Spotting, poor sleep, and estrogen absorbing issues — stop HRT or try compounded?

Almost 4 years post meno---Started HRT in late Oct 2024 with a .0375 patch + 100 mg oral progesterone. Progesterone wires me, so I’ve had zero sleep improvement. My doctor increased the patch to .05 after 2 months, then to .075. I’ve also tried gels and now Evamist — but nothing’s helping, especially with sleep and night sweats.

I had first spotting 4–6 weeks ago after a dose change, followed by a week-long light bleed. Ultrasound was normal, but the in-office biopsy (cervix too narrow to get tissue sample). Now I’m spotting again 4–6 weeks later, with continued night sweats. I know labs are not advised, but since my symptoms haven’t improved, I’ve had a few done — and my estradiol has stayed under 30 despite the dosage changes.

I can’t take oral estrogen due to upcoming hip surgery in one month. The plan is to do a hospital biopsy and place a Mirena a few months after recovery.

Could this be an estrogen/progesterone imbalance? Should I quit everything now or try compounded estradiol cream? I absorb testosterone cream well, so wondering if compounded estrogen might be better. Just feeling really frustrated — my doctor’s main concern is the bleeding, even though my lining is normal and there are no structural issues.