Thanks to you lovely lot, I have been successfully taking T4 Levothyroxine 125mcg x1 with self-prescribed T3 25mcg x twice daily. I feel I’ve hit the right spot with my thyroid regime.
I take Almus brand 100mcg, with Wockhardt 25mcg T4 Levo. I take the Tiromel brand for my T3.
I’m coeliac, so have avoided gluten for 25+ years. I currently supplement my excellent diet with D3/K2, iron/ ferritin/ folate and B vits - though not at the same time!
Today, after campaigning for HRT for nearly 4 years (I was deemed ‘too young’), I’m thrilled to be prescribed HRT for perimenopausal symptoms.
I’m 45 (and yes, I cited NICE guidelines and until now got nowhere, even in the months following my 45th birthday). I also tried at least 6 GPs at my local surgery, all women, all completely disinterested/ dismissive of my perimenopausal symptoms (despite me having the most classic peri list imaginable!). Of course, with the mismanagement of my thyroid for so many decades I shouldn’t have been surprised.
In the past few years, due to the reluctance of the GPs’ in my surgery to prescribe me HRT, I became so desperate to alleviate perimenopausal symptoms I even tried four different Birth Control Pills (BCP) - which I’ve never got on with. In fact, my OH had The Snip a decade ago so that I never had to take any! Needless to say, none of them suited me and the progestin-only pill made me genuinely suicidal. It was terrifying.
However, finally today I have been prescribed the bio-identical hormones transdermal Oestrogel (Estradiol) 750mcg x2 pumps; and oral Utrogestan 100mg (progesterone) x1 on Days 1 to 25 of 28 day cycle.
I have always suffered from PMDD - severe PMT - in the lead-up to my periods due to the drop in oestrogen.
After my negative reactions to the BCPs I’m worried about the progesterone in my new HRT routine, but since it’s different from the progestin I took before, hopefully I’ll be OK. I’m still bleeding so can’t avoid progesterone altogether. Also, I’ve done loads of research on ways to take the minimum amount of progesterone, from taking it via vaginal pessaries to alleviate pressure on the liver/ common side-effects, to taking it every two months - or for the fewest days a month one can safely get away with. Like with finding the right levels of T4 and T3, it’s all still to play for, and no doubt will also vary over time.
So; how do I use the Oestrogel and Utrogestan without them impacting my thyroid meds?
For example, Ustrogestan’s supposed to be taken at night as it can make you sleepy, and it also needs to be taken 4 hours away from food. However, I usually take my second T3 at bedtime, as late afternoon has never worked for me (apart from anything else, I need a cuppa and a snack to get through the afternoon!).
How many hours should there be between HRT hormones and thyroid meds?
What’s the best way to take HRT without it impacting on my thyroid meds?
With all these things to get right with oestrogen and progesterone levels - let alone testosterone, which I haven’t even got to yet - it feels a bit like starting on the T3 journey all over again.
So all and any information, experiences, hints and tips gratefully received. I just want my brain back… And the rest!
Thank you 😊
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Abi-Abster
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Hi I just wanted to point out that it is (to my understanding ) low progesterone that causes PMS not low estrogen, have you heard of the late Dr Katherina Dalton she was a pioneer of hormones and advocated natural progesterone cream she coined the term PMS, you are lucky to be presribed natural progesterone not all GPs do
Absolutely. I think it was because the progestin BCP made me suicidal. Also, I’ve since read up on the Oestrogel and Uterogestan combo, and apparently it’s - quote - the ‘gold standard’ treatment, and a very common approach by many GPs. So I’m not that special after all!
I believe PMT/ PMDD is oestrogen related as it occurs in the run-up to a period when oestrogen levels plummet.
Additionally, I have ADHD which is also worse at that time of the month (think neurotypical brainfog + concentration issues x warp speed).
For we ADHDers, an increase in symptoms is scientifically linked to a decrease in oestrogen. It’s a fact! If this applies to anybody reading, Dr Sandra Kooij is an amazing ADHD psych at the forefront of all this hormonal research, and I suggest you Google her - even if you’re not ADHD yourself.
