What Causes Bleeding on HRT in Perimenopause? | PYHP 157

In this episode, we address a question from "Victoria" (name changed for privacy), who is experiencing prolonged bleeding while undergoing hormone replacement therapy (HRT). Victoria is in perimenopause and is taking compounded T4/T3 thyroid medication and progesterone. Despite normal test results, she often has bleeding that lasts up to 14 days, and her menstrual cycles are becoming shorter. These symptoms are quite common during perimenopause or when HRT is not properly balanced. Additionally, Victoria is dealing with joint pain and inflammation and wonders if these issues could be related to her hormones. Topics Discussed: The relationship between perimenopause and HRT Causes of prolonged periods during perimenopause Managing menopausal bleeding with HRT Understanding estrogen dominance Is estrogen therapy suitable for perimenopausal women who are still menstruating? Optimal timing for progesterone HRT: continuous vs. cyclical use The connection between hormones, inflammation, and joint pain   Victoria’s Question: "Hi! Your podcast is awesome, thanks for making it available! I turned 50 four months ago. Still menstruating monthly - every 27-28 days (with one exception - see below). Generally feeling good - no hot flashes or night sweats that I can tell, sleeping 7-9 hours a night (might wake up once or twice on occasion but generally able to go back to sleep quickly). My brain is working fairly well and my mood is good. No vaginal dryness or libido issues so far. For reference, my mum had her very last period four months after she turned 54, and she has never ever had hot flashes (in case that's useful). For the last two years I have been taking 100mg bio-identical progesterone from day 14 (sometimes I might start it on day 12 or 13 of my cycle if I feel PMS-like symptoms). I have also been taking 1,5 grain compounded thyroid for the last two years. I can honestly say the progesterone and the thyroid medication saved me from a lot of suffering I had started to experience 6 months before I started taking them: I had just turned 48 and I started to gain weight, couldn't sleep, felt depressed and brain-fogged. After starting the progesterone capsule and the compounded thyroid medication I gradually returned to feeling normal again. Lately I have even managed to lose some of the weight I put on. My issues right now: My period, although still regular, is characterized by long bleeding. I can easily bleed for up to 14 days. Granted, the bleeding will lighten up after day 5 or 6 but it will continue for at least as many days, albeit light. And to cap it all, this month I finished bleeding on day 14 and started bleeding again on day 19 (this is the first time my cycle is that short for as long as I can remember). I do yearly vaginal ultrasound - all normal. My last one was in June this year. Questions: Could I manage the bleeding by starting the progesterone earlier in my cycle? If so, on which day? Or do I need to start adding a bit of biest into my regiment? My doctor suggested that I could introduce 2.5mg biest (80/20 ratio) from day 5 to day 25 of my cycle, but I am unclear on how this could solve the bleeding issues. Lastly, I am experiencing some joint pain and joint inflammation lately, and I keep reading that this could be a (peri)menopausal symptom. Could adding a bit of biest help the joint pain? Oh, my skin is also drying up and sometimes breaking out a bit, and I guess that's also related to the change of hormones. It's the bleeding and the joint paint though that I am mostly bothered about. I already have l...