation like hysteroscopy - but these can be done without anaesthetic as a minor procedure.

If you are taking HRT because you are menopausal (eg post-meno or late peri) then taking Utrogestan alone will not help and may well mean you experience a resumption of menopausal symptoms.

Another alternative is take a Provera tablet - which is a powerful synthetic progestogen so will also help reduce any abnormal thickness (provided there is nothing else going on).

I hope this helps - sorry its a bit rambling I think!

Hurdity x

[HelloSaffy]

Thanks for the welcome and the detailed response!  I've had a pelvic scan but not a transvaginal scan - I'm supposed to go back for one of those - there was a bit of an administrative mix up, though I'm not quite sure what it will add other than they didn't get a proper picture of one of my ovaries (though I've had a negative CA125).  The scan report says possible hyperplasia because of the thickened lining in the fundus, but this is what I'm a bit sceptical about. 

I'm nearly 53, so getting on a bit, but was having regular periods still when I started HRT.  I might be being a bit unfair on the GP, she may reconsider the utrogestan once I've had a chance to talk to her about my scan results - she's the women's health specialist - but the practice in general seems overwhelmed so it's difficult to get an appointment with anyone (I've only read my scan results on the NHS app so far).  She did say she'd refer me to the menopause clinic depending on the scan results.

I bled all the time on the minipill and I was investigated for endometriosis for symptoms in my 20s, but the consultant concluded I had "crap hormones", which I suspect is what's currently going on rather than anything more sinister!  I'm sick of the constant bleeding though, and the underlying anxiety that it's something more worrying.  I think I'll reduce the oestrogel a bit and see what happens.

Thanks again!