Of course there are no surprises the patriarchal system hasn’t even thought to research the relationship between exacerbation of ADHD and perimenopause (also see NOT prescribing Testosterone to women yet treating men with Viagra: menopausedoctor.co.uk/news/... ; and not teaching medical students about the peri/menopause in for more than one paltry afternoon). But I digress.
I was also told about the connection between oestrogen levels falling and PMT for neurotypical folk. And, for me and my ADHD brain at least, there’s no question oestrogen drop-off and PMDD are linked. Especially as I feel PMDDy all the time I’m on additional progestin (with every BCP I’ve tried).
I do know both the Progesterone and Oestrogen hormones fluctuate during the month however, so thank you for taking the time to reply - I will look into it further.
I get the feeling it’s an endless dive into many scientific papers and forums to then apply contrasting treatments opinions to the individual. Much like learning about T4 and T3. Wish me luck!
Hi, I've got Hashimoto's, and have been on Levothyroxine for thirty years and on HRT for almost twenty as I had premature ovarian failure when I was 42. You are absolutely right, dermal oestrogen like oestrogel (or patches) with vaginal uterogestan are the gold standard. A site that is very informative is menopausematters.co.uk and so is the recent book "Preparing for the Perimenopause and the Menopause". Taking your thyroid meds and your HRT separate from each other is key. Another very good site which is limited to women who have had surgical menopause but where the publicly accessed pages have good very advice on troubleshooting different types of HRT is surmeno.blogspot.com Good luck !
As far as I know, transdermal estrogen (gels, creams, sprays, patches) does not interfere with thyroid hormone absorption. I´ve been using it for a few years and it never affected my thyroid hormone levels. Vaginal progesterone won´t affect them either. It´s ORAL estrogen and progesterone that should be taken several hours away from thyroid hormone. Transdermal/vaginal hormones are not processed by the stomach so cannot affect thyroid hormone absorption.
You may very well be right, but my understanding is that these hormones do not interfere with absorption at the gastric level but rather at the cellular level because of their interaction with SHBG
Sorry I meant to type Thyroid binding globulin (TBG). Transdermals do have a lesser role than orals in increasing its secretion from the liver, thus binding the thyroxine available, but I'm not sure the effect is zero.
Thanks for your response. Good to know you haven’t noticed any adverse effects on your thyroid level. I use Vagifem for localised oestrogen but Oestrogel is a whole new thing. How have you found the transdermal oestrogen as part of your HRT regime? Has it been beneficial to you?
Yes, it has. I have read the books by Belgian hormone specialist Thierry Hertoghe, MD., especially "The hormone solution", and he is adamant you should not take estrogen orally, as it is harder on the liver, will raise thyroid binding globulin levels (which makes less thyroid hormone available to the body), and also increase the risk of blood clots (VRT). It would seem all known risks are linked to ORAL, not transdermal/vaginal, HRT. He also stresses that progesterone shoud be bio-identical, not synthetic and, unlike estrogen, taken orally (the only bio-identical progesterone available in Europe is called Utrogestan), as transdermal progesterone may not be absorbed so well. So, I looked until I found a doctor prescribing bio-identical HRT. Even if some people are critical of anti-aging doctors, this is one area where I trust their expertise. Bio-identical sex hormones have a structure identical to our own, whereas synthetic sex hormone drugs do not. Just reading about all the side effects associated with birth control pills (containing synthetic estrogen and progestins) was enough to convince me never to go near them.
Extremely helpful to know. Thank you for taking the time to write the above! Thankfully, I’ve been prescribed Utogestan, so hopefully the progesterone part will work out for me.
I’ll look up Dr Hertoghe - he sounds like a very useful source. Thank you 😃
He is very useful indeed. Like UK doctors such as Drs. Skinner and Peatfield, he has had his fair share of critics for prescribing NDT/T3, other bio-identical hormones, and for refusing to treat every patient the same.
Incredibly interesting thread! I also tried Utrogestan and Eostrogel but felt awful and had lots of bleeding. I have also had terrible pms when had periods. My doctor suggested Mirena coil for me (I’m 56!) and I have to say it’s been brilliant - I’m 2 mths in and bleeding and pains stopped but I’m not sure it’s bio identical progesterone. Any thoughts?
So brilliant the Mirena’s working for you! Great news 😃 You must be relieved.
In terms of progesterone/ progestin, I’m not sure which kind the Mirena uses, but I do know it’s at a far lower dose than is used in Birth Control Pills. Not getting on at all well with Progesterone, the Mirena was recommended to me for this very reason: it’s low progesterone/ whatever kind it has. But unfortunately it won’t work with my body (I’ve got funny insides so can’t use the coil).
It does seem to be those who struggled with PMS/ PMT and PMDD (Pre-Menstrual Dysmorphic Disorder) like me have a harder time with the perimenopause and menopause, which is unfortunate. It does make sense, however… Annoyingly!
Thank you for your input. It’s great to hear from someone with experience 😃
Agree that the Menopause Matters website is invaluable. Didn’t know about the second site you mentioned, and it’s super-helpful. Thanks so much for the share!
Where did you hear about the transdermal/ cellular level effect? I’m interested to know as I would otherwise apply my Oestrogel at the same time as I take my morning T4 & T3 (morning routine/ shower/ bathroom cupboard, etc).
Glad to be of some help..I googled estrogen HRT and levothyroxine uptake or something like that. I used Oestrogel for 16 years, it helped a great deal. I tried to space about an hour or two between it and thyroxine, just in case.
It is so incredibly frustrating that people do not understand that most of us are oestrogen dominant. It's progesterone that pre, post and menopausal women need. Progesterone cream got me through with no side effects, as it's a natural product. All these people asking about HRT.... drives me crazy! But I'm having a bad day
I hear what you are saying marigold22Whilst oestrogen is essential many illnesses are due to low progesterone for example postpartum psychosis postpartum hashimotos and many autoimmune disorders - though genetics play a part too
Hi Abi-Abster, I've read your post with interest. Something that might be of interest to you is that PMT is linked with GABA levels dropping premenstrually in some people (and being low in some people who suffer from depression). Trials found that these people who practised yoga (whole yoga, not just the poses but all the rest so often not included in classes) found they no longer experienced PMT and depression and their GABA levels did not fall premenstrually and remained at 'normal' levels in those who were formerly depressed. If you like yoga it might be worth seeking out a very good and properly trained teacher in your area. Here's a link to more info about GABA on my website and I'm not looking for more students though do lead just one online class, just letting you know as it might help you: pennyjollyyoga.com/healing-...
Thank you Penny, you’re such a sweetie to explain the above - I’d actually just stumbled across the GABA link right before reading your comment, so you were right on the money!
I’m actually a yoga teacher myself, but I have to confess to getting complacent about my own practise and meditation since the first lockdown (small house, kids at home, no space - mental or physical - to do anything else!), and funnily enough it’s only this week I’ve started to meditate again, which was much needed. Again, you’ve hit the mail on the head!
Further reading is definitely required…
NB: FWIW - and again, for anyone else with a similar hormonal history to myself - there’s a proven correlation between ADHD and PMDD, which I didn’t learn until my own ADHD diagnosis at 41, after my girls had been diagnosed (by which time I’d suffered with PMDD for decades.)
Thank-you Abi-Abster for such a lovely reply and how exciting that you too are a yoga teacher so you can help yourself! Oddly, like you, I did much less yoga and meditation during lockdown. The correlation between ADHD and PMDD is very interesting.
Hi Abi-Abster - I've been round the block a few times with oestrogel and utro (10 years). The oestrogel worked quite well for a while and then I seemed to have trouble absorbing it or, as I think was probably the problem, my thyroid starting waning and I started to get all the classic hypo symptoms, increasing oestrogel or patches or any kind of oestradiol either transdermally or orally made me feel even more hypo, but i didn't know that at the time. Eventually I stopped using oestradiol and i felt marginally better. My point is that it's understood that oestradiol has an effect on TBG and can, for some, mean a tweak in thyroid meds. I'm not currently medicated as my endo thinks my thyroid is healthy, but i've got to this point, like many of us, through experimenting on myself. I'm now able to tolerate a very small amount of oestrogen and progesterone (I use 20-1 cream) because I'm taking 1 metavive i a day. If i stop the metavive, the hypo symptoms return, and when I reintroduce it, I'm fine. As you're already diagnosed, you'll be aware how to look for hypo symptoms returning on your HRT but I came at it the opposite way around!
In terms of utrogestan - I was great for 2 days (I used it vaginally at 100mg), I felt really energised, clear headed, in top form! I now know that that was probably because there's an interaction between progesterone and T3. However, after 2 days, the progesterone would build up and cause depression, fatigue, awful digestive problems and extreme brain fog. I'm going to try utrogestan again now that i'm using metavive because I'd like to see if I can now tolerate it. Again, just a gentle warning that it can produce these symptoms but as you're successfully medicated you may not experience any of these. Also, using utrogestan vaginally can cause some vaginal and urethral irritation. There are compounding pharmacies who will make bioidentical hormones after a private consultation, in the form of lozenges and creams in various dosages if you find the utrogestan too powerful. I hope this helps and isn't too confusing!
Thanks so much for this lovely long response, Jamima
I had no idea HRT could *negatively* affect the thyroid, but it makes sense. Interesting!
And I love that you wrote this today because after a bright and optimistic start - and feeling like a whole new person - I’m now on Day 11 and have been feeling rubbish for the past few days: low mood, no motivation, sleepy, extra brain-fog, the works. It’s very similar to how I felt on the progesterone-only Birth Control Pills they put me on previously to manage my perimenopause symptoms (only without the suicidal tendencies…yet).
I was concerned beforehand that the progesterone aspect might not suit me, but as I’m still having periods I was told I had to take it alongside the Oestrogel so that I could still shed the womb lining every month. Anyway, as predicted I’m now feeling awful. As you said, it feels like the progesterone has built up over that time.
That said, the GP also mentioned that I could increase the Oestrogel dose to more pumps per day. I wonder if this will help counter the progesterone blues?
I’m taking 100mg Utrogestan daily for Day 1 to 25 of my cycle, where I’m supposed to stop for a few days and bleed. The GP said it was the lowest dose they offered. Which is a shame, as progesterone really doesn’t work for me! Ugh…
Yes, that sounds like fairly classic utro problems. There’s a couple of options that gp’s won’t offer as it’s off licence but you can do a search for the papers on alternative day dosing with utro. It’s based on using 1/2 pumps oestrogel or a 25/50 patch (rough equivalent) and alternate nights vaginal utro. I’ve tried this but it got me in the end with all the usual symptoms, but that may have been due to my thyroid and wouldn’t apply to you. It means lowering your oestrogen but I think there’s an option for a slightly higher oestrogen dose too. It really depends on how much each woman is absorbing and if they’re producing their own E&P. There’s also an off licence method which is strictly for low dose ie. 1 pump oestrogel, it’s prescribed in France and Switzerland this way and it’s to use the utro vaginally twice per week, vaginslly on non consecutive nights. The final option is to try and cycle the hormones ie oestrogen only for 14 days then oestrogen and progesterone for 14 days, stopping the progesterone after 14 days and then having a bleed. You’re currently on a continuous combined hrt which should really only be used if you’re post menopausal. Peri women should be on cyclical hrt but most gp’s don’t know this.
OK, so does the final option above mean that I would feel rubbish for 14 days a month rather than the 25 days I’m prescribed now?
And with the previous options, is it about about reducing the Oestrogel dose because you’re also reducing the Progesterone (I take my Utrogestan orally)?
I’ll copy and paste other low progesterone options I’ve found on the web, below -
Our group still uses oestradiol implants, often with the addition of testosterone for loss of energy and loss of libido, in our PMS clinics but we have reduced the oestradiol dose, never starting with 100 mgs. We will now insert pellets of oestradiol 50 mgs or 75 mgs with 100 mgs of testosterone. These women must have endometrial protection by oral progestogen or a Mirena (Schering Healthcare) levonorgestrel-releasing intra-uterine system (LNG IUS).(20) As women with PMS respond well to oestrogens but are often intolerant to progestogens and it is therefore common-place for us to reduce the orthodox 13 day course of progestogen to 10 or 7 days starting, for convenience, on the first day of every calendar month. Thus, the menstrual cycle is reset.
These women having moderately high dose oestrogen therapy must of course have cyclical progestogen if they still have a uterus in order to prevent irregular bleeding and endometrial hyperplasia. The problem is that women with hormone responsive depression enjoy a mood elevating effect with oestrogens but this is attenuated by the necessary progestogen. This hormone can produce depression, tiredness, loss of libido, irritability, breast discomfort and in fact, all of the symptoms of premenstrual syndrome, particularly in women with a history or previous history of PMS. A randomised trial of Norethisterone against placebo in oestrogenised hysterectomised women, already referred to clearly showed this and in fact the paper was subtitled a "A model for the causation of PMS".(16)
If women become depressed with 10 to 12 days of progestogen, it may be necessary to halve the dose, decrease the duration or change the progestogen used.(35) It is our policy to routinely shorten the duration of progestogen in women with hormone responsive depression because adverse side-effects with any gestogen are almost invariable. We would therefore use transdermal oestrogens either 100 mcgs or 200 mcgs of an oestradiol patch or a 50 mg oestradiol implant and then we would reset the menstrual bleeding by prescribing Norethisterone 5 mgs for the first 7 days of each calendar month. This will produce a regular bleed on about day 10 or 11 of each calendar month.
If heavy periods occur, (and they usually do not), to extend the duration of progestogen to the more orthodox 12 days. At this stage many women would prefer to have a Mirena coil inserted so there will be no bleeding, no cycles nor any need to take oral progestogen with its side effects. It is It is not unusual for women at this stage who understand the benefits of oestrogens and the problems of their menstrual cycles, to request hysterectomy and bilateral salpingo-oophorectomy with hormone replacement therapy with oestradiol and testosterone.(33) This is a fact of medical life and patient choice but it will be at least another 15 years before psychiatrists attempt to leap over that hurdle.
Summary:
1. Oestrogen therapy is effective for the treatment of postnatal depression, premenstrual depression and perimenopausal depression the triad of hormone responsive mood disorders.
2. Transdermal oestradiol 100 mcg or 200 mcg patches producing plasma levels
3. approximately of 500 pmol/l and 800 pmol/l respectively should be used.
4. These patients often require plasma levels of more than 600 pmol/l for efficacy.
5. Consider adding testosterone for depression libido and energy.
6. They require a cyclical progestogen or Mirena IUS if the patient still has a uterus.
7. The most effective longterm medical therapy is oestradiol patches or an implant of oestradiol and testosterone with a Mirena IUS in situ.
studd.co.uk/var_summary.php^ Women with a uterus need endometrial protection with progestogen. The usual duration is 14 days but if the extra risk to the breasts from progestogen is confirmed it would be sensible to reduce the duration to 7 days each calendar month. This shortened course is also useful in women with progestogen intolerance and is adequate for endometrial protection. Alternatively a Mirena IUS can be inserted. The long term value and safety of low dose unopposed estrogen is unproven.
If loss of libido and loss of energy remain a problem the addition of testosterone to estrogen should be considered. Androgen as well as oestrogen is often necessary after hysterectomy and bilateral oophorectomy. Hysterectomized women do not need progestogen.
Many of us get round the side effects of progesterone by increasing the estrogen slightly during the progesterone phase. So, maybe go from 2 pumps to 3.
The other option which I use under medical supervision, is to have a longer estrogen-only phase - but this is with a private consultant who monitors and advises. Your GP is likely to not 'allow' it as it's off -label, but you could increase the number of estrogen-only days a little without much risk.
take progesterone that triggers bleeds on a three-monthly basis, rather than every month. This could have mitigated the side effects of the progesterone intolerance.
^ Studd diagnosed progesterone intolerance and also I have osteopenia, my ostrogen levels were v low too. He put me on 3 pumps of gel, 7 days of utro X 100 mg and testim (testosterone). I think he more or less starts everyone on this although I've seen others on a variation of this. However he's worked with me to tweak this and find the perfect dose.
I'm now on 2 pumps of gel and my ostrogen levels have gone from around 180 to nearly 700, I'm using a tiny blob of testim and the progesterone we are working on as for me this is the biggest issue as I struggle with even the 7 days. He's asked my GP to refer me for a hysterectomy to be rid of progesterone for good and I see her on Friday. I guess in short I've found him delightful and life changing
Using Utrogestan (progesterone) tablets, 100mg for seven days a month, vaginally, really works for me. I get a regular bleed each month and with minimal side effects, compared to using Femoston, where I got nothing re a bleed but all the side effects.
Yes, that’s essentially it. The prog is needed to counteract the build up of womb lining. You can do this 2 ways: continuous prog = no build up, or cyclical = a bleed every month. To further confuse things there’s a long cycle option which isn’t really suitable for peri women as you’ll have breakthrough bleeding as you still produce some of your own hormones, but the idea is to take oestrogen only for up to 3 months, then add progesterone for 14 days and have a withdrawal bleed.
If you are prepared to try, the vaginal method is usually less problematic as it isn’t broken down by the liver as oral is, and therefore the nasty metabolites aren’t produced, it didn’t work for me but does for many women. There’s also an option to take the utro for 12 days per cycle. Menopause matters has an entire thread spanning years in oestrogel/utrogestan- worth looking on there.
Don’t get despondent, you’ve still got options and it sounds like the oestrogen is suiting you as you felt well for almost 2 weeks.
The only other HRT I got on with was FemSeven patches. They use levonorgestrel which is synthetic and a testosterone derivative which is helpful for some women, there’s also the mirena coil which some women get on really well with. So, still plenty options. It’s really unusual to hit the perfect HRT first time round and it’s advised to give it a couple of months before tweaking but utro can be hell.
I think the accumulated build-up of progesterone really doesn’t work for me. I’d hoped it wouldn’t be so bad because Utrogestan is progesterone rather than progestin (which is what sent me loopy previously). But apparently not!
After feeling more alive than I had in years, I started feeling rubbish on Day 9.
I’ll head back onto Menopause Matters to see if I can glean any more information. It’s such a fantastic resource.
I can’t have the Mirena unfortunately, as I have two wombs and two cervixes(!).
Thanks so much for your input. I hope our conversation helps others (hence why I pasted all the info I’d found above) 😃
I was a patient of professor studd’s - he’s quite the character! You really just need to tweak the doses and find a way to keep utro to a minimum. There’s a lady call Maryg on MM who uses 50mg compounded progesterone lozenges very successfully. She gets it prescribed privately. Might be worth talking to her. Good luck, you’ll get there!
Ha! Amazing. Love that you see Prof Studd yourself. He sounds like a bit of a hero!
Def need to keep Utrogestan to a minimum. Just need to work out how… tweaking is so draining! I’ve had to do it with thyroid meds, ADHD meds, etc, and it takes aaaaaages to work out what’s best. Wouldn’t it be lovely to be able to take medication straight off the bat?!
MM really is an invaluable resource. Will search for MaryM - thanks for the tip 😃
It’s MaryG. Yes, it’s entirely exhausting, can’t believe I’m doing it all over again with thyroid! Those days when you feel your best are what keep us searching I suppose.
It’s the same product as you have, you just use it vaginally instead of orally. If your GP is uncertain you can offer that you’ll have twice yearly endo scans privately to check all is well. They’re available at babybond throughout the U.K., around £90 per scan.
Just had another thought. It might be worth asking your gp if you can trial oestrogel alone for a month just to make sure it’s not causing any thyroid med issues. It’s always difficult to tell what’s causing what when more than 1 hormone is introduced at a time.
No problem, come back and ask if you can’t find answers to anything in particular. I’ve literally been through every hrt! I’ll try and find those scientific trials on low dose prog.
Please do, that would be wonderful. I won’t be able to stick HRT if I can’t get the progesterone right for me, but I’m equally scared of going back to peri symptoms and crazy Birth Control Pills. Eek!
